How integrational care can address hepatitis, HIV, and syphilis

In recent years, the global community has committed to eliminating mother-to-child transmission of HIV and syphilis as a public health priority. A program in Uganda is taking this one step further by planning to combine efforts around hepatitis B elimination into existing HIV and syphilis programming as part of a triple elimination strategy.

The three diseases share several features including forms of transmission and prevalence, which means the idea of tackling them together could lead to saving time and money as well as progress toward elimination, said Harald Nusser, head of global patient solutions at Gilead Sciences.

“When it comes to working at the community level, one condition rarely comes alone … That means testing for several diseases simultaneously through midwives or community health workers or linking approaches up with maternal and child health programs can holistically avoid vertical transmissions,” he said.

Africa has a comparatively high prevalence of all three diseases, with estimates that 1.4% to 6.7% of people aged 15 to 49 are living with HIV, and 3% of children under age 5 have hepatitis B.

In Uganda, the Ministry of Health estimates that 4.1% of people have hepatitis B. While vertical HIV infections have dropped in the past two decades, with coverage of maternal antiretroviral therapy now at 95%, there were still around 5,300 new child infections of HIV in 2020.

“We’re trying to integrate hepatitis into initiatives for other diseases, tagging it onto noncommunicable diseases and HIV, and saying if you’re tested for HIV then you can come on board and also test for hepatitis,” explained Rachel Beyagira, a medical doctor and viral hepatitis technical officer at the Ugandan Ministry of Health.

New program

As a first step, the Ministry of Health, in partnership with Center for Disease Analysis Foundation, plans to implement a program specifically aimed at reducing MTCT for hepatitis B virus, using resources for existing HIV and HBV programs.

Under WHO guidelines, one of the most important interventions to reduce MTCT of HBV is vaccination of all newborns within 24 hours of birth, followed by the standard triple-dose regimen.

Uganda’s current HBV program, in practice since 2015, has conducted testing and mass vaccination of adolescents and adults born before 2002. Since 2002, children in Uganda have received the pentavalent vaccine, which protects against five diseases including HBV, at 6, 10, and 14 weeks old but they don't receive the birth dose vaccine. If the first dose of the HBV vaccine is administered within 24 hours of birth, it is highly effective in preventing MTCT of the virus during birth.

While the current measures have cut the prevalence of HBV among children under 5, it is still above the 0.1% target set by the World Health Organization amid efforts to eliminate viral hepatitis as a major public health threat by 2030. WHO estimates that more than 6% of the population is infected with HBV, and research shows that 2 to 30% of cases are contracted through MTCT. This is why further action, such as the implementation of the birth-dose HBV vaccine, is vital.

But to vaccinate all thousands of children born annually in Uganda would be a significant cost, said Homie Razavi, founder and managing director of CDAF, adding that around 40% of births happen at home, making administering the birth dose vaccine complicated.

Through close cooperation on costings between CDAF and Uganda’s Ministry of Health, the two organizations have realized that integrating a new program within existing health care structures could massively reduce cost, making rollout feasible.

Uganda has a robust HIV program, and already carries out screening of all pregnant women for hepatitis, as well as HIV and syphilis, explained Razavi.

By harnessing the existing screening program for HBV and targeting the birth dose vaccine only for those testing positive, CDAF estimates the associated cost per infected infant averted would be $27, dropping from over $350 to cover everyone. It would also reduce the number of day-old infants who need vaccinations to around 50,000 infants annually, with much easier logistics for reaching those born at home. 

The idea is to implement a pilot study that would test all pregnant women for HBV and HIV at five regional maternity hospitals. If approved, the program could start in early 2022 and will run for 18 months.

Razavi estimates that prevalence of HBV could be reduced to below 0.1% among 5-year-olds across the country in as little as six months from the pilot finishing. “That goes back to the point of why triple elimination is so important,” he said. "If some of the cost is shared with other programs, then the incremental cost of treating hepatitis B mother-to-child drops significantly.”

If successful, other elements to tackle syphilis will be added. “We shall be working closely with the immunization and maternal [and] child health programs to fully implement the project. I believe that the triple-elimination strategy will really come to pass for us,” Beyagira said.

Scaling up

The hope, Razavi said, is to use this type of approach in other countries too.

There is a need for more horizontal health care that works toward triple prevention and other types of integration in many countries, Nusser agreed. “Looking into this from a more holistic or person-centric perspective is not the common narrative,” he said. "But it’s time to look at models which allow local governments to take increased ownership and treat people, not diseases.”

This is only possible when the need for donor aid is reduced by cutting costs, said Nusser, adding that different private sector and multilateral organizations will also need to support these approaches.

"What I’m looking at is finding ways to support governments in taking ownership of solving these health problems and do what we can to work on these solutions together,” he said.

There is a call for the private sector to move beyond thinking of just providing access to their specific solutions and rather innovate around shared-value initiatives that yield benefits for society as a whole. If this leads to making the respective health system more robust, it will eventually yield business benefits for local private sector, too, said Nusser.

Gilead seeks to work more closely with CDAF on the integrated approach. This could be at the scaling-up phase or in, for example, enabling replication of the integrated approach to these three diseases into other countries, Nusser said.

Razavi, however, reminded that integrated models must be tailored to individual locations.

“There’s no simple template that can be used across all countries, so it’s really about developing customized programs,” he said. “We hope that some of this [work in Uganda] is transferable to other countries. But if not, what we’ve learned is by having those conversations we can find solutions that will work.”

Beyagira agreed that the Ugandan initiative shows the value of integrating lessons learned from existing programs, along with coordination between ministry departments. Her department, the Vaccines and Immunization Division, has, for example, been working closely with the Department of Reproductive and Child Health to enable this joint approach.

Partnerships similar to that with CDAF, academia, and civil society groups are key, she said, as they include technical and data-driven support and awareness raising.