Article from the Economist Intelligence Unit Technology offers creative strategies to prevent and treat HCV at scale Hepatitis C virus (HCV), known as the silent epidemic, is a blood-borne infection that can lead to liver cirrhosis and cancer. While 71 million people live with chronic HCV globally, many of those infected remain asymptomatic and undiagnosed until the disease progresses and causes liver damage. There is currently no HCV vaccine, though curative treatments are becoming increasingly available. To explore policies and initiatives to curb the spread of HCV, The Economist Intelligence Unit (EIU), with the sponsorship of AbbVie, launched The Path to Zero programme to enhance awareness and initiate a global dialogue around innovative solutions towards eliminating HCV. This article explores the benefits of technological innovation towards the elimination of HCV. Introduction Lack of awareness, insufficient healthcare infrastructure and competing priorities have slowed progress to eliminate HCV. Many governments lack national strategies to combat the disease, despite its link to more deaths than HIV/AIDS in some countries. Innovative treatments that are easy to administer have only recently become available. No single intervention can alleviate the global burden of HCV. Yet technology, or the application of scientific knowledge and methods, can help address complex challenges associated with HCV. Electronic medical records systems and mobile apps, for example, can help raise HCV awareness, facilitate patient-provider communication and encourage continuity of care by leveraging population data and connecting with patients outside the hospital. Importantly, these digital tools, combined with the growth in internet access around the world, help service providers reach populations at scale. Indeed, the proliferation of connected devices has helped health practitioners better engage patients by overcoming geographic constraints and lack of resources that may have hampered earlier HCV prevention efforts. The path towards HCV elimination is a great undertaking, but technology will be a vital component along the way. 1
Raising HCV awareness In addition to the lack of awareness of HCV among the general public, clinicians are not always informed of the latest guidelines for prevention and treatment. Digital tools such as telehealth, videoconferencing services, mobile apps and social media have sought to address gaps in knowledge by educating health practitioners, particularly those in remote areas, about HCV. Such initiatives are important for several reasons: Telehealth and videoconferencing services can raise awareness among physicians and build health system capacity in underserved rural communities. Patients in remote areas are frequently unable to access care simply because of distance. This challenge is exacerbated for low-income patients. Sanjeev Arora, hepatologist at the University of New Mexico, often found that patients with HCV struggled to receive care because of a shortage of HCV specialists in the state. There was an eight-month wait to see me, says Dr Arora. Patients drove hundreds of miles. In 2003, less than 5% of diagnosed HCV patients in New Mexico then estimated at 28,000 had been treated. Dr Arora launched Project ECHO (Extension for Community Healthcare Outcomes) that same year to train rural primary care doctors in New Mexico via videoconference. A team of HCV specialists held weekly case-based trainings with practitioners and helped physicians set up rural clinics to screen for HCV and treat patients in hard-toreach areas. Most practices don t do a lot of screening for Hepatitis C because they don t understand it well, says Dr Arora. But that changed after the training. Clinicians and their teams became experts at diagnosing Hepatitis C, assessing the severity of liver disease and treating patients, he says. Today Project ECHO has more than 70 US sites and over 120 global partners. Fourteen sites are expected to open in 2017. Mobile apps can help physicians make treatment decisions. Given the variations in health system capacity and HCV prevalence across countries, new mobile apps seek to simplify treatment decisions among physicians. For example, at the International Liver Congress in 2017, the European Association for the Study of the Liver (EASL) launched a smartphone and web-based app, HCV Advisor, that assists practitioners in selecting treatment regimens. The app uses various criteria, including viral characteristics, drug approval status, and potential interactions and side effects, to offer treatment recommendations within national guidelines. The app is intended for use across many countries and already available in English, German, French and Italian. In addition to physicians, online tools can prepare community health workers to assist HCV patients and other vulnerable populations. Online courses in particular can help various types of health practitioners learn how to best support HCV patients. Hepatitis Victoria, a community-based non-profit in Australia, created an online education programme known as HEPReady to help community health workers expand their knowledge of HCV. Importantly, the courses target nurses, pharmacists, social workers and other health practitioners that work with diverse populations. One course, HEPReady Essentials, addresses stigma and discrimination and offers advice on how to conduct sensitive conversations. Another more comprehensive course enables students to complete an online assessment and receive certification for their studies. Ultimately, the flexibility of online tools to educate different types of health workers can ensure that HCV prevention strategies properly engage patients at all points of care. 2
Digital campaigns and social media outreach across international boundaries can also raise global HCV awareness and encourage knowledge sharing. Several international networks of HCV advocates have linked up to strengthen global dialogue on HCV prevention, and technology is a key component of their communication and outreach strategies. For example, the World Hepatitis Alliance, a patient-led non-profit that collaborates with governments and other strategic partners, has launched the NOhep campaign to raise HCV awareness and share best practices among people who are committed to HCV elimination by 2030. The massive campaign has utilized a variety of digital media such as video interviews with patients and leading hepatitis experts. NOhep has also conducted extensive outreach on social media channels, leveraging the networks of its member organisations, and even created data visualisation tools to map NOhep engagement across countries. A similar initiative, the Canada-based Global Hepatitis C Network also seeks to facilitate knowledge exchange about HCV across borders. Both initiatives are multi-stakeholder technology platforms that not only serve as central hubs for information regarding hepatitis but also mobilise greater community engagement in prevention and treatment efforts around the world. Linking patients and providers Raising HCV awareness can still be challenging if individuals do not believe they are at risk. Even after testing positive, many patients do not enrol in care. Therefore, more medical providers are deploying sophisticated electronic medical records (EMR) systems to identify patients for HCV screening. Some hospitals are also launching hotlines to encourage continued engagement in services. Such initiatives benefit HCV prevention efforts for several reasons: EMR systems leverage population data to identify at-risk individuals. EMR systems are particularly useful because they facilitate HCV screening at scale. In Boston, Beth Israel Deaconess Medical Center a network of academic hospitals, primary care practices and community health centres implemented an HCV screening tool based on its internal EMR system. An electronic prompt in the system identifies people born between 1945 and 1965 when they appear for care. This group, commonly referred to as Baby Boomers, is five times more likely to be infected than other adults, according to the US Centers for Disease Control (CDC). The CDC has recommended screening for all individuals who meet this demographic criterion. When Beth Israel Deaconess 5,500 clinicians log in at the point of care, they also have access to resources such as billing codes for HCV antibody tests and current clinical guidelines. The three-year-old programme has tested 56,000 people, including Baby Boomers and other at-risk patients. Approximately 1,700 patients were infected with HCV. Hotlines and chatting services offer patients educational resources and referrals. Contact with a health professional through such a service can guide patients to appropriate next steps at various stages of care. The hotline HELP-4-HEP, run by several US advocacy organisations, offers a peer-managed, toll-free support line for people living with HCV. They are really the only service like that, notes Ryan Clary, executive director of the National Viral Hepatitis Roundtable in Washington, DC. If a patient comes to me and says, I am having trouble finding a provider in my area, I refer them to this help line. 3
Mobile apps provide both healthcare workers and patients proper medical information and testing tools. Mobile apps have been successfully applied to HIV prevention and are now being tested for HCV across a range of low- and high-income countries. Nitika Pant Pai, an associate professor of medicine at McGill University, created HIVSmart!, a mobile app that allows people to self-test for HIV. In recent months, she piloted a similar solution through which volunteer peer counsellors in India used an app to help pregnant women determine whether they have HCV and HIV co-infection. The Canadian Institutes of Health Research is funding another mobile app initiative to help patients across Canada navigate HCV. The solution will be adapted to assist many different populations in Canada, including aboriginal and immigrant communities. This is an example of reverse innovation, where solutions developed to help the marginalized in one country can be adapted to solve problems of rural and urban poor in another country, says Ms Pai. Facilitating continuity of care and treatment adherence Beyond initial linkage to care, some patients find it difficult to remain engaged in services and adhere to treatment. Mobile phones, apps and other software platforms are increasingly used to facilitate continuity of care. There are several lessons learned from such technologies: Technologies that facilitate continuity of care can provide cost savings to providers and payers Disruptions in care and treatment often lead to higher costs because of resulting complications from disease progression, including avoidable hospitalisations and additional treatment needs. RxAdvance, a US-Indian technology company, developed a cloud-based pharmacy benefits management platform to deliver actionable, real-time information to physicians and pharmacists at the point of care. If a patient experiences side effects that could lead to treatment discontinuation, the platform instantly shares that information and clinicians may follow up with patients to review treatment options. Even a couple of days discontinuation of a Hepatitis C drug can make the patient repeat the whole course again, notes Ravi Ika, president and CEO of RxAdvance....Still, challenges may arise, and creative strategies are needed to complement technology use. Some patients, for example, may not have access to certain technologies. Curant Health, an Atlanta-based organisation, employs care co-ordinators and clinical pharmacists to make frequent calls to patients with chronic conditions, including people with HCV. Vickie Andros, pharmacist and director of clinical services at Curant Health, notes that some HCV patients may be difficult to reach because they have pay-as-you-go phones. When patients cannot be reached because their minutes have been depleted, we communicate with the provider to reach the patient, says Ms Andros. In some cases, medication is shipped directly to the clinic to ensure that the patient has access to therapy. Adherence packaging, or multiple medications in the same pillbox, can also simplify treatment. 4
Measuring progress Public health researchers also benefit from the ability of technology to easily reach patients. Online or web-based surveys, for example, help researchers measure progress towards HCV elimination. Indeed, surveys offer several benefits: Online surveys can produce patient-led insights at scale even when operating with limited resources. Online surveys are easily deployed and thus particularly useful for reaching large audiences. Hep-CORE, a patient-led study organised by the European Liver Patients Association (ELPA), used online surveys to investigate how countries are implementing Hepatitis B and C policy recommendations. The survey was led by Professor Jeffrey V Lazarus, a senior researcher at the Barcelona Institute for Global Health, and at the Centre of Excellence for Health, Immunity and Infections, Rigshospitalet, University of Copenhagen. The survey asked questions such as, Are there free and anonymous HCV testing services targeting high-risk populations in your country? and Are there any HCV testing or screening sites outside of hospitals available for the general population? We, as patients, did not want to wait years for other organisations like the WHO and the European Centre for Disease Prevention and Control to develop a strategy and action plan. We wanted to do something soon, and this was it, says Marko Korenjak, an ELPA board member and programme manager. Such research can inform countries policy decisions by offering evidence-based measures of progress to eliminate HCV. Hep-CORE has already produced notable findings: more than half of the 27 countries surveyed lacked national strategies to address viral Hepatitis B or C, despite the World Health Assembly resolution of May 2016, which called upon all countries to have one in place. This is the first and only patient-led survey done after the signing of the global viral hepatitis elimination strategy, says Mr Korenjak. The group plans to repeat parts of the survey every year, he says, to measure the progress of governments in the fight against hepatitis. Hep-CORE s plans to repeat the study on a regular basis will help public health experts compare results between countries, inform evidence-based interventions and ultimately advance the dual goal of eliminating Hepatitis B and C. Indeed, continued data collection and analysis will be vital to help ensuring that hepatitis prevention and treatment initiatives are tailored to the needs of specific populations and settings. Technology offers a diverse set of tools to improve HCV prevention across populations and must be leveraged to tackle the challenges associated with diagnoses, treatment and care. 5
Conclusion While more countries are investing in the elimination of HCV, the success of such efforts will require raising awareness, linking patients to services, facilitating treatment adherence and continually monitoring progress. Technology can assist with capacity building, particularly in countries or settings with insufficient resources. Public health practitioners and researchers should emphasise the necessity of good data to inform policy decisions and to guide implementation of national strategies. These measures can help governments, businesses and other stakeholders manage their budgets and maximise the utility of new and existing tools to eliminate HCV. Public health practitioners and researchers should emphasise the necessity of good data to inform policy decisions and to guide implementation of national strategies. 6