Testing simultaneously for several infectious diseases in primary health care settings is feasible and can help to bring down the burden of chronic hepatitis C, HIV, sexually transmitted infections (STIs) and tuberculosis (TB) in countries in eastern Europe and central Asia, results from Georgia and elsewhere in the WHO European Region show.
These countries have seen high numbers of people affected by chronic hepatitis B and C, HIV and TB compared to the rest of the European Region. However, the adoption of integrated testing services in a number of countries, including Georgia, has revealed that combined testing is not only feasible but can identify infections before they become deadly.
Coinfection is common but finding those affected in a timely manner in order to provide care and life-saving treatment can be a challenge if each disease falls under a separate health programme. Equally, there can be stigma attached to HIV testing, while hepatitis C, known as the silent killer, can go undiagnosed because patients often experience no obvious symptoms.
Providing a people-centred service
In 2018, Georgia piloted integrated screening for hepatitis C virus (HCV), HIV and TB in the region with the highest burden of these diseases. Primary health care physician Dr Tamar Imedadze is one of the people who have been steadily urging patients to try the service.
“People who we test through the integrated testing programme usually don’t know about the opportunity; they either come to our centre for other health issues and we offer them free testing for HCV, HIV and TB at the facility, or they connect with us through our mobile teams, who include a physician, a nurse and a driver, and offer free testing in communities and work places,” explains Dr Imedadze.
“I find that people are often motivated to get tested when we explain and offer the free service. The main advantage is its convenience – patients don’t need to travel specifically to get tested; they are offered screening when they seek medical care or, even better, they are offered testing at home or at their work place for free. The service is centred around people’s needs.
“In a month, my team usually tests 200–300 individuals through the integrated screening programme and other teams have similar targets. We do get a small monetary incentive for every individual tested, but the main motivation for me and my colleagues is the recognition of our role by local communities and the government,” says Dr Imedadze.
Badri Qvariani, a 54-year-old artist, is one of the people who, through the integrated screening programme, found out that he had chronic hepatitis C. Badri experienced frequent exhaustion – a symptom of liver damage from hepatitis. One day in 2010 when visiting his hospitalized mother, he saw an ad for integrated testing and decided to sign up for it. The HCV, HIV and TB tests showed Badri to be infected with hepatitis C.
Badri is grateful to his primary care physician for guiding him through his treatment options. “When the test confirmed that I had hepatitis, I was offered treatment at no cost for which I am very thankful. I am free of hepatitis today,” he declares.
Integrated testing and decentralization – instrumental for eliminating hepatitis C
When Georgia embarked on its hepatitis C elimination programme back in 2015, more than 5% of the adult population were chronically infected with HCV, and two thirds of those infected were unaware of it. The country also has a high incidence of TB, although this has gone down in recent years. HIV prevalence is low at 0.4%, but coinfections are of concern in Georgia. Up to 22% of people living with HIV had active TB and up to 32% had latent TB. Furthermore, among people with TB, 21% had a hepatitis C infection.
Integrated screening services are essential for eliminating hepatitis C and controlling the HIV and TB epidemics, but introducing the service does require an outlay of funds. Georgia approached the Global Fund to fight AIDS, Tuberculosis and Malaria for support and found them willing.
“The Global Fund’s money was instrumental for mobilizing local government and communities, developing the integrated screening protocol, raising awareness and for training primary health care physicians, nurses and village doctors. The monetary incentives for primary health care teams came from local municipal budgets,” explains Dr Amiran Gamkrelidze, who has worked in health-care management for more than 35 years and is now the Director General of the National Centre for Disease Control, Georgia.
“The pilot project proved that integrated testing was highly effective. Screening coverage of the local population increased by 60% in the 7 months of the pilot compared to the 3 years prior to the project. We then adopted the model across the country, with state support. This has been especially useful for reaching individuals who generally don’t seek medical care and wouldn’t get tested otherwise,” he says.
During the COVID-19 pandemic, although screening for hepatitis C did go down, many primary health care clinics offered integrated HCV, HIV and TB screening to individuals being testing for COVID-19.
Although Georgia is yet to reach the ambitious targets set in 2015 to identify 90% of people living with chronic hepatitis C by the end of 2020, the results of national screening and treatment services are still impressive – 73.7% screening coverage and 56.8% treatment coverage, with a 98.9% cure rate.
“I hope that the lessons learned from the introduction of integrated screening in Georgia will help inform similar programmes in other countries striving to eliminate HCV and stop HIV and TB,” adds Dr Gamkrelidze.
European Testing Week, held from 14–21 May this year, also promoted voluntary testing for viral hepatitis, HIV and STIs.