Evaluation of a mass screening and treatment program for Hepatitis C virus in Rwanda
Creators: name: Nisingizwe, Marie Paul
name: Makuza, Jean Damascene
name: Janvier Serumondo
name: Nsanzimana, Sabin
name: Hedt-Gauthier, Bethany
name: Bansback, Nick
name: Janjua, Naveed
name: Law, Michael
Publisher: name: Gates Open Research
Year: 2019

description: Background: Globally, in 2015, 71 million people were living with chronic hepatitis C, and approximately 400,000 people died from HCV. In general, though it is well known that timely diagnosis and delivery of antiviral therapy can cure and prevent progression to later stages of the disease, access to HCV diagnosis and treatment has been limited. In sub-Saharan Africa (SSA), this is a particular problem as almost 20% global of HCV infections are in SSA, yet access to services remains very challenging due to limited health system resources.<br> <br>Over the past 20 years, Rwanda has improved access to health care services across numerous indicators. However, less than 1% of HCV patients were on treatment in 2015. To address this issue, the Government of Rwanda launched a voluntary mass screening and treatment campaign in 2017. As part of the scheme, patients with a confirmed diagnosis are initiated on treatment free-of-charge. As this is the first screening and treatment program implemented in the region, it is crucial to evaluate whether this massive effort has achieved its goal of improving access to HCV care services.<br><br>Research objectives: This study will consist of several interrelated studies: 1) to describe the cascade of care for HCV patients and identify factors associated with drop-out at each stage; 2) to gain an understanding of challenges encountered by HCV patients in Rwanda that influence them to drop out of care at different stages of the cascade; 3) to determine HCV-related costs for chronically infected patients; 4) to assess the cost-effectiveness of the mass screening and treatment program for HCV infection compared to the strategy of routine screening at health facilities or no screening.<br> <br>Study design and data: I will conduct an explanatory sequential mixed method design to achieve my objectives. The quantitative component will include a retrospective cohort study that will use secondary data to describe the cascade of care and assess factors associated with treatment dropout. The qualitative component will follow an inductive approach and data will be collected through one-on-one semi-structured interviews with patients to understand barriers and facilitators to HCV services. A retrospective review of medical records and interviews with patients will be carried out to determine the direct and indirect costs related to HCV care. Lastly, I will conduct an economic evaluation to assess the cost-effectiveness of the screening and treatment strategy.<br> <br>Statistical Analysis: I will generate descriptive statistics to estimate the proportion of completion at each stage of care. I will use a mixed-effects logistic regression model to assess factors associated with gaps in care. I will use a thematic approach to analyze qualitative data. I will transcribe, translate, and code collected information to identify common themes described by research participants. I will conduct an economic evaluation from a health care perspective, and I will adopt a previously-developed Markov model to simulate the disease progression through HCVs natural history. The model will utilize disease- and economic-related parameters from published sources, combined with the data obtained through the prior aims to determine the costs associated with HCV in Rwanda. I will use the model to compare costs and quality-adjusted life-years (QALYs) of the three strategies (HCV mass screening and treatment, no screening and treatment, and routine screening and treatment at health facilities).<br><br> <br>Study contribution to the advancement of knowledge: For Rwanda to achieve the ambitious global HCV elimination target by the year 2030, there is a need for research that will inform future policy decisions. This study will provide evidence on which type of interventions would be more impactful on the successful treatment of patients with HCV or the level of care that need more interventions. The cost and cost-effectiveness findings will guide policymakers regarding resource allocation. The lessons learned from this study can be utilized by officials in other countries with similar settings that are looking to initiate HCV programs.