The ‘Right to Health’ project
The ‘Right to Health’ pilot project aimed to improve viral hepatitis C prevention, screening, and linkage to care for current or former drug users in Bucharest. The first initiative of its kind in Romania, the project ran between October 2019 and June 2021.
ARAS – the Romanian Association Against AIDS.
Romania is thought to have one of the highest prevalence of viral hepatitis C (HCV) in Europe. Although there is no recent data, a national study from 2006-2008 estimated HCV prevalence at 3.2% (2.29% – 3.49%) in the general population, with more cases among women than men. Another study conducted amongst hospital patients in 2013 indicated a HCV prevalence of 5.6%.
Epidemiological data from people who inject drugs (PWID) revealed a steady increase in HCV cases in Romania amongst this risk group, with around 45% of those in opioid substitution treatment (OST) and needle exchange programmes infected in 2017. Amongst the 80 new HIV patients registered among PWID in 2018, 66.25% were co-infected with HCV and 11.25% with Hep B and C.
Between 6% and 15% of PWID were infected with HCV genotype 3 – the treatment of which has only been added to the national health coverage since March 2022. Worse still, access to HBV and HCV treatment is only possible for those insured and registered with a family doctor, which means that HCV diagnosis (genotype testing) and treatment services are not easily accessible to most PWID as they are uninsured.
Individual or group sessions were organised with PWID and OST users to prevent infections, by educating them on HCV transmission routes, diagnosis options, benefits of early detection and linkage to care, as well as ways to reduce the risk of exposure and avoid HCV transmission to others. These sessions took place at harm reduction sites and two OST centres run by ARAS. The attendees were subsequently offered free-of-charge HCV testing at ARAS-operated harm reduction centres.
Testing was accompanied by pre- and post-test counselling. With the help of nurse navigators, those who tested positive were given HCV genotype screening and were then linked to appropriate treatment. Again, the nurse navigator guided patients through the system, identified available patient support services and helped patients to solve any treatment-related or administrative issues they encountered. Those who initiated treatment also benefited from organised sessions to improve treatment literacy, adherence, and, ultimately, patient outcomes.
2,186 PWID participated in the educational sessions and 35% of them (775) subsequently agreed to an HCV test, with 210 testing positive (76% male and 24% female). 123 agreed to be referred to a specialist doctor who detected HCV genotypes 1 or 4 in 89 patients, genotype 3 in 7 patients and 27 presented inconclusive results. The 89 patients with HCV genotype 1 or 4 were referred to a specialist doctor for HCV treatment. 50 patients had completed their free treatment by June 2021.
In Romania, HCV among PWID remains a public health challenge. Urgent changes are required in the national legislation regarding healthcare services organisation as well as measures to improve access among the most vulnerable and often uninsured. The adoption of integrated models of care may significantly improve HCV diagnosis and treatment. In addition, simplifying access to free-of-charge HCV treatment and revising coverage rules is critical to ensure universal access to HCV treatment among PWID.
Moreover, avoiding disruption to continuity of HCV care due to fiscal year transitions is necessary to avoid patient loss through the care pathway. For better patient retention, HCV treatment delivery must be simplified, and unnecessary commutes avoided. HCV diagnosis in provided by an often unfriendly, bureaucratic and stigmatising health system, adding to the stigma and discrimination faced by PWID. The support of nurse navigators proves to have significantly improved and accelerated PWID access to and uptake of HCV treatment.
Alina Bocai, Romanian Association Against AIDS (ARAS)