Paying for Hepatitis Elimination: Tashkent's Catalytic Funding Pilot, 2019–2020

In 2016 the World Health Organization (WHO) set targets to cut viral hepatitis incidence by 90% and deaths by 65% worldwide by 2030. For countries like Uzbekistan, where hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are common, the obstacle is money: big donor programs for hepatitis are largely absent, and grants and donations are hard to find. This report describes a pilot that tried a different way to pay.

The scale of the problem

• In 2015, an estimated 257 million people worldwide had active HBV infection, 71 million had active HCV, and about 1.3 million died of viral hepatitis and the liver disease it causes. Vaccines and treatments exist, but few low- and middle-income countries have sustainable, scalable elimination programs — even though there is evidence of a positive return on investment.
• Uzbekistan, population about 30 million, had in 2016 an estimated 2.5 million (8.3%) people with HBV — of whom 10% were diagnosed and 0.5% (about 12,500) treated — and 1.3 million (4.3%) with HCV, of whom 5% were diagnosed and 2% (about 26,000) treated.
• In 2017 the country's president decreed that both infections be eliminated to meet WHO's targets. Doing so would cost US$1.3–1.7 billion over ten years; the budget was US$1.0 million a year for treatment and US$0.3 million for testing.

How catalytic funding works

The Center for Disease Analysis Foundation (CDAF) designed the model, and launched the pilot in Tashkent on December 6, 2019, with the Uzbekistan Research Institute of Virology and the Ministry of Health.

• Seed money — far less than the program's total cost — buys the first round of tests and medicines.
• Testing is free for everyone, on the bet that most people will accept a free test.
• About 20% of patients, chosen by income, get free treatment. The other 80% buy their medicines at a small markup, which pays for the next rounds of tests and drugs, covers the free patients, and repays the seed money at the end.
• It rests on the idea that most people, even in poorer countries, will pay for treatment priced below the catastrophic health expenditure level — the out-of-pocket limit that keeps a family from destitution, calculated at US$925 for Uzbekistan.

Keeping costs down: medicines and tests of assured quality were bought in bulk through the nonprofit Global Procurement Fund; the government waived most import duties and supplied staff, clinic space and lab equipment; and a national pharmacy chain sold the drugs at just a 5% markup.

The whole program was costed at US$3,238,000 — about a quarter of the US$13,419,000 a conventional program of the same size would cost — and needed only US$1,616,000 up front.

Simplified test-and-treat

General practitioners took the place of specialists, following streamlined steps:

• Hepatitis B: a rapid surface antigen (HBsAg) test; if positive, rapid HIV and creatinine (kidney) tests. Those who tested HIV-negative and had normal kidney function were offered 12 months of tenofovir disoproxil fumarate, with free follow-up tests at a year. People with HIV were referred to HIV clinics.
• Hepatitis C: a rapid antibody test at the same visit; if positive, blood tests for HCV core antigen (to confirm current infection), creatinine, AST and platelets. An APRI score estimated the chance of cirrhosis. People with signs of cirrhosis or impaired kidney function went to the Institute of Virology; everyone else was offered three months of sofosbuvir/daclatasvir and asked to return in 12 weeks, once treatment was complete, for a free test to confirm a cure.

13 polyclinics in Tashkent were to test about 250,000 adults over a year, with roughly 16,662 HBV and 6,866 HCV patients expected to qualify for treatment. Nurses were trained in rapid tests, motivational interviewing and registration; doctors in reading results, drug interactions, dosing and more. Records went into the open-source REDCap registry on tablets and laptops.

The first three months

From December 6, 2019, to March 15, 2020:

• 24,821 people tested — about 10% of the year's target.
• 1,084 (4.4%) positive for hepatitis B and 1,075 (4.3%) for hepatitis C antibody; 51 had both.
• Women were about three quarters of those tested (75.9%), though Tashkent's population is evenly split — why is unknown. Yet infection was more common in men: newly diagnosed hepatitis B in 4.7% of men vs 2.1% of women, hepatitis C in 4.2% vs 2.9%.
• 428 (39%) of hepatitis B and 291 (27%) of hepatitis C antibody-positive people already knew they were infected; 176 and 128 had been treated before.
• Of those with hepatitis C antibodies, 65.1% had active infection by core antigen.

Where patients were lost:

Of the 438 who started, 86.5% paid for their medicines and 13.5% got them free.

People retained at each stage of care. Image from the Centers for Disease Control and Prevention

Too many drop-outs — so far

Free testing and cheaper drugs drew people in, and patients proved willing to pay when prices are low. But the model needs at least 55% of diagnosed patients to start and stick with treatment; after three months, only 23.0% had started. At that rate the program could not repay its seed money. The next steps are to find out why people drop out and fix it; CDAF is working with international partners on the problem.

Limitations: Tashkent may not represent all of Uzbekistan, and the study was not designed to find out why people did not take part, dropped out or were lost to follow-up.

The lesson for others: simplified test-and-treat rules, general practitioners in place of specialists and new financing can cut costs sharply — a model other low- and middle-income countries with little donor support could adapt, if the gaps in care can be closed.

Sources

Based on "Progress Toward Hepatitis B and Hepatitis C Elimination Using a Catalytic Funding Model — Tashkent, Uzbekistan, December 6, 2019–March 15, 2020," by Rick Dunn, Erkin Musabaev, Homie Razavi, Shakhlo Sadirova, Shokhista Bakieva, Katie Razavi-Shearer, Krestina Brigida, Saleem Kamili, Francisco Averhoff and Muazzam Nasrullah, Morbidity and Mortality Weekly Report 69(34), Centers for Disease Control and Prevention; a work of the United States government in the public domain.