Challenges to hepatitis C virus testing and treatment in a rural setting of Lao People’s Democratic Republic

Collaboration

• Centre d’Infectiologie Lao-Christophe Mérieux.
• Lao Tropical and Public Health Institute.

Funding

• Luxembourg Ministry of Foreign and European Affairs, Defence, Development Cooperation and Foreign Trade.
• Luxembourg Institute of Health.
• Fondation Mérieux.
• Aid Care China.

Objectives

The objective of the study was to evaluate treatment compliance among individuals receiving direct-acting antivirals (DAAs) for hepatitis C in a rural setting.

Background

The prevalence of hepatitis C virus (HCV) in Laos has been estimated at 1-2% across different demographic groups. We observed an unusually high incidence of HCV exposure in one of our previous studies in Saravan province (Figure 4). Participants from the rural district of Samuoi, located in the eastern part of the province, exhibited exposure rates of 24%, suggesting a substantial future burden of liver disease. In response to these surprisingly high exposure rates, a case-control study was conducted in the Samuoi district to explore the risk factors associated with HCV exposure. In the framework of this case-control study, direct acting anti-virals were provided as treatment to 92 viremic individuals, and adherence to the medication was evaluated.

Methodology

The treatment regimen involved a daily intake of 400 mg of Sofosbuvir and 100 mg of Velpatasvir for a duration of 12 weeks. The compliance was assessed at three intervals through pill counting during follow-up visits at the district hospital, specifically at weeks 4, 8, and 12. Face-to-face interviews were conducted to gather information on socio-demographics, risk factors for non-compliance, medical history, health status, and awareness of the disease and its treatment.

Figure 4: HCV seroprevalence, Laos, May 2017–March 2019. A) Location of Saravan Province; B) districts of Saravan Province. Colors represent seroprevalence levels. HCV, hepatitis C virus. Figure reproduced from: Black AP, Khounvisith V, Xaydalasouk K, Sayasinh K, Sausy A, Muller CP, et al. Unexpectedly High Prevalence of Hepatitis C Virus Infection, Southern Laos. Emerg Infect Dis. 2022;28(1):256-259. https://doi.org/10.3201/ eid2801.211307

Results

The majority of participants were male (78.3%), married (96.7%) and under 50 years of age (56.5%) (Table 3), with a mean age of 50 years (SD = 13, ranging from 24 to 90 years). In total, 19 participants were lost to followup. Reasons for that were lack of transportation means, challenging road access, relocation, severe illness, and time constraints due to work.

Of the 73 participants that attended the final checkup at 12 weeks, the average compliance to treatment (percentage of pills taken) was 97.7% (±6) with a range of 61-100%. Several reasons were identified for incomplete compliance: forgetfulness (56.2%); lost pills (13.7%); being busy with work (7.8%); confusion regarding dosage; traveling for work; fear of side effects; inaccessible at due time.

Table 3. Characteristics of study participants.

Discussion

The study highlights the challenges and successes of providing hepatitis C treatment in rural Laos, with findings suggesting that compliance can be achieved when patients have reliable access to care. However, logistical barriers, particularly transportation and road access, contributed to a significant loss of follow-up.

The World Health Organization has advised the implementation of simplified and decentralized diagnosis and treatment methods, proven effective in various regions. Given the concerning conditions in Saravan and in accordance with the Lao National Strategic Plan on Viral Hepatitis, there is a critical need to develop and establish a scalable decentralized intervention for HCV testing and treatment.

Conclusion & perspectives

Our study identified significant challenges to treatment compliance for HCV in a rural community in Laos. In order to overcome these barriers, the implementation of local interventions, training healthcare workers and raising public awareness are necessary.

The study was published as:

Akkhasith D, Sayasone S, Homsana A, Hübschen JM, Virachith S, Black AP, Paboriboune P. Challenges to Hepatitis C Virus Testing and Treatment in a Rural Setting of Lao People’s Democratic Republic. Journal of Clinical and Experimental Hepatology 14, no. 5. 2024 October. https://doi.org/10.1016/j.jceh.2024.101426.

Publications in 2024

Dekker T, Hefele L, Neven A, Hübschen JM, Essink DR, Black AP. Factors associated with hepatitis B vaccination in Laos: findings from the multiple indicator cluster surveys in 2011/12 and 2017. Lancet Reg Heal – West Pacific. 2024 May 1;46:101059. https://doi.org/10.1016/j. lanwpc.2024.101059.

Akkhasith D, Sayasone S, Homsana A, Hübschen JM, Virachith S, Black AP, Paboriboune P. Challenges to Hepatitis C Virus Testing and Treatment in a Rural Setting of Lao People’s Democratic Republic. Journal of Clinical and Experimental Hepatology 14, no. 5. 2024 October. https://doi.org/10.1016/j. jceh.2024.101426

Virachith S, Phakhounthong K, Khounvisith V, Mayxay M, Kounnavong S, Sayasone S, Hübschen JM, Black AP. Hepatitis B virus exposure, seroprotection status and susceptibility in Healthcare Workers from Lao People’s Democratic Republic: Cross-Sectional Study. Accepted by JMIR Public Health & Surveillance. 2024 November.

Congress

Oral presentations.

Dekker T, Hefele L, Neven A, et al. (2024), Factors associated with hepatitis B vaccination in the Lao People’s Democratic Republic: findings from the Multiple Indicator Cluster Surveys in 2011/12 and 2017. Oral presentation at the Conference on Tropical Medicine and Global Health in Düsseldorf, Germany, 19th to 21st of October 2024.

Hefele L, Virachith S, Khounvisith V, et al. (2024), Hepatitis B virus epidemiology in the Lao PDR. Oral presentation at the Conference on Tropical Medicine and Global Health in Düsseldorf, Germany, 19th to 21st of October 2024.

Posters.

Vantava S, Hefele L, Virachith S, et al. (2024), Low seroprotection against diphtheria and tetanus in Lao adolescents. Poster presentation at the Luxembourg Microbiology Day, Luxembourg City, Luxembourg, 16th of May 2024.

Black AP, Virachith S, Khounvisith V, Hefele L, Paboriboune P, Hübschen JM. High exposure to hepatitis C virus in Saravan, southern Laos; identification of several risk practices. Poster presentation at the Luxembourg Microbiology Day, Luxembourg City, Luxembourg, 16th of May 2024.

Hefele L, Virachith S, Khounvisith V, et al. (2024), Hepatitis B virus epidemiology in the Lao PDR. Poster presentation at the Luxembourg Microbiology Day, Luxembourg City, Luxembourg, 16th of May 2024.

Black AP, Virachith S, Khounvisith V, Hefele L, Paboriboune P, Hübschen JM. High exposure to hepatitis C virus in Saravan, southern Laos; identification of several risk practices. Poster presentation at the Conference on Tropical Medicine and Global Health in Düsseldorf, Germany, 19th to 21st of October 2024.

Congress attendance.

Siriphone Virachith was invited to contribute with her expertise to the “National Strategic Plans for Viral Hepatitis in Lao PDR, 2024-2030” meetings, organized by the Department of Healthcare and Rehabilitation (Ministry of Health) and the World Health Organization. The meetings were held on 26th of July and 28th of August.

Teaching activities

(lectures given in universities, during seminars, etc.).

Siriphone Virachith gave lectures to 1st and 2nd year students at the LTPHI in the framework of the hepatitis seminar:

• Lecture: Introduction to viral hepatitis.
Generalities on viral hepatitis.
Natural history of viral hepatitis.
Epidemiology and distribution of viral hepatitis.
Co-infections of viral hepatitis.

• Lecture: Non-hepatocarcinogenesis viral hepatitis.
Hepatitis A (HAV) and Hepatitis E (HEV): biology, epidemiology, situation in Laos, pathophysiology, virological diagnosis, and follow-up of infection.

• Lecture: Public Health issues related to viral hepatitis.
Viral hepatitis screening.
Mother-to-child transmission.
Hepatitis management in developing countries.

• Lecture: Laboratory practices for Viral Hepatitis.
Rapid Diagnostic Test.
ELISA test.
PCR test.

Training activities

Training given by the team:

In the framework of the project “Reasons for hospitalization in children under five years of age”, Mrs. Diaz and Dr. Khounvisith have conducted three training sessions at the Children’s hospital to introduce electronic data collection with REDCap.

Training undertaken by the team:

Both Vilaysone Khounvisith and Siriphone Virachith attended several trainings:

• Basic bioinformatics at Institut Pasteur du Laos; 27th to 28th of September 2024.
• In-silico Identification of protein at Institut Pasteur du Laos; 30th September to 4th of October 2024.
• LIPS workshop at Institut Pasteur du Laos 28th of October to 7th of November 2024.

In addition, Siriphone Virachith attended the “Regional Trials for Epidemic Preparedness & Response Workshop” organized by the PREPARE – Programme for research in epidemic preparedness and response in Singapore from 26th of February to 1st of March 2024.

In the third year of her PhD studies, Vilaysone Khounvisith took courses in Switzerland during the spring semester (February to May 2024), focusing on project management, data analysis in epidemiology and Quantum Geographic Information System (QGIS). During this period, she also advanced data analysis for her project and contributed to manuscript preparation.