Mind the gap: HCV policies versus community experiences

By Coalition PLUS

In 2016, WHO Member States adopted a global strategy to eliminate hepatitis C by 2030. This resolution followed shortly after the arrival of medicines that have revolutionized hepatitis C (HCV) treatment. Known as direct-acting antivirals (DAAs), these medicines offered people living with hepatitis C (PLHCV) a safe, highly-effective cure. To the public health community, DAAs presented an unprecedented opportunity: a means to eliminate an infectious disease through a medicine. Yet while the goal of elimination can appear simple enough on paper, the design and implementation of programs to achieve it require further elaboration of country-level strategies and corresponding budgets. In turn, the translation of strong policies to successful practice at ground-level will prove the key catalyst to elimination. The exploration of such a gap—between policy commitments on paper and the reality of their implementation in practice—represented the focus of a study conducted by Coalition PLUS and its partners. Through over 40 hours of structured focus group discussions with 240 at-risk individuals [primarily people who inject drugs (PWID) and people living with HIV/AIDS (PLHIV)] and PLHCV, the survey provided communities an opportunity to voice their perspectives and experiences. To further strengthen groundlevel insights into the HCV response, 51 healthcare workers providing HCV services were also interviewed.

This report complements the evaluations of hepatitis responses conducted by fellow stakeholders. One particular inspiration was the WHO’s recent development of country response profiles through a survey on a checklist of indicators of structure (e.g., policy decisions), input (e.g., budget allocation) and process (e.g., implementation of WHO guidelines). To complement the WHO’s top-down macro-level overview of HCV responses, the Coalition PLUS survey provides a bottom-up micro-level evaluation of the HCV response at selected sites in five middleincome countries: India, Indonesia, Malaysia, Morocco, and Thailand. As an explanatory and qualitative survey, the findings and recommendations serve to inform the response in the countries involved in the study. In addition to highlighting potential gaps between policy adoption and policy implementation/coverage, this evaluation exposed a variety of thematic gaps in awareness, health workforce capacity, service affordability, funding, and political will. Analysis of these gaps contributes qualitative context to complement the strategic information that governments have accumulated. In particular, it aims to nourish the dialogue that country updates on the 2020 targets—to be presented at the World Health Assembly in 2021—will surely provoke. Four years away from 2020, the latest global estimations of progress toward those goals show that most regions face a massive gap between present cascades and regional/global targets.