Community based intervention to improve access to public healthcare for hepatitis B and C for high risk groups

Since 2010, United Way Mumbai has addressed the challenge of increasing prevalence of hepatitis B and C infections. As a part of our Community Impact Initiative, we target high-risk populations such as female sex workers, people who inject drugs and migrants, as well as the general population. The strategy adopted includes medical interventions among the high-risk groups for controlling the infections, (with testing, medical referral, follow up and support for treatment compliance, patient support activities, etc.). Additionally, we provide health education to the masses to generate awareness and prevent the spread of infections.

The campaign

As India has one fifth of the world’s population, it holds a large percentage of the world’s hepatitis B virus carriers. It is estimated that India has around 40 million hepatitis B carriers and three to nine million persons have active hepatitis C virus.

The programme, SEHAT (Health in Hindi),  aims at targeted medical interventions with High-Risk Groups (HRGs) or those ‘very vulnerable’ for hepatitis B and hepatitis C infections, such as injecting drug users (IDU), men who have sex with men (MSM), sexual minorities (LGBTQIA), female sex workers (FSW), single male migrants, and truck drivers in the communities.

Carrying out the project involves engaging with a large group of people from within the same communities. This is to ensure outreach to the families and relatives of the high-risk group members and to create greater sensitivity and a supportive ecosystem.

The strategy involves educating people from HRGs with information on hepatitis infections, as well as providing testing facilities for timely diagnosis of hepatitis B and hepatitis C, and immunization and referral for treatment in case of infection. It is required that those who test positive for infection should be empowered with useful information about the virus and the treatment available. Further, those found to have the virus need to be followed up with to ensure they complete the full course of prescribed treatment.

For this, the project team executes a two-pronged strategy to identify and mobilise high-risk groups in the targeted geography. They start by collaborating with non-government organisations and community based organisations already working with high-risk group community members in project target areas. This way the project team leverages existing infrastructure and reaches other organisations to facilitate project intervention with the high-risk groups. The projects team also identifies and arranges screenings of people who are at high risk of infection at community healthcare outlets such as sexually transmitted infection (STI) clinics run by the government of India. For this, the project team consults and officially partners with the government authorities. This is done by reaching out to the relevant government officials and consulting them on high-risk populations under their jurisdiction. A primary assessment of the communities with such populations is carried out with community health volunteers (government health workers). Community health volunteers help in mobilising the high-risk populations for testing and vaccination camps. Such a partnership enables infrastructure and human resources to be leveraged to mobilise community members for these interventions.

The following interventions are undertaken as part of this strategy:

Focused outreach and education:

  • Organising community based activities for one-to-one health enquiry, preventive education sessions, home visits and door-to-door interactions etc. on key aspects related to hepatitis B and hepatitis C among high-risk groups.

Identification of people with hepatitis B or C:

  • Screening of people from high-risk groups during outreach activities. The focus as mentioned earlier is on injecting drug users (IDU), men who have sex with men (MSM),sexual minorities (LGBTQIA), female sex workers (FSW), single male migrants and truck drivers in the communities.

Vaccination for people who test negative for hepatitis B

  • Ensuring three vaccination dosages for hepatitis B among high-risk community group members who test negative for infection.

Medical management of people identified as positive for hepatitis

  • Medical referral of the community members who test positive for viral hepatitis to the Public Hospital -Lokmanya Tilak Municipal General Hospital (LTMGH) -Sion Hospital where free treatment for the disease is available for community members as part of the government’s efforts to eliminate viral hepatitis.
  • Follow up for treatment compliance is undertaken by the project team by accompanying the identified patients for their hospital visits, assisting them with any paper work (as most of the community members from target groups have low levels of education) etc. to ensure medical registration, treatment compliance and psychological support.
  • Patient counselling: An important factor in managing hepatitis B and hepatitis C patients is psychological support.

Social and peer support

  • The project team is trained as trainers to train and co-ordinate to promote awareness by involving community health volunteers (CHVs) from the Municipal Corporation, community volunteers from non-government organisations (NGOs) and community based organisations (CBOs) operating in the project area.
  • Involving local youth groups, women in “Self Help Groups” and other CBOs to transfer information and solicit support for the awareness campaign.

Top tips for success

  • To make sure people from high-risk groups undergo voluntary testing for hepatitis B, it was necessary to break the stigma attached and provide them utmost privacy. The project maintains the highest levels of data confidentiality and does not require individuals who want to get tested, vaccinated or individuals identified as hepatitis B positive to travel far for counselling, as the services are available in the community itself. This has led to improved cooperation from the population.

Achievements to date

  • Partnering with non-governmental organization, community based organizations and other associations helped in mobilising people in huge numbers for hepatitis B testing and vaccination. The testing camps were organized at community levels to ensure participants do not need to spend excessive amounts of time or money to get the necessary medical support. Keeping the camps in local communities also helped to ensure ease of follow up for the team with those identified as positive for hepatitis B. With this strategy, the project team could successfully provide hepatitis B testing and vaccination services to more than 22,000 individuals and is currently aiming at more than 4000 more people from high risk groups.

Challenges

  • One of the major challenges was to track down the people who have undergone testing and had the first hepatitis B vaccine dose for the subsequent two doses. The population covered under the activity is extremely unstable in terms of their location and at times the team has had to reach out to them individually at their next location.

Successful stories

Priyanka (her name has been changed) underwent testing for hepatitis B at a camp at Kamathipura with a local NGO. Priyanka’s late mother was a commercial sex worker and suffered from HIV and hepatitis B co-infection. Priyanka tested positive for hepatitis B. The UWM team met her for counselling and understood that she was planning to get married soon. The team conducted counselling for both Priyanka and her fiancé to guide them on next steps to ensure her fiancé is protected from hepatitis B and that Priyanka does not face any discrimination. The team conducted a hepatitis B test for her fiancé and provided him all three doses of hepatitis B vaccine. Priyanka was taken to LTMG hospital where she underwent further tests and was given suggested lifestyle modifications but no medical treatment. The team is in regular contact with Priyanka to ensure her treatment compliance and follow up.

Key learnings

  1. To ensure high coverage of hepatitis B and C screening, the tests have to be taken to the doorstep of the community especially those who are more vulnerable to this infection.
  2. Building a strong rapport with the beneficiaries is key to ensure compliance to vaccination, further blood tests and treatment
  3. Multi-stakeholder engagement is necessary to achieve greater impact and to ensure sustainability of interventions.

 

Find out more

If you are interested in community-led intervention to improve access to medical care for vulnerable communities, contact anil@unitedwaymumbai.org