Health x Wellness

Micro-elimination initiatives can accelerate Singapore’s progress to eradicate hepatitis C by 2030

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Micro-elimination initiatives such as the ETT programme provides direct help for high-risk hepatitis C (HCV) patient groups. Following phase 1 in 2022, HCSA will be launching phase 2 through partnerships, improving programme reach and addressing the urgent and unmet need for access to care. 

In Singapore, hepatitis C (HCV) is ranked the second most cancer-causing mortality and within the top 20 causes for years of life lost to disease.

Hepatitis B (HBV) and C (HCV) are blood borne viruses; that means it is mainly found in infected blood. HCV is most commonly transmitted through injecting drug use through the sharing of injection equipment.

HCV can also be passed from an infected mother to her baby, through the transfusion of unscreened blood and blood products and via sexual practices that lead to exposure to blood (for example, people with multiple sexual partners and among men who have sex with men); however, these modes of transmission are less common. Vertical transmission during pregnancy is the most common risk for HBV.

Hepatitis A (HAV) virus is transmitted primarily when an uninfected person ingests food or water that has been contaminated with the faeces of an infected person. Hepatitis cannot be spread through breast milk, food, water, or casual contact such as hugging, kissing and sharing food or drinks with an infected person.

Unlike the initial infection from HAV, patients with HBV and HCV are generally asymptomatic. Many remain undiagnosed until the infection becomes chronic leading to serious complications.

Although there is no specific treatment for HAV, and treatment for HBV is lifelong, the introduction of direct-acting antivirals (DAAs) has made HCV a curable disease through a 12-weeks oral medication course of oral medication, which has shown to have a treatment efficacy of 99 percent.

The prevalence of HCV in Singapore is around 0.2 percent. Unfortunately, it much higher for vulnerable populations, such as people who inject drugs. Around 30-40 percent of former drug users are estimated living with HCV.  

HCV is a curable condition, but social stigma, lack of information and the asymptomatic nature of the disease continue to hinder HCV eradication.  

We discuss HCV and the ETT programme with Kim Lang Khalil, Chief Executive Officer, HCSA Community Services.

the Active Age (AA): Who are the patients or persons most at risk of HCV? 

Kim Lang Khalil (KLK): As HCV is transmitted through the sharing of HCV-contaminated needles, individuals who use intravenous drugs are often the ones at greatest risk of contracting HCV. If not treated, their condition will worsen and become more life threatening over time, as they risk developing liver cirrhosis or liver cancer, and their loved ones may also be exposed to the risk of contracting HCV.

AA: What challenges has HSCA Community Services seen in addressing HCV in Singapore? Why is this so?

KLK: One of the biggest challenges is awareness, amongst individuals who are at the highest risk of HCV transmission, such as drug offenders and their families, on the condition, modes of transmission and available treatment. Greater education and understanding of HCV will reduce the stigma of people living with HCV and encourage more people to come forward to get tested, linked to and complete treatment.

Another challenge in addressing HCV amongst former drug offenders is the barrier cost in testing and treating HCV, particularly the cost of and access to HCV medication. As the majority of former drug offenders typically do not have much savings to rely on following release from incarceration, they will likely prioritise securing a sustainable livelihood and housing for themselves and their family. Sadly, they often do so at the expense of their own health and wellbeing, and delay treatment of medication conditions such as HCV – because they are unable to afford HCV medication while providing for themselves or their family.

AA: What are some of the steps HSCA Community Service is taking to inform, educate and help patients seek treatment?

KLK: HCSA Highpoint – Educate, Test, Treat! (ETT) programme was launched in July 2022 as part of a broader national effort to eliminate HCV within the high-risk population of Singaporeans, namely individuals who inject drugs or used to inject drugs, by 2030.

We were blessed to receive support from Gilead Sciences on the ETT programme where our ex-offenders are offered HCV testing at no cost, and learn more about HCV, how it could affect their lives, and options for treatment.

This is complemented by the FriEnd-C Befriender Programme, an integrated support system to guide patients that are HCV positive and ensure that they have the right support to access treatment and do not fall out of the programme due to socioeconomic concerns. Ex-offenders who reside in our partner network of halfway houses also receive support from our nominated program coordinator, typically a former drug offender who has had prior experience living with HCV but has since been cured, to provide strong peer support.

To sustain and drive further education among target at-risk groups, we continue to drive educational campaigns through a range of initiatives, including talks at HCSA Highpoint Halfway House and other halfway houses in Singapore.

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Assoc Prof Muhammad Faishal Ibrahim, Minister of State, Ministry of Home Affairs & Ministry of National Development (centre), at the MOU Signing Ceremony of ETT Programme Phase Two

AA: Can you share more about micro-elimination and the ETT programme?

KLK: Micro-elimination projects, like the ETT programme, focus on high-risk groups for which treatment and prevention interventions can be delivered more efficiently. We hope this comprehensive approach will increase the likelihood for an individual to come forward for testing and to receive treatment if they have tested positive for HCV.

The programme offers a high possibility to be expanded to more halfway houses, especially in encouraging active screening to understand the disease burden and strategise the HCV elimination programme. The effectiveness of onsite and targeted HCV micro-elimination programmes like ETT lies in the convenience of access to free HCV testing facilities at halfway houses where a sizable proportion of ex-offenders reside. This is important as it helps raise the visibility and lower the barriers of access to HCV testing for our ex-offenders, who may not be aware of HCV or the urgency to be treated.

If testing rates continue its current traction and treatment is maintained, it is possible for the prison network to achieve the programme’s target of 80 percent testing and 70 percent of diagnosed patients commenced on treatment.

AA: What are some lessons/insights from the ETT programme’s phase 1? 

KLK: Since its launch one year ago, over 200 ex-offenders have participated in the ETT programme of which over 70 participants were found to be HCV positive and who were subsequently referred to Tan Tock Seng Hospital for further tests and treatment.

Encouraging over 200 ex-offenders to join the ETT programme within its first year was no small feat, and we could not have done it without our partner halfway houses: Selarang Halfway House, The Helping Hand, and Teen Challenge Singapore.

It is through this first-of-its-kind collaboration between halfway houses to test and treat our ex-offenders for HCV, not just within one halfway house but across the ex-offender community, that we have been able to take our first important step towards eliminating HCV nationally as a public health threat.

AA: If you had a magic bullet, what would be the optimal way for phase 2 to take place?

KLK: Under Phase 2, the ETT programme will seek to double its impact by testing and supporting up to 400 ex-offenders over the next year. To achieve this, we are looking for more halfway house partners to come onboard, thus allowing us to test more comprehensively within our ex-offender community.

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Muhammad Faishal Ibrahim, Minister of State for Home Affairs & National Development (费绍尔副教授, Larry Sociago, Assistant Case Coordinator, HCSA Highpoint Halfway House

AA: How are you planning on achieving a successful phase 2?

KLK: In anticipation of supporting a greater number of HCV-positive ex-offenders, we will also be looking to partner with more hospital partners to increase options and availability to linkage-to-care services in phase 2, as the limited availability of our ex-offenders due to their irregular work hours and heavy work schedule may impede their ability to seek treatment.

It is our belief that with the support of industry partners, like Gilead Sciences, our partners in government and other halfway houses, we will steadily achieve our goal to eliminate HCV in Singapore by 2030.

I hope that the spirit of collaboration also trickles down to the community. I am always inspired by stories of comradery where former drug offenders step up to help others struggling in their community. I hope that as they continue to build a better life for themselves, they answer the call to also take their health seriously – to get tested and treated if diagnosed with HCV.

Photos credit to HCSA Community Services.