Decentralised model for hepatitis and opioid-substitution therapy

Key information
- Organisation: NACOSA
- Country: South Africa
- Region: Eastern and Southern Africa
- Stage of innovation: Stage 3: Pilot
- Start date: 11/01/2023
- End date: 03/30/2025
- Type of innovation: Services delivery innovation: new or different way of providing a service
- Budget: $509,348.15
- Funders: Global Fund
Summary of intervention
In South Africa, hepatitis C (HCV) treatment is usually only available in tertiary hospital settings. In August 2021, NACOSA piloted a community-based model of viral hepatitis screening and treatment services in three opiod substitution therapy (OST) sites (Johannesburg, eThekwini, Cape Town). In April 2022, this was scaled to an additional two OST sites (Ekurhuleni and Sedibeng). However, availability was still limited to fixed sites (drop-In centres), which often required clients travel great distances for daily treatment.
NACOSA responded by bringing hepatitis and OST services closer to communities through mobile clinics. The availability of services in hotspots for people who use drugs attracted new clients for OST, as this minimised the wait time and travel costs at stationary sites. For those already initiated on OST, retention improved from 67% (April 22-March 23) to 91% in (January 2024), as they could refill at mobile clinics. Decentralised services increased uptake of HCV treatment and adherence rates for those already on HCV treatment — direct-acting antiviral (DAA). Loss-to-follow-up also reduced and completion of HBV vaccination improved, with 233 vaccinated at mobile clinics (November 2023 to September 2024), opposed to 135 vaccinations at stationary sites (1 January 2023 to October 2023).
People who use drugs trust this new model of service delivery. More people on methadone means positive behaviour change leading to a reduction in criminal activities. More people on methadone and HCV treatment means less injecting and more people cured of HCV, which strongly supports HIV and HCV preventative and integration strategies.
learnings
Using mobile clinics to decentralise services has improved performance and adherence to opiod substitution therapy (OST), direct acting antiviral (DAA) treatment, antiretroviral and tuberculosis treatment, even though OST services still require a fixed site to store medication, client files and commodities. Improved adherence to OST and DAAs minimised the loss-to-follow-ups, therefore requiring sufficient budget to procure the additional methadone and DAAs with the steadying of the treatment cohort. There is a threat to this decentralised model, with mobile clinics frequently breaking down due to daily travelling across tough terrains, and security risks in outreach settings as methadone is a highly desired street commodity.
next steps
Additional linkage officers will be appointed to assist with tracking and tracing clients for OST and DAA support, and to provide the necessary adherence support and linkage to other clinical services. This model will be expanded to the other six districts for people who use drugs in the GC7 grant cycle by increasing the number of mobile clinics and clinical staff per district to allow for more OST and hepatitis C treatment initiations and case management. A digital case management tool will be developed to record follow-up appointments and blood work due dates for hepatitis C clients, which will assist in determining the impact of this decentralised model.
sustainability
Global Fund Grant Cycle 7 would provide continuous funding from April 2025 to March 2028, but all current principal recipients (PR) have to reapply for GC7. There is a risk that NACOSA may not be a PR in the next funding cycle, but will ensure lessons learnt and recommendations on mobile clinic expansion is transitioned to the new PR as this decentralised model works.
Tags
Harm reductionHealth SystemsHepatitis B & CPeople who use drugs