Georgia becomes 'a global leader' in the elimination of hepatitis C

In 2015, the country of Georgia launched the world’s first national hepatitis C virus screening and elimination program with a goal of reducing prevalence of the disease by 90% by 2020.

While Georgia’s program has not yet achieved that goal, it has made remarkable progress – screening up to three million of the country’s approximately four million people and treating 83,000 people – more than half of those estimated to be infected. The program’s cure rate is 99%. 

From the 2015 launch to 2021, Georgia’s prevalence rate for active hepatitis C has decreased by 67% from 5.4% – one of the highest rates in the world – to 1.8%. Its health leaders have recommitted to reaching the 90% reduction goal by 2025.

Georgia’s hepatitis C program demonstrates how civil society can help the government reach vulnerable communities and make critical health services more convenient and accessible. It also demonstrates how a vertical program can help strengthen the health system as a whole.

The US Centers for Disease Control and prevention has called Georgia, “a global leader … a model for other countries with large numbers of HCV-infected persons.”

To understand how Georgia achieved this progress, Exemplars News spoke with Dr. Maia Tsereteli, who leads the country’s HIV/AIDS, Hepatitis, STI & TB division at the National Center for Disease Control and Public Health (NCDC) within Georgia’s Ministry of Health about how the country took on the disease, which is a silent killer, infecting the liver and causing liver dysfunction and liver cancer, sometimes decades after infection.

How did Georgia discover that it had a high hepatitis C rate and what was the cause of this high infection rate?

Dr. Tsereteli: Before 2015, there had been small-scale surveys that indicated we had a problem with hepatitis C. But we didn’t know the full extent of it so, in 2015, with the support of the United States Centers for Disease Control and Prevention, our NCDC conducted a nationally representative survey. The survey estimated that 7.7% of adults had evidence of exposure to hepatitis C and 5.4% of adults had chronic hepatitis C infection. The same survey found that 2.9% of adults had chronic hepatitis B virus. These are quite high prevalence rates, among the highest in the world.

Understanding how this came to be was revealed, in part, by the data. Our survey found that men aged 40–49 years had the highest rate of anti-HCV positivity at 20.8%, followed by men aged 50–59 years at 17.4%. A history of intravenous drug use was the strongest predictor of HCV infection in this survey. Of the individuals who tested positive for hepatitis C exposure, 38.2% reported prior drug use. They confirmed a widespread practice of sharing needles.

Intravenous drug users can be a challenging population to reach. How did Georgia ensure that the campaign to eliminate hepatitis C would reach this population?

Dr. Tsereteli: The government recognized that it needed to rely on organizations that knew this population well, were already working with this population, and had the trust of this population. So, we worked very closely with NGOs that were already working with IV drug users and understood the problem well. We developed a working group with representatives from these NGOS. They were very actively involved in developing the country’s work plan to end hepatitis C.

We also supported the establishment of patient associations which included well-known people in Georgia who spoke publicly about being infected and successfully treated of the infection, to destigmatize the illness and encourage open conversations. This contributed to an increase in public awareness around the HCV infection and promoted testing with key populations.

We also expanded the reach of harm reduction centers, as we recognized that stigma often prevents IV drug users from attending clinics and hospitals. We have six of these centers, each equipped with mobile labs conducting routine testing within hard-to-reach areas and populations where there is the biggest need. These centers and mobile units offer free testing and offer to start patients on treatment. They also offer needle exchanges, HIV testing, counseling services, and condoms. We also made these health services available in prisons and at drug treatment sites.

What have been the key drivers of your success thus far?

Dr. Tsereteli: Our program benefits first and foremost from strong political commitment to end hepatitis C infection as a public health threat in Georgia. Even our prime minister has been involved in driving the progress of the program from the very beginning. We also benefit from strong international collaboration, including from the US CDC. We have been able to draw on our country’s strong human resources and experience in delivering healthcare, our previous experience running large-scale national health programs (such as our HIV and TB programs), and our strong logistics capabilities. And Gilead pharmaceuticals provides the treatment, called Solvadi, to the government for free.

We also benefit from public-private partnerships. Most health clinics in Georgia are private. They have partnered with us on delivering services, with the government paying the bill. Including private clinics has allowed us to expand the number of screening and treatment sites. We have more than 1,300 locations providing testing around the country with more than 1,800 providers participating.

And, of course, we could not have done this without the partnership from civil society organizations and our medical staff across the country serving our target population.

How did the campaign against hepatitis C impact your health system and public health capacity more broadly?

Dr. Tsereteli: The program absolutely stimulated the development and strengthening of our health system. It prompted us to develop laboratory capacities and electronic data systems and registries to capture the up-to-date data on the testing and treatment of HCV infected individuals, allowing us to strengthen surveillance activities and plans based on the identified gaps. Data was a big problem for us in the past and it remains a big problem for many post-Soviet countries to this date.

The program also prompted us to create and update our blood safety and infection control regulations which were outdated and not meeting standards. This is particularly important because a history of a blood transfusion was reported by 20% of the people who tested positive for hepatitis C.

And the program led us to create an integrated TB/HIV/HCV screening program at primary healthcare centers with financial support from The Global Fund to Fight AIDS, Tuberculosis, and Malaria.

Can you share key learnings from hepatitis C initiative?

Dr. Tsereteli: When we started our program, the testing and treatment was only partly paid for by the government. There was some financial contribution required by the patient. But, especially given the target population, we realized that we would not achieve our screening and treatment goals with this model. So, in 2017, we decided to make everything free. That helped. Thus far, we have performed 6.6 million tests. In hindsight, it would have been better just to start the program with free testing and free treatment to eliminate any confusion and increase demand.

Another learning is that during COVID, many of our communications campaigns – our billboards and radio spots – shifted to COVID-related messaging. That gave people the mistaken belief that the hepatitis C program was over. So now we are starting the campaign again with the goal to achieve the end of hepatitis C in Georgia by 2025. It is an ambitious target. But we are hopeful.

This interview was edited for length and clarity. Coalition for Global Hepatitis Elimination, a program of the Task Force for Global Health, offers a variety of tools and resources for health leaders working to eliminate hepatitis C.