Our experience demonstrates that mobile hepatitis clinics are a feasible treatment strategy to promote same-day treatment initiation for hepatitis C patients in resource-constrained settings. Through our mobile clinics, we were able to initiate 64.9% of all patients awaiting treatment on DAAs during an eleven- week period. The number of patients initiated on treatment through the mobile clinic program exceeded the total number of patients who were initiated on treatment under the standard of care during the previous 25 months. While some of this difference may reflect expanded testing capacity in Rwanda as new initiatives have been introduced, for example the adoption of rapid diagnostic tests and same-day venous blood collection for viral load testing during the mass screening campaigns, our results demonstrate that mobile clinics can be used to ensure prompt linkage to care where services are not decentralized. This strategy is especially useful following mass screening campaigns, when large numbers of patients are awaiting treatment initiation. To our knowledge, this is the first mobile clinic hepatitis c treatment program model implemented in Rwanda and sub-Saharan Africa. Our program may serve as a model elsewhere in Rwanda and to other countries seeking to scale up access to hepatitis C treatment.
When including the cost of the DAAs in our program, we found that the costs of implementing the mobile clinic system reflected only 32.8% of the total cost per patient initiated. In Rwanda, where the national government is committed to providing DAAs free-of-charge to all patients with hepatitis C, this relatively small increase in per-patient costs may be an important investment to ensure adequate linkage to care and equitable access to treatment for all citizens. Although we did not conduct a formal cost-effectiveness analysis, the per-patient cost of this program compares favorably with an antenatal care program in Rwanda where the first visit costs $21 per woman (23). The cost of our program also compares favorably to the cost of HIV care and treatment visits and antiretroviral therapy, which is estimated to cost an average of $208 per patient per year in Rwanda, Ethiopia, Malawi and Zambia (24).
Mobile clinics have successfully increased access to care in rural settings for other programs, including prenatal care, HIV, and other sexually transmitted infections (25). Mobile clinics can be used to both reduce patient costs and improve health outcomes in underserved and vulnerable populations (26). Since 83% of Rwandans live in rural areas (27) many of them have to walk long distances or arrange costly transport to access health services at district hospitals. We estimated that our mobile clinic program was able to cut transport time in half and reduce patients’ out-of-pocket expenses by $9.87. This is a meaningful cost reduction in a country where 43.1% of the rural population live under poverty and 18.1% in an extreme poverty (22). Over one third of the reduction in out-of-pocket costs is attributable to our provision of free liver and renal function tests through the mobile clinic program. To strengthen support for vulnerable patients and to promote the goals of the national hepatitis C elimination campaign, the government of Rwanda may consider including liver and renal function tests as a covered service in CBHI/Mutuelle package at health center for patients with viral hepatitis.
During the implementation of the mobile clinic, not all expected patients could be reached to schedule their appointment. Although we worked with community healthcare workers to seek patients in their home villages, some patients were impossible to contact, possibly because information was entered incorrectly during the mass screening campaigns. As evidenced by our analysis, having complete data on telephone number and address were strongly associated with being able to be linked to care during the mobile clinic campaign. To improve the effectiveness of these mass-screening campaigns, we recommend the adoption of high-quality training for data collectors, investment in an electronic data capturing system, and real-time monitoring and feedback to ensure that data collectors are collecting information as accurately as possible. Importantly, we did not observe differences in mobile clinic coverage by age, gender, or socioeconomic status, suggesting coverage of the mobile clinic program was relatively equitable across demographic groups.
We identified several additional lessons learned while implementing the mobile clinic campaign. First, we were unable to provide ultrasound exams for hepatitis patients who presented with suspected liver decompensation. Although there were very few cases with suspected liver decompensation, the availability of a mobile ultrasound machine could have improved our ability to provide same-day initiation for these patients. Second, clearly communicating with the patients the starting hour for the mobile clinic was critical for enabling collective pre-treatment counselling, processing biochemistry and hematology tests in one batch, and ensuring that teams had enough time to initiate all patient by the end of the day. Finally, our mobile clinics were implemented following a mass screening campaign that identified a large number of patients who required treatment initiation in a short period of time. However, the cost-effectiveness of this strategy depends on having a relatively large number of patients awaiting treatment per health center, as would typically be the case after a mass screening campaign. Ultimately ensuring long-term, sustainable, decentralized access to hepatitis treatment requires task shifting, where health center-level nurses are trained to manage hepatitis on a daily basis. Decentralization of care has been demonstrated model to be feasible by the HIV task-shifting model, where nurses who have been well trained, mentored, and given support can effectively manage HIV treatment (28, 29). During our campaign, we did provide infectious disease nurses working at health centers with training on hepatitis management, and, in collaboration with the Ministry of Health, we have also been supporting theoretical and practical training sessions to allow these nurses to become certified in hepatitis management.
Our analysis has some limitations. We used clinical records to assess the number of patients initiated to treatment before and during the period of mobile clinic geographic and budgetary data to assess costs associated with the program. These data sources were not intended for research purposes and may suffer from missing or incomplete data. Furthermore, because medical records did not include explicit information about mobile clinic participation, we had to rely on dates of screening, viral load testing, and treatment initiation to assess mobility clinic eligibility and participation. However, because we were the only health care provider offering hepatitis treatment in our catchment area and because our results are very similar to daily records kept by mobile clinic staff during the campaign, we believe any misclassification is minimal. As part of our campaign, we also initiated some patients who had screened positive for HBV; however, we did not include these patients in this analysis. Including these patients in our costing analysis would have reduced the per-patient costs of the overall campaign. Finally, we did not compare the quality of care provided during mobile clinics to what was provided prior to the initiation of the mobile clinic program. Despite these limitations, we believe this analysis demonstrates the feasibility of a mobile clinic-based model for hepatitis C treatment initiation, and hope that it can be used to inform future interventions in similar contexts.