The prevalence rate of Hepatitis C Virus (HCV) infection and HIV/AIDS in Manipur, mostly due to injecting drug use, is considered high. The majority of the population, be it the general population or the vulnerable group, however, are still unaware about the National Viral Hepatitis Control Programme (NVHCP) of the National Health Mission under which a patient can avail expensive antiviral treatment and medicines free of cost.
There is also the lack of awareness of the need for prevention and treatment of HCV, misconception about the illness and government facility. Misconception has also given way to stigmatization and discrimination of HCV patients in the state.
It may be recalled that NVHCP of the Union Health and Family Welfare Ministry was launched in collaboration with the World Health Organisation (WHO) on July 28 – the World Hepatitis Day – 2018, to control Hepatitis C in India. It aims at both prevention and treatment of hepatitis free of cost in all government hospitals in India to reduce mortality and morbidity associated with it.
A year later, in July 2019, the programme was launched in Manipur in view of the high prevalence of HCV and HIV/AIDS in the state.
With the launch of the programme, two model treatment centres with diagnostic facility were set up, one each at the Jawaharlal Nehru Institute of Medical Sciences (JNIMS) and the Regional Institute of Medical Sciences (RIMS) in Imphal where HCV patients in the state can avail free antiviral treatment and medicines.
Now, it’s been one year of the implementation of NVHCP in Manipur. What change has the National Health Mission programme brought to the state? Will the state be able to achieve the national target of eradication of HCV by the year 2030?
A survey by the Imphal Free Press in the capital area found that the programme has had little impact on HCV prevalence in the state till today, largely owing to lack of awareness creation and misconception about the illness and government facility launched - NVHCP.
The estimated data of HCV infection in the state is yet to be prepared by the authority concerned. Manipur, however, is placed ninth among the highest prevalence rate of IDU in the country based on the national survey on Extent and Pattern of substance Abuse in India conducted by the Social Justice and Empowerment Ministry in 2019. And, according to a survey conducted by the Community Network for Empowerment (CoNE) Manipur in association with the Regional Institute of Medical Sciences (RIMS) in 2018, it is estimated that 43 per cent of total Injecting Drug Users (IDU) i.e. over 14,767 IDU must be infected with HCV.
While the number of IDU in the state is very high, the number of HCV patients treated or cured under the NVHCP in Manipur is very low compared to the rate of HCV burden in the state.
According to the data made available to the Imphal Free Press by the state health department, NVHCP, National Health Mission, the number of patients initiated for treatment in nearly one-and-half years, from July 2019 to October 2020 is only 614. Out of it, 460 HCV patients completed their treatment successfully.
If the state continues to implement the programme in this speed and manner, the National Health Mission target of NVHCP to eradicate viral hepatitis in India by 2030 would only remain a mere dream.
Today, the health sector all over the world has been most affected with the onset of the COVID-19 pandemic. COVID-19 pandemic spread to Manipur in March with the return of people who were making a living or pursuing studies outside the state in various parts of the country. The viral scourge has been spreading fast and wide in the state, affecting normal life all across the state.
The present COVID-19 situation could be attributed as one of the major causes for the less number of HCV treatment in the state as people are advised against moving out and to stay indoors.
However, lack of creation of awareness about HCV, the need to prevent and treat the illness and the available government facility for the patients may be largely responsible for the dismal treatment report.
Lack of awareness about HCV and NVHCP
According to a survey conducted by the Imphal Free Press on the impact of the launch of one-year-old NVHCP in the state, it is learned that many people, including both general as well as vulnerable groups (like PLHIV or IDU) are not aware of NVHCP, a programme of the National Health Mission. They are not aware that this programme can give new life to many helpless HCV infected people who cannot afford the treatment cost of HCV.
The cost of HCV treatment in the state at private health centres differs and it differs from doctor to doctor. According to the patients, they are charged Rs 10,000 to 15,000 a month, which cumulative treatment duration of three months would amount to around Rs 30,000. In critical cases, the treatment would last for six months. This is a reduced rate after the entry of generic drug to treat the illness. However, the treatment charge is exorbitant to poor patients. Most poor patients in the state cannot afford it. So, the NVHCP was launched in the state to meet the 2030 target.
Failure of private doctors to inform the patients about free treatment and medicines
However, the survey by Imphal Free Press found that some health professionals do not inform their HCV-infected patients about NVHCP when they come for treatment in their private clinic. Whether the doctors are aware or unaware about the programme is unclear.
One of the common responses that the Imphal Free Press received from the general population during the survey is that they are aware of the high prevalence of the infection but never thought of learning or knowing what exactly is the virus and what steps the government has taken to address this health problem.
In an interaction with one of the HCV cured patients, Thoiba (name changed), who is in his 20s and a driver by profession, said that NVHCP is a “useful programme”. He said, “Everyone should avail this facility without any hesitation. If they suspect themselves of being infected by the viral hepatitis, they can get the diagnosis and the treatment free of cost”.
Thoiba was treated at the Model Treatment Centre, JNIMS. He was not aware of HCV infection. While being treated for pile treatment, the doctor (whom he consulted) advised him to go in for HCV testing. Thoiba took the advice and was tested positive for HCV in September 2019.
“I never expected that I would be infected with this virus. The moment I came to learn of the result, I remembered that I had shared the injection needles with others to fix my heroin dose and realized that it could be the reason for the positive result. It was my first trial and didn’t continue for long,” he said as he recalled the depression he suffered when he learned of the infection.
The depression grew when he learned that besides him, his wife was also infected by the virus. The couple, who lived below the poverty line became helpless as they were unable to afford the HCV treatment.
“Our doctor told us the treatment would cost Rs 60,000 for both, my wife and me. While searching for some means for the treatment from pillar to post, someone informed us about NVHCP” he said.
In December, they began free treatment under the NVHCP and finally their result came with virus undetected in March, Thoiba said, alleging that his doctor, perhaps, was not aware about the programme or didn’t share the information with the motive to earn money.
Following the NVHCP guidance and treatment helped him to come clean and get cured, he added.
Another patient, a 64-year-old man in Imphal, who got treated under NVHCP from the Model Treatment Centre, Regional Institute of Medical Sciences (RIMS), Ibohal (name changed) from Yumnam Leikai said that his treatment started in January. The completion of three-month-long treatment made him realize that HCV can be easily cured if treated in time.
Sharing his experience with the Imphal Free Press, he said that the treatment service being given is satisfied. People should not compare and doubt that this free treatment might not be effective. It is better than the treatment provided by private doctors.
As there exist apparent lack of awareness among the people about the government programme, Ibohal suggested that the authority concerned should create extensive awareness about the HCV and NVHCP to the public, otherwise the state would not be able to eradicate HCV by the target year 2030.
“I didn’t know about this programme. I was almost about to begin my treatment from a private doctor. But fortunately one of my friends working in an NGO informed me about NVHCP,” he said
Misconception and stigmatization
The HCV-cured patient also said that people have the misconception of HCV transmission through sweat and touching. This misconception about the virus has created stigmatization and discrimination of patients with HCV. This stops people from declaring their HCV status voluntarily. They also fear to access free treatment.
Another HCV-cured patient from Yaishkul in Imphal West, 55-year-old Arun (name changed), said that being a PLHIV patient, he was concerned about HCV infection. As such he always conducted testing from time to time. He started the treatment immediately from Model Treatment Centre JNIMS after knowing the result.
Arun said that though the NVHCP is launched in the state following the report of high incidence of viral hepatitis and to check the spread, the state is witnessing increasing drug menace. IDU are most prone to the iIlness owing to the sharing of injection needles. The problem of HCV will increase in due course of time as many are not aware of the treatment facility in the state, he said.
Government must make more efforts to create awareness
The state government must make extra efforts to create awareness and check the prevalence of HCV in the state, otherwise, Manipur will not achieve the target set to eradicate the illness by 2030, Arun added.
Owing to the high prevalence of viral hepatitis in the state, many IDU and PLHIV have lost their lives, as they could not afford the cost of anti-viral treatment in private health centres.
Before the NVHCP was rolled out in the state, some NGOs such as CoNE and YRG Care working for substance abuse or drugs was providing treatment at subsidiary rate and sometimes free of cost. But due to limited resources, the NGOs could not cater to a large number of population.
Speaking exclusively to the Imphal Free Press, CoNE president RK Nalinikanta said that the organization is happy that through the NVHCP, at least some people got cured from HCV. But considering the PLHIV rate in the state, the turn up level of HCV treatment is very low. The government should increase awareness level and scale up mass testing to reach out to the maximum population, which is the major component of the NVHCP.
Nalinikanta also said that though HCV is vulnerable to IDU and PLHIV. And to prevent it, some NGOs working for substance drug abuse are persistently working to create awareness about viral hepatitis, which is the leading cause of liver cancer or liver cirrhosis. But awareness level among the public is still low even among the infected and vulnerable groups.
HCV can also infect the general population through blood transfusion, contact with blood from infected person, unprotected sex, especially when blood is present. According to the data of the Manipur Blood Bank, 1.5 per cent of blood is donated from HCV-infected persons. This clearly explains why HCV risk and prevalence rate among the general population is also high, he added.
Nalinikanta further said, “CoNE is playing a major role in advocating HCV infected persons and linking with Model Treatment Centre of RIMS and JNIMS. From July 2019 till September 2020, CoNE had linked up 271 people for antibody tests in the two centres at JNIMS and RIMS and 135 patients had started their treatment.
“It is a known fact that awareness level among the public about viral hepatitis which is termed as silent killer is quite low. The only way to get rid of this health issue within the targeted time period is to enhance awareness and conduct mass screening, he added, appealing to authority concerned to take serious note of conducting mass awareness about viral hepatitis and NVHCP like the way the government is going full steam about the ongoing COVID-19 pandemic.
In view of the high prevalence of the viral infection and considering it as one of the universal public health issue, the United Nations stepped up to fight HCV under its Sustainable Development Goals (SDGs).
The UN plan was adopted by all countries in 2015. Then in 2016, the WHO adopted the Global Health Sector Strategy (GHSS) on viral hepatitis. The GHSS’s target is to eradicate hepatitis as a public health threat by 2030.
The 2015 WHO report estimated around 325 million people as living with viral Hepatitis B and C. Of it, 290 million people i.e. 89 per cent of them are unaware that they are infected by these viruses irrespective of gender, age, ethnicity or geography, it stated. Such lack of awareness has resulted in the risk of transmitting the virus unknowingly, it added.
In 2018, to identify the unaware infected patient, the World Hepatitis Alliance started an awareness campaign “Find the missing million”, as early detection is the key to crush this silent disease. Till date, 1.34 million has died of viral hepatitis globally which is a figure comparable to deaths due to tuberculosis worldwide. In India, WHA stated that about four crore of its population suffer from Hepatitis B and 0.6-1.2 crore people are suffering from Hepatitis C.
In line with the country’s global commitment towards SDG 3.3, the Government of India launched the NVHCP. The government had approved Rs 600 crore with the target to treat a minimum of three lakh Hepatitis C cases in three years’ time.