In this interview, we explore global and local efforts to combat viral hepatitis with Lindsey Hiebert, Deputy Director of the Coalition for Global Hepatitis Elimination (CGHE), and James Amugsi, a Mandela Washington Fellow and Physician Assistant at Sandema Hospital in Ghana. Together, they provide valuable insights into the challenges, successes, and the importance of partnerships in the fight against hepatitis.
Could you both briefly introduce yourselves and describe your roles?
Lindsey Hiebert: My name is Lindsey Hiebert. I am the Deputy Director of the Coalition for Global Hepatitis Elimination. I joined the Coalition shortly after it was launched in 2019. At the Coalition, I lead the development of the Coalition's overall strategy and manage projects such as our technical assistance, strategic information and data dashboard, and webinar series initiatives.
James Amugsi: I am James Amugsi, a Mandela Washington Fellow, a viral hepatitis advocate, and a Physician Assistant at the Sandema Hospital in the Upper East of Ghana. In the "STOP HEPP C" project, I prescribe antiviral medications to hepatitis C patients and also follow up on their response to treatment. I work in collaboration with a gastroenterologist from the University of Ghana Medical Center. Besides, I conduct hepatitis B and C awareness creation and screening services to community members, as well as linking people living with chronic hepatitis C to care in various treatment centers within Northern Ghana.
Can you give us an overview of the Coalition for Global Hepatitis Elimination and its main objectives, both globally and specifically in Ghana?
Lindsey Hiebert: The Coalition for Global Hepatitis Elimination (CGHE), a program of the Task Force for Global Health, is a nonprofit organization that brings together global partners to achieve the worldwide elimination of viral hepatitis.
The Coalition strengthens local capacity by building the necessary knowledge base, providing technical assistance, and mobilizing commitment to achieve elimination goals. The Coalition focuses primarily on hepatitis B and C in accordance with WHO 2030 elimination goals. The Coalition works to bring an end to hepatitis B by promoting vaccination, testing, and greater access to treatment. To combat hepatitis C globally, the Coalition promotes screening and linkage to curative care, particularly for vulnerable communities.
The three strategic areas of the Coalition's work are:
- Connecting and supporting programs: Connect programs in a Community of Practice to facilitate peer learning and support programs with evidence-based tools, technical assistance, and strategies that build local capacity to prevent, diagnose, and treat hepatitis.
- Building the evidence base: Update existing hepatitis elimination data and tools, spearhead data analyses and new research, and develop new technical assistance tools.
- Mobilizing commitment: Mobilize commitment for global hepatitis elimination among public and policy stakeholders in partnership with civil society, advocacy organizations, and other critical partners around the world to build awareness, instill urgency, and secure funding for elimination
Can you explain hepatitis, the different types, and why it is such a significant public health issue?
James Amugsi: Hepatitis refers to inflammation of the liver and has a variety of causes. Hepatitis can present as acute infection (less than six months) or chronic infection (more than six months), and there are different types, which are categorized broadly as viral hepatitis and nonviral hepatitis. The most common types of viral hepatitis are Hepatitis A, B, C, D, and E. Nonviral hepatitis includes Alcoholic hepatitis/liver disease, autoimmune hepatitis, and drug-induced hepatitis.
While viral hepatitis is caused by a virus – e.g., hepatitis A, B, C, D, and E viruses, nonviral hepatitis may be caused by excessive alcohol consumption, autoimmune disorders, intake of certain drugs, or exposure to chemicals or toxins, among other factors.
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Hepatitis A and E are similar in their mode of transmission and disease severity, while hepatitis B and C also share similarities and usually cause chronic infection. People infected with the hepatitis B and C viruses may not show symptoms initially or have non-specific symptoms, so the best way to know whether one is infected or not is to get tested.
Hepatitis A and E can spread through contaminated food and water, while hepatitis B and C are commonly spread through blood-to-blood contact, from infected mothers to their children during childbirth and unprotected sexual contact. It is important to note that casual contacts such as handshake, hugging, kissing, or sharing of food or drinks do not typically transmit hepatitis B or C. However, any activity that could result in the exchange of blood, such as the sharing of razors or toothbrushes, should be avoided to prevent the transmission of hepatitis B and C.
Complications of hepatitis include liver cirrhosis, liver failure, or cancer. The hepatitis B vaccine can prevent hepatitis B, but there is currently no vaccine for hepatitis C. One needs to adopt a healthy lifestyle to reduce the risk of infection with the hepatitis C virus. The good news is that hepatitis C is curable!
Hepatitis is a public health problem globally and, especially in Ghana, because new infections, as well as mortalities, keep increasing in contrast to WHO's viral hepatitis target of 2030.
Lindsey Hiebert: The Coalition focuses on the elimination of viral hepatitis B and C, which are blood-borne infections that cause liver disease. As of 2022, 304 million persons are living with chronic hepatitis B (HBV) or C (HCV) virus infection. Of the 254 million persons living with HBV, 86% are unaware of their infection, and 97% have not been treated. Of the 50 million persons living with HCV, 63% are unaware of their infection, and 80% have not been treated.
Currently, viral hepatitis is the second leading infectious cause of death, only after COVID-19.
The elimination of viral hepatitis as a public health threat by 2030 will prevent 7.1 million deaths.
Please see WHO's webpage: https://www.who.int/health-topics/hepatitis#tab=tab_1
What are some common misconceptions about Hepatitis among patients in northern Ghana, and how do you address them?
James Amugsi: Some people are still of the view that Hepatitis has a spiritual cause – the work of witches or other deities. Many people also believe that hepatitis B and C can be transmitted through eating together and contact with an infected person's sweat or saliva. Correcting the myths about viral hepatitis is a herculean task and calls for concerted efforts. On my part, I address these misconceptions through continuous health education for both health workers and non-health workers on the causes and transmission of viral hepatitis.
What inspired you to become involved in hepatitis advocacy in northern Ghana, and what are the key challenges you face in this role?
James Amugsi: As a Mandela Washington Fellow, I have learned to give back to society no matter how little it may be. Besides, as a health professional, I have seen many people die of Hepatitis, including close relatives. The greatest motivation for me is that hepatitis C is curable while hepatitis B is preventable, but many people don't know, so I have decided to be a carrier of hope for the hopeless in society. Combining my professional paid job as a Physician Assistant and hepatitis advocacy, as well as family commitments, has been very challenging. Although I prioritize the needs of others, I do so without neglecting my profession and family. I have, therefore, managed to maintain a balance for the benefit of my community and Northern Ghana at large.
Could you discuss the key partners involved in the Coalition's efforts to eliminate Hepatitis, particularly in Ghana? How do these partnerships enhance the program's impact?
Lindsey Hiebert: The Coalition works with more than 350 partners across more than 60 countries, representing all WHO regions. The Coalition works through building partnerships to strengthen national hepatitis programs.
The Coalition has a number of programs to empower local communities, policy-makers, and clinicians to advance progress toward elimination in their settings. In Ghana, the Coalition has collaborated to implement these programs to improve our understanding of the burden of disease, strengthen national planning, and expand awareness. Currently, only 0.4% of persons living with HBV and only 4.69% of persons living with HCV have been diagnosed in Ghana, based on 2022 estimates from the World Health Organization.
To support the development of a national testing policy, in 2020, the Coalition provided a grant to local researchers and community-based organizations to implement the Hepatitis Evaluations to Amplify Testing and Treatment (HEAT) project. The HEAT project involved assessments of the epidemiological burden of HBV and HCV and a laboratory testing capacity assessment. Under the guidance of the Principal Investigator, Dr. Yvonne Nartey, a team of field epidemiologists consulted public health laboratories, national health information management systems, and more than 134,676 records of HBV and HCV tests for these analyses.
Along the way, CGHE provided technical support and training to epidemiologists and trainees. The HEAT Project revealed stark differences in the prevalence of hepatitis across the country and major gaps in access to testing where the highest burden of disease was estimated. The HEAT Project was implemented in coordination with the Ghana Health Service, and the Ghana Hepatitis Foundation organized a dissemination meeting to brief stakeholders on the results and plan for the next steps.
With the information and momentum from the HEAT project, Egypt pledged to donate HCV medicines to treat 50,000 Ghanaians. The STOP-HEPC Ghana Project was launched in March of 2023 to raise hepatitis awareness and inform Ghanaians on how to get tested and treated for Hepatitis.
Dr. Nartey stayed on with the Coalition team as a Hepatitis Evaluation, Research, and Outreach (HERO) Fellow to support the development of STOP-HEPC, following the HEAT project. The STOP-HEPC program aims to implement a general population screening campaign, with a focus on the Northern Ghana base where the highest burden of disease is, as shown by the HEAT project; enroll patients in a nationwide registry; and link persons living with HCV to care in regional hospitals. STOP-HEPC also plans to strengthen data reporting systems and train reporting personnel.
In addition, in 2022, as part of an initiative funded by US CDC to improve coverage of hepatitis B birth dose in African countries, CGHE collaborated with the Ghana Hepatitis Alliance to develop information materials, implement educational training for midwives, and arrange meetings with Ministry of Health officials and other policymakers to advocate for birth dose introduction.
The Coalition has developed a National Hepatitis Elimination Profile for Ghana in collaboration with the partners mentioned above, available here: https://www.globalhep.org/tools-resources/view-national-hepatitis-elimination-profiles.
Join the Fight: A UN Group of Friends to Eliminate Hepatitis
What specific projects or initiatives have you been involved in within northern Ghana to combat Hepatitis? Could you share a success story or a notable experience from these efforts?
James Amugsi: I have been involved in the following projects:
- STOP HEP C project, where I served as the team lead for the Sandema Hospital case management team.
- Initiation of the 'no vaccination, no discharge' policy at the Sandema Hospital for babies born to hepatitis B-positive mothers. These babies are given at least the hepatitis B monovalent birth dose vaccine before discharge
- Awareness creation and screening tests for hepatitius C virus
- Viral hepatitis research (Community-based hepatitis C prevalence), which is about 8%
We have achieved about 80-90% hepatitis C Sustained Virological Response (SVR) rate at the Sandema Hospital case management center. Free hepatitis C viral load/RNA for about 100 community members done in partnership with Dr. Yvonne Nartey and Mpharma Ghana. Sandema Hospital is being used as a case study for the decentralization of viral hepatitis treatment in Ghana.
How does the Coalition monitor and assess progress in hepatitis elimination efforts in low- to low-middle income countries, and what are the primary metrics or indicators used?
Lindsey Hiebert: In 2021, the Coalition launched an initiative to develop National Hepatitis Elimination Profiles. These resources comprehensively assess the status of hepatitis B and C elimination across countries. The profiles bring together data on the burden of hepatitis, coverage of key interventions, and the development of essential policies. The profiles assess progress toward program targets and health outcomes and highlight achievements, challenges, and feasible next steps to advance hepatitis elimination.
Objectives of the profiles include:
1. Bring together key data to assess the status of hepatitis elimination efforts, with a special emphasis on the policy environment to build a sustainable elimination program:
- Hepatitis burden
- Implementation of hepatitis prevention, testing, and treatment services
- Policy development
- Health equity for key populations
2. Assess progress toward program targets and health outcome goals
3. Highlight achievements, challenges, and feasible next steps
Assessing progress across WHO's target interventions is essential, including coverage of prevention, testing, and treatment access. Globally, two of three new infections are in the African region, and a growing proportion of them are mother-to-child transmissions. The birth dose of the hepatitis B vaccine, given within 24 hours, is an important intervention to prevent transmission. Only about 15 African countries have policies for hepatitis B birth doses. The Coalition closely tracks hepatitis B birth dose policy development and coverage. The Coalition also has developed a toolkit to support countries in developing policies for the first time.
Across all countries, the first step to developing a national program is to establish national elimination goals and develop national strategies. The Coalition also tracks which countries have adopted these practices.
The full set of indicators the Coalition monitors via the National Hepatitis Elimination Profiles is available here: https://www.globalhep.org/approach-national-hepatitis-elimination-profiles
How do you engage and educate the local communities in northern Ghana about hepatitis prevention and treatment?
James Amugsi: For face-to-face interaction, I try to identify key stakeholders in the community, such as the chief or assembly member. When I secure permission to engage community members, word will be sent around through the community health volunteers or the 'Rooftop announcement' starting from the chief/subchief house. The venue, date, and time of the meeting are often communicated during these announcements. This mode of communication has proven to be very effective.
I also reach community members via local radio stations, where they can phone in and ask questions. Places of worship, such as churches and mosques, are also used to provide health education. Social media, such as Facebook and WhatsApp, is the most cost-effective method of creating viral hepatitis awareness. However, information sent through this medium usually targets the literate/youth.
What are the main obstacles you encounter in the fight against Hepatitis, and how do you address these challenges?
Lindsey Hiebert: Two of the greatest obstacles are political commitment and financing. The public health tools are available—vaccination for hepatitis B, reliable tests for hepatitis B and C, effective treatment for hepatitis B, and cures for hepatitis C. However, these existing tools are not available to most persons living with Hepatitis.
All governments must commit to hepatitis elimination. To encourage diplomatic commitments to hepatitis elimination, the Coalition is the Secretariat for the UN Group of Friends to Eliminate Hepatitis. The UN Group of Friends creates a forum for Member States to exchange information on progress, innovations, and lessons learned with other Member States, organizations within the UN system, technical experts, civil society organizations, and other stakeholders. By raising awareness at the diplomatic level, the UN Group of Friends brings high-level attention to donor agencies, development banks, philanthropic organizations, and national governments, helping low- middle-income countries (LMICs) eliminate Hepatitis.
The moral and economic case for hepatitis elimination is clear; hepatitis elimination saves lives, prevents morbidity, and is cost-effective while saving health systems money in the long run. The Coalition recently published policy briefs to summarize the evidence on the economic and health benefits of why countries should invest in hepatitis elimination now. These briefs are available here: https://www.globalhep.org/projects-research/new-policy-briefs-consequences-inaction.
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James Amugsi: Some of the obstacles include misinformation about viral hepatitis from herbal medicine practitioners and some health workers who lack adequate knowledge on the disease, stigma, inadequate funds for screening and awareness creation campaigns, high cost of hepatitis B and C viral load, inadequate government support, lack of strong motor bikes or a car to convey volunteers and logistics, etc. I address some of these through continuous health education, engaging multiple donors, including individuals and local and international organizations, partnerships with other local CSOs, continuous lobbying, etc.
Can you share a story of a patient whose life was significantly impacted by the Coalition's efforts or your advocacy work?
James Amugsi: Patient Alie (not real name) – A 25-year-old lady from Builsa North Municipal: "Before the STOP HEP C project, I asked for hepatitis C treatment and was told it was GHS 7,500.00. So I left my life to fate because I could not afford that amount, but through the project, I was given a three-month dose of hepatitis C drugs for free. I used to get tired easily, but after treatment, I am now doing well. I have also been cured of hepatitis C! I am very grateful to the STOP HEP C project team."
This year's theme for World Hepatitis Day is "Take action, Test, Treat, Vaccinate." How does this theme resonate with the Coalition's mission, and what specific actions are being taken in Ghana to align with this call to action?
Lindsey Hiebert: Hepatitis elimination requires a global commitment to ensuring everyone has access to hepatitis B and C prevention, testing, and treatment. The Coalition is committed to building partnerships to ensure all people, everywhere, can benefit from hepatitis B and C elimination. In Ghana, the Coalition will continue to support STOP-HEPC and efforts to expand access to hepatitis B testing and treatment. To date, there is limited access to hepatitis B testing and treatment in Ghana, and available tests and treatment can be prohibitively expensive. Lessons learned from the hepatitis C program must soon be adapted to expand access to hepatitis B care, as well.
James Amugsi: The "STOP HEP C" Ghana project, launched in 2023 by the Ghana Health Service (GHS) and its partners, sought to screen 50% of the eligible population, link 90% of identified hepatitis C patients to care, and initiate 95% of patients' treatment.
So far, about 300 hepatitis C patients have received treatment nationwide. Also, through a partnership with Hepatitis Alliance Ghana, SynLab, and MDS Lancert, there is a subsidy for hepatitis C viral load testing to enable patients to benefit from the free treatment. The challenge, however, is that there is still low hepatitis C testing and publicity. Many people from Northern Ghana cannot also afford the hepatitis C RNA/viral load test, which is about GHS 800.00
On my part, about 5,000 community members have been screened for hepatitis C for free, and 400 are being linked for further evaluation and care.
To me, a call for action in viral hepatitis elimination in Ghana will mean more publicity on viral hepatitis, more testing, affordable hepatitis B and C DNA/RNA tests, and the implementation of the hepatitis B birth dose vaccine now!
Where can readers find more information?
About Lindsey Hiebert
Lindsey Hiebert serves as the Deputy Director of the Coalition for Global Hepatitis Elimination.
The Coalition is based at the Task Force for Global Health, an international NGO in Atlanta, United States. At the Coalition, Lindsey manages initiatives related to technical assistance, operational research, advocacy, and policy to advance hepatitis B and C elimination globally, including the development of National Hepatitis Elimination Profiles for more than 30 countries. Before joining the Coalition, she was a Program Officer at Pharos Global Health. At Pharos, she managed collaborative projects in South Africa, Indonesia, Senegal, Malaysia, and Morocco on viral hepatitis program strategic planning, investment case development, and epidemiological, program, and economic modeling. Lindsey has also worked as a research project coordinator and data analyst at Yale University and BRAC in Dhaka, Bangladesh. She received a MPH in Epidemiology and Global Health and BS in Global Affairs from Yale University.
About James Amugsi
James Amugsi is a Physician Assistant (Medical) at the Sandema hospital in the Upper East Region of Ghana and is the clinical lead for the hepatitis C case management team at the hospital.
James is actively involved in viral hepatitis advocacy and research in Northern Ghana. Driven by servant leadership, James has been giving back to his community after his Mandela Washington Fellowship experience in 2018 at Howard University, USA.
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