BACKGROUND

Globally, 9% of people who inject drugs (PWID), a key hepatitis C-infected population, reside in sub-Saharan Africa. In South Africa, hepatitis C seroprevalence in PWID is high. It is almost 84% in Pretoria and hepatitis C genotypes 1 and 3 predominate. Access to hepatitis C care for PWID is inadequate given low referral rates, socio-structural barriers, homelessness and limited access to harm reduction. Traditional care models do not address the needs of this population. We piloted a simplified complete point-of-service care model, a first of its kind in the country and sub-continental region.

METHODS

Community-based recruitment from Pretoria’s PWID population occurred over 11 months. Participants were screened with point-of-care rapid diagnostic tests for HBsAg (Alere Determine™), hepatitis C and HIV antibodies (OraQuick®). Qualitative HCV viremia was confirmed on site with Genedrive® (Sysmex), similarly at week 4, end of treatment and to confirm sustained virological response. Viremic hepatitis C participants were initiated on 12 weeks of daily sofosbuvir and daclatasvir. Harm reduction and adherence support, through directly observed therapy, peer support, a stipend and transport, was provided.

RESULTS

A total of 163 participants were screened for hepatitis C antibody, and 66% were positive with 80 (87%) viremic. An additional 36 confirmed hepatitis C viremic participants were referred. Of those eligible to initiate treatment, 87 (93%) were commenced on sofosbuvir and daclatasvir, with 98% (n = 85) male, 35% (n = 30) HIV co-infected, 1% (n = 1) HBV co-infected and 5% (n = 4) HIV/HBV/HCV triple infected. Some 67% (n = 58) accessed harm reduction packs, 57% (n = 50) opioid substitution therapy and 18% (n = 16) stopped injecting. A per protocol sustained virological response of 90% (n = 51) was achieved with 14% (n = 7) confirmed reinfections following a sustained virological response. HCV RNA qualitative testing performance was acceptable with all sustained virological responses validated against a laboratory assay. Mild adverse effects were reported in 6% (n = 5). Thirty-eight percent (n = 33) of participants were lost to follow-up.

CONCLUSION

In our setting, a simplified point-of-service hepatitis C care model for PWID yielded an acceptable sustained virological response rate. Retention in care and follow-up remains both challenging and central to success. We have demonstrated the utility of a model of care for our country and region to utilize this more community acceptable and simplified practice.

Large protracted outbreaks of hepatitis E virus (HEV) have been documented in displaced populations in Africa over the past decade though data are limited outside these exceptional settings. Serological studies can provide insights useful for improving surveillance and disease control. We conducted an age-stratified serological survey using samples previously collected for another research study from 206 residents of an internally displaced person camp in Juba, South Sudan. We tested serum for anti-HEV antibodies (IgM and IgG) and estimated the prevalence of recent and historical exposure to the virus. Using data on individuals' serostatus, camp arrival date, and state of origin, we used catalytic transmission models to estimate the relative risk of HEV infection in the camp compared with that in the participants' home states. The age-adjusted seroprevalence of anti-HEV IgG was 71% (95% confidence interval = 63-78), and 4% had evidence of recent exposure (IgM). We estimated HEV exposure rates to be more than 2-fold (hazard ratio = 2.3, 95% credible interval = 0.3-5.8) higher in the camp than in the participants' home states, although this difference was not statistically significant. HEV transmission may be higher than previously appreciated, even in the absence of reported cases. Improved surveillance in similar settings is needed to understand the burden of disease and minimize epidemic impact through early detection and response.

BACKGROUND

Hepatitis C virus (HCV) is a major cause of liver diseases globally. Transmission is primarily bloodborne through unsafe injections or healthcare practices. Effective treatment exists, yet access to diagnosis and treatment is limited. Few data indicated high HCV exposure among Rohingya refugees/FDMN residing in crowded camps in Cox’s Bazar District, Bangladesh, where Médecins Sans Frontières is pioneering HCV services. Representative information on the prevalence of active HCV infection and exposure risk factors was lacking.

METHODS

A cross-sectional survey was carried out in May-June 2023, including adults (≥18 years) by simple random geo-sampling (one participant per household, target sample 680), in seven camps (8W, 12, 13, 16, 17, 18, 19) in Cox’s Bazar District. Participants were screened with an HCV-antibody test (SD Bioline), and active infection assessed with Xpert® HCV Viral Load test (Cepheid) if seropositive. A structured questionnaire was administered to identify risk factors of exposure.

RESULTS

Of the 641 participants, median age was 34 years [IQR 28, 46], 66.3% were female. The estimated prevalence of HCV-seropositivity was 29.7% (95%CI: 26.0-22.8), and the prevalence of active infection was 19.6% (16.4-23.2). Multivariable regression revealed higher odds of HCV-seropositivity for female (adjusted odds ratio (aOR)=1.7 (1.0-2.6)), age groups ≥25 years old (aORs ranging from 2.3 to 2.9), reported medical injection(s) (aOR=1.7 (95% CI: 1.0-2.6)) or surgery (aOR=4.7 (95%CI: 1.3-16.7). Half of participants never heard about Hepatitis C, 4.0% of viremic participants reported previous HCV treatment.

CONCLUSION

The survey revealed a significant burden of active HCV infection among adult Rohingya camp residents, which, extrapolated may affect an estimated 86,000 individuals. Urgent action is required to expand diagnosis and treatment to prevent advanced liver disease and transmission. A collaborative task force with camp-based health stakeholders is now underway for a mass screening and treatment initiative, as well as a camp-wide HCV awareness campaign.