BACKGROUND:In Ethiopia, chronic hepatitis B virus (HBV) prevalence is high (∼6%) and infant vaccination targets are unmet. We assessed HBV vaccination uptake and associations with parental sociodemographic and obstetric factors among children (aged 12-36 months) in Ethiopia. METHODS:We utilised the 2016 Ethiopian Demographic and Health Survey. We included a weighted sample of 3,855 children (aged 12-36 month) to assess HBV vaccination coverage level (none, incomplete, and complete) and its spatial distribution. Additionally, we identified associated factors of HBV vaccination coverage level using ordinal logistic regression. RESULTS:Overall, 51.2% of children received complete HBV vaccination, with wide regional variation. Older maternal age (adjusted odds ratio (AOR)=1.05, 95% confidence interval (CI): 1.02-1.07), better maternal education level (mean AOR=1.66-2.08), higher household wealth quantile (mean AOR=1.51-2.32), distance to a healthcare facility not a big problem (AOR=1.54, 95% CI: 1.25-1.89), and complete maternal continuum care utilisation (AOR=2.59, 95% CI: 1.25-5.30) were positively associated with HBV vaccination coverage, while higher number of children in the household (AOR=0.86, 95% CI: 0.79-0.92) was negatively associated. CONCLUSIONS:HBV vaccination coverage falls below World Health Organization (WHO) targets in Ethiopia and has substantial regional variation. Targeted vaccination campaigns for mothers in lower socioeconomic groups and larger families may improve vaccination coverage.

Hepatitis C virus (HCV) endemic regions require accessible treatment interventions. Effectiveness and costs of a pilot HCV treatment programme were evaluated at an embedded primary care service within a tertiary care centre at Indus Hospital and Health Network in Karachi, Pakistan. Data on patients (n = 1288, median age 40 years) initiating direct-acting antiviral (DAA) treatment (October 2016 to December 2018) were extracted from hospital records. Eligible patients had chronic HCV, were treatment naïve, and without hepatic decompensation. Multivariable logistic regression analysed factors associated with treatment outcomes (not completing treatment, treatment completion without sustained virological response test at 12 weeks (SVR12) visit, and treatment completion with SVR12). Costs (2019 USD) were estimated using micro-costing from financial records and staff interviews. Among 1288 patients (63% women), 93% (1200/1288) completed treatment, and 74% (884/1200) attended SVR12 visit, with 98% (n = 870/884) cured. Compared with 0-29 year-olds, incomplete treatment was lower among 30-49 year-olds (aOR 0.47 [0.26-0.83]) and ≥ 50 year-olds (aOR 0.48 [0.24-0.93]). SVR12 non-attendance was higher for 24-week versus 12-week regimens (aOR: 3.46 [1.51-7.93]), but lower for patients with APRI scores 0.5-1.49 (aOR 0.69 [0.50-0.96]) and ≥ 1.5 (aOR 0.44 [0.24-0.78]) compared to 0-0.49. The mean treatment cost was $370.74 per patient, driven by clinic visits $271.80 (73.3%), labs $68.32 (18.4%), and DAAs $30.62 (8.3%). Overall, a high treatment completion and cure rate were achieved, with a low average cost per patient, indicating that this HCV treatment model can be affordable and may be considered for widescale treatment scale-up in Pakistan.

Hepatitis C virus (HCV), an often overlooked public health concern, is highly prevalent among marginalized groups. Refugees, asylum seekers, and internally displaced people (RASIDP) constitute an underserved population in healthcare. Given that displacement rates are increasing and that HCV is endemic to many African countries, we aimed to determine the prevalence of HCV among RASIDP communities in Africa. Studies investigating HCV prevalence within RASIDP communities across Africa were identified via the following database searches: Ovid MEDLINE, EMBASE, Web of Science, APA PsycINFO, and the WHO Africa Index Medicus. Seroprevalence estimates were meta-analysed using a random-effects model, with data stratified by participant region, age, and gender. Across 9 studies, we estimated a pooled HCV seroprevalence of 3.63% (95% CI: 0.54, 9.16) among RASIDP in Africa. Seroprevalence varied by region of origin and age, with those from Northern Africa and those aged > 40 years having the highest seroprevalence, at 10.03% (95% CI:9.03, 11.13) and 5.70% (95% CI: 0.81, 14.21), respectively. RASIDP communities represent a marginalised and vulnerable population that often faces significant barriers to accessing healthcare. Our findings show that HCV seroprevalence within these communities varies by region and age, thus suggesting a need for targeted screening approaches.

[This corrects the article DOI: 10.1371/journal.pgph.0004706.].

BACKGROUND:In England, up to 5% of people living with HIV are undiagnosed and the proportion of late diagnoses remains high. Opt-out testing could help to identify people living with undiagnosed HIV who might not access testing in other settings. We aimed to evaluate the cost-effectiveness of the first phase of UK National Health Service (NHS)-funded opt-out testing for HIV in emergency departments, which scaled up from 2022. METHODS:We adapted a previously developed deterministic model of HIV diagnosis, progression, and transmission to simulate the impact of the first 33 months of the opt-out testing intervention in improving HIV diagnosis, incorporating programme data on CD4 cell count at diagnosis. We conducted a bottom-up costing of the intervention in two sites, from an NHS perspective, and gathered costs of HIV care from the literature. In the base case we assumed 93% of new diagnoses would not have been diagnosed elsewhere during the programme as these individuals had never previously been tested for HIV. Cost-effectiveness is presented as incremental costs per quality-adjusted life-year (QALY) gained over 20 years compared with a £25 000-35 000 per QALY threshold. We explored scenario analyses to address the limitations of the model assumptions. FINDINGS:The mean cost per HIV test was £6·31 (US$7·91). Under base case assumptions, emergency department opt-out testing is projected to avert 187 HIV-related deaths (95% credible interval 182-196) and 28 secondary acquisitions (26-52) over 20 years, costing £18 630 (17 413-23 119) per QALY gained. This result is robust (below £35 000 per QALY) to different assumptions about HIV-related quality of life and HIV care costs, HIV-related mortality, and the rate of diagnosis outside the programme. Under a lower test yield scenario of 0·20 new diagnoses per 1000 tests (compared with 0·29 in the base case), the intervention remains cost-effective at £25 000 per QALY. INTERPRETATION:Emergency department opt-out testing for HIV in England was cost-effective due to averted HIV-related morbidity and mortality resulting from improving diagnosis and linkage to care for people who would otherwise not be tested, many of whom have already reached an advanced stage of HIV progression. Our findings provide evidence to support continuation of the opt-out testing programme as part of the HIV Action Plan for England. FUNDING:National Institute for Health and Care Research and NHS England.

Approximately 8.8 million people are living with chronic hepatitis C virus (HCV) in Pakistan. We assessed factors related to health-related quality of life (HRQoL) among the general population screened for HCV and calculated the national burden in quality-adjusted life years (QALYs). A cross-sectional study was conducted in community and clinic-based settings in Karachi and Gujranwala. HRQoL was assessed before diagnosis using EQ-5D-3L (Pakistan value set). Propensity score matching (PSM) was used to address socio-economic differences between HCV RNA-positive (viraemic) and HCV-antibody-negative participants. We assessed socio-demographic and HCV-related predictors of HRQoL (Tobit regression) and problems by EQ-5D domain (logistic regression). The HCV transmission model was used to estimate the burden of HCV in terms of morbidity- and mortality-related QALY loss in 2024. After PSM, 778 individuals remained in each group from a total of 5468 participants. HCV-positive participants had lower HRQoL (EQ-5D-3L score, p < 0.001) and higher odds of problems in all five EQ-5D dimensions. Lower HRQoL was associated with older age and unemployment, while married or Urdu-speaking participants had higher HRQoL. There was little evidence that cirrhosis was associated with HRQoL (p = 0.140) among HCV-positive participants. The total estimated QALY loss due to HCV in Pakistan in 2024 was 804,580 QALYs, of which 55% was due to mortality. HCV infection is associated with reduced HRQoL and substantial QALY losses in Pakistan. Our findings emphasise the role of socio-demographic variables on HRQoL. Further research in Pakistan is needed to determine if HCV treatment can mitigate these effects.

Background Women who inject drugs (WWID) face heightened HCV and HIV risk compared to men (MWID); yet underlying differences in social and injection networks are not well understood, particularly in resource-limited countries. Methods We enrolled 3152 people who inject drugs (PWID) in Kenya using respondent driven sampling. Participants were tested for HIV, HCV, and HBV, and completed a survey with behavioral and network questions. An individual’s social network members (NMs) were defined as participants they had used any drugs with and knew by name. Bivariate analyses were conducted for associations between gender, network characteristics, and injection behaviors. Multivariate logistic regressions were conducted for both men and women to examine the associations between network characteristics and disease status. Results About one-tenth of participants were women (9.7%, N= 306), 19.3% were HCV antibody-positive (N = 610), and 9.7% were HIV-positive (N = 306). Women were significantly more likely to be HCV antibody-positive (26.5% vs. 18.6%, p < 0.001) and HIV-positive (31.1% vs. 7.4%, p < 0.001) than men. Women were significantly more likely to have injected and had sex with people in their networks than men were (3.9% vs. 1.0%, p < 0.001). Knowledge (or lack thereof) of NM’s HIV and HCV status had significant associations with HIV and HCV positivity for both women and men. Conclusion Women face differential HCV- and HIV-related risk in part based upon their relationships to and behaviors with their network members. Further research examining nuances of injection and sexual relationships among women and men who inject drugs is needed. Interventions accounting for gender-based risks should also be considered.

BACKGROUND:In Haiphong, Vietnam, most hepatitis C virus (HCV) infections occur among people who inject drugs (PWID). As part of multiple respondent-driven sampling (RDS) surveys among PWID in Haiphong, an intervention (DRIVE-C) provided HCV testing and treatment in 2019. Centres providing opiate agonist treatment (OAT) or antiretroviral therapy (ART) also provided HCV testing and linkage-to-treatment in 2021/22. We modelled the impact and cost-effectiveness of HCV testing and treatment for PWID in Haiphong. METHODS:An HCV transmission model among PWID and former injectors was calibrated in a Bayesian framework using data from Haiphong. A status quo (SQ) scenario modelled past interventions, with no future HCV treatment. A future intervention scenario modelled the impact of providing HCV testing and linkage-to-treatment in OAT and ART centres, and annual RDS survey interventions over 2025-2030, each testing 1400 PWID. We estimated the incremental cost-effectiveness ratio (ICER) per disability adjusted life-year (DALY) averted for the future scenario compared to SQ over 2025-2054 (3 % annual discount rate). RESULTS:For the SQ scenario, HCV incidence decreased from 8.1 (95 % credibility interval 5.1-13.6) per 100 person-years (/100pyrs) in 2015 to 5.3/100pyrs (3.0-9.6) in 2023 and increases to 6.2/100pyrs (3.5-10.7) in 2030. In the future intervention scenario, incidence decreases to 2.7/100pyrs (1.0-6.4) by 2030. The mean ICER is €884/DALY averted; cost-effective at a willingness-to-pay threshold of €2334 (57 % of Vietnam's 2023 GDP per capita). CONCLUSIONS:Using RDS surveys and other care settings to scale-up HCV-testing and treatment are cost-effective strategies to reduce HCV incidence among PWID in Vietnam.

Understanding risk factors for hepatitis C virus (HCV) is critical for targeting screening and prevention. We systematically reviewed risk factors associated with HCV seroprevalence among the general population in sub-Saharan Africa (SSA). Comprehensive systematic review of HCV seroprevalence of community-based observational studies reporting HCV risk factors in SSA. Study quality was assessed using Joanna Briggs Institute tool. Random effect meta-analyses were used to estimate odds ratios (OR) with 95% confidence intervals (CI). We identified 92 studies. Higher odds of HCV seroprevalence were observed among age 21-64 (OR = 1.77, 95% CI 1.17-2.68) and 65+ groups (OR = 11.75, 95% CI 5.51-25.05) compared to those aged ≤ 20 years; not being formally educated (OR = 1.78, 95% CI 1.35-2.35) compared to secondary/above and being married (OR = 1.91, 95% CI 1.45-2.51) or divorced (OR = 3.20, 95% CI 1.91-5.36) compared to never married. Family history of HCV (OR = 1.52, 95% CI 1.17-1.96), being a person living with HIV (OR = 2.64, 95% CI 1.61-4.33) or being HBsAg positive (OR = 1.66, 95% CI 1.10-2.50) were all positively associated with increased HCV seroprevalence, as was having a history of blood transfusion (OR = 1.81, 95% CI 1.33-2.45), hospitalisation (OR = 1.55, 95% CI 1.22-1.96), medical operation (OR = 1.28, 95% CI 1.01-1.62), scarification (OR = 1.29, 95% CI 1.01-1.64) and injection drug use (OR = 7.04, 95% CI 1.16-42.68). Pilot HCV screening programmes targeting older adults and people exposed to healthcare-associated factors could potentially lead to the efficient detection of HCV cases and reduce future HCV exposures among the general population in SSA countries.

OBJECTIVES:To explore patient, carer and clinician experiences of the QbTest and its impact on patient outcomes for attention deficit hyperactivity disorder (ADHD) diagnosis and medication management. DESIGN:Mixed-methods systematic review. DATA SOURCES:MEDLINE, EMBASE, PsycINFO, CINAHL, ClinicalTrials.gov and WHO ICTRP (from inception to September 2024). STUDY SELECTION:Primary studies, of any design, that evaluated any version of the QbTest (QbMini <5 years, QbTest 6-12 or 12-60 years, QbCheck for remote assessment via webcam or QbMT smartphone version), for ADHD diagnosis and/or medication management and provided data on any of the following outcomes, were eligible: time to assessment/diagnostic decision, use of services, impact on clinical decision-making, healthcare professionals' confidence in assessment, intervention use, morbidity, mortality, health-related quality of life, cost, ease of use, experience and acceptability of the test to patients, carers and clinicians. DATA EXTRACTION AND SYNTHESIS:Two reviewers independently screened titles and abstracts and assessed potentially relevant reports for inclusion. One reviewer conducted data extraction and risk of bias (RoB) assessment, checked by a second reviewer. Mixed-methods synthesis followed the convergent-integrated approach. RESULTS:We identified 10 eligible studies (9 QbTest; 1 QbCheck), including 1 randomised controlled trial (RCT), 2 feasibility RCTs, 5 before-and-after studies, 1 mixed-methods study and 1 diagnostic study. Most studies enrolled children in the UK and included surveys or interviews with patients, carers or clinicians. The RCT and before-and-after studies were judged at high/serious RoB. Six survey components and two qualitative interview components were judged at some concerns of RoB. We identified one ongoing study of the QbMT and no studies for QbMini. We organised themes emerging from the qualitative synthesis into two broad conceptual categories: views around the helpfulness of the QbTest (contribution to ADHD diagnosis, treatment decision-making, communication with caregivers) and barriers to QbTest implementation (practical barriers and acceptability of the test to patients and caregivers). Findings suggested that the addition of the QbTest may reduce time to diagnosis, improve clinician confidence in the diagnostic decision, increase the proportion of patients with a diagnostic decision and reduce cost and number of clinic appointments. The QbTest appeared to be generally well received by clinicians, patients and carers. However, barriers to test implementation were reported. Clinicians cited staffing, room requirements and issues with technology, and patients highlighted the test length and repetitive nature. Little data exist on the use of the QbTest for medication management. CONCLUSIONS:The available evidence suggests the QbTest may be a useful addition to ADHD assessment in children and young people. Further well-designed RCTs with qualitative substudies are required to assess the impact of the QbTest on patient outcomes, user experience and cost, particularly for medication management and in adults, where evidence is scarce. Such RCTs should include economic analyses, direct comparisons to other continuous performance tests with motion trackers and subgroup analyses including age, sex, ethnicity and comorbidities. PROSPERO REGISTRATION NUMBER:CRD42023482963.

Background:HIV and Hepatitis C (HCV) are blood borne infections (BBIs) that remain a significant cause of global morbidity and mortality among people who inject drugs (PWID). UNAIDS and WHO have set goals for the elimination of viral hepatitis and HIV as major public health threats by 2030. To achieve these targets, innovative strategies are required among marginalized populations such as PWID, especially in resource-limited countries where coverage of harm reduction services is often limited. The goal of this study is to inform targeted strategies to prevent transmission of BBIs among PWID. Methods:We will use respondent driven sampling (RDS) to recruit PWID from needle and syringe programs in Kenya. Participants will complete biobehavioral and social network surveys and receive point-of-care HCV, HIV, and hepatitis B (HBV) testing. Participants will return for at least one follow-up visit to complete additional surveys and testing. We will use network data from RDS, egocentric, and viral phylogenetics to identify how highly central PWID contribute to transmission networks and use mathematical modelling to investigate the impact of targeted interventions based on network characteristics. Discussion:This study will provide important information for policymakers and researchers designing strategies for BBI elimination. Network- and molecular epidemiologic-informed tools to guide targeted strategies may be critical to maximizing the impact of treatment and prevention efforts in resource-limited settings. This approach may provide a durable template for future studies, including prospective assessments of targeted prevention and elimination strategies among PWID, and assist with monitoring elimination progress in resource-limited settings.

Background: We evaluated the cost and cost-effectiveness of alternative screening pathways during 2018-2022 within Georgia's hepatitis C elimination program, which started in 2015. Methods: We calculated patient-level costs (2022 USD$) of hepatitis C treatment with centralized and decentralized diagnostic testing in hospitals, primary healthcare (PHC), harm reduction providers (HRP), or specialized providers (SP) from reimbursement records including the value of donated direct-acting antivirals (DAAs). We model hepatitis C case-finding, transmission, and progression over a 20-year time horizon to project cost-effectiveness of treatment for each screening pathway in terms of cost per quality adjusted life year (QALY), compared to a willingness-to-pay threshold of $1,337. Findings: Unit costs of treatment decreased from $3942-$4247 across screening pathways in 2018 to $300-$338 in 2022, primarily due to reductions in DAA costs. The cascade of care varied by screening pathway, with highest hepatitis C virus (HCV) antibody prevalence and percent linked to viremia testing among HRP and SP, while total number of patients screened was highest in hospitals. While DAA costs decreased, the cost of case finding increased during 2018-2022, with the biggest increase in hospital settings mainly due to decreasing yield. The program was not cost-effective with full DAA costs, but excluding DAA costs or using lower 2022 costs make all pathways cost-effective and SP, HRP, and PHC potentially cost-saving. Interpretation: Donated drugs allowed Georgia's HCV elimination program to be cost-effective, while future programs with generic drug costs are likely to be cost-effective. Reductions in yield from hospital screening suggest that later stages of elimination programs should prioritise targeted pathways. ### Competing Interest Statement Disclosure of Interest Statement: This study was funded by Gilead Sciences through an investigator-sponsored research grant to PV and JGW. The funder played no role in the study design, collection, management, analysis, or interpretation of data, in the writing of the report, or in the decision to publish. PV also acknowledges support from the National Institute for Health and Care Research (NIHR) Health Protection Research Unit in Behavioural Science and Evaluation at University of Bristol. Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention. ### Funding Statement This study was funded by Gilead Sciences through an investigator-sponsored research grant to PV and JGW. The funder played no role in the study design, collection, management, analysis, or interpretation of data, in the writing of the report, or in the decision to publish. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The National Center for Disease Control and Public Health Institutional Review Board waived ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors

Pakistan has the largest national burden of hepatitis C virus (HCV) infections (9.8 million). High levels of testing and treatment are needed to achieve HCV elimination, but little data exists on this in Pakistan. A household sero-survey from Sindh province (2019-2020) collected self-reported data from adults on previous HCV testing and treatment, and undertook HCV-antibody (HCV-Ab) testing of participants (2988 children (<18) and 3684 adults) and HCV-RNA testing of HCV-Ab positive individuals. We determined the self-reported HCV cascade-of-care among adults ever eligible for HCV treatment, defined as either having a past infection (HCV-Ab positive and HCV-RNA negative) with self-reported treatment history or current infection (HCV-RNA positive). We assessed factors associated with self-reporting ever being HCV-tested using multi-variable logistic regression. Overall, 10.8% (397/3684) of adults tested HCV Ab-positive in the sero-survey, of which 80.9% (321/397) had a HCV-RNA test result. Of adults defined as ever treatment eligible (n = 232), 40.9% (95/232) reported a previous HCV test and 91.2% (87/95) reported testing positive. Of these, HCV treatment was reported by 69.0% (60/87) and 46.7% (28/60) of treated individuals tested HCV-RNA-negative. Overall, 25.9% (60/232) of treatment-eligible adults reported being treated. The regression analysis suggested that males, older adults (>25 years), and adults with a secondary or higher education level were more likely to have ever been tested for HCV, as were individuals with a family history of hepatitis, received HBV vaccination or that had various risk factors linked to HCV transmission (e.g., blood transfusion, having tattoo/acupuncture, hospitalisation or therapeutic injection (s) history). The cascade-of-care for HCV needs improving to eliminate HCV in Pakistan, especially among younger adults, women and people with low education levels.

BACKGROUND AND AIMS:In 2024, < 10% of hepatitis C virus (HCV) cases were treated in Eastern Europe and Central Asia (EECA) and the burden remains high. We aimed to estimate the cost-effectiveness of treating anyone with HCV ('treat all') or targeting people who inject drugs (PWID) in 14 middle-income EECA countries. METHODS:We gathered costs of screening, confirmatory tests, direct-acting antiviral (DAA) treatment and monitoring from published country-specific data, Georgian costs from previous analyses, and UNICEF. We combined decision tree modelling with a dynamic transmission model of HCV calibrated for each EECA country to calculate quality-adjusted life years (QALYs) gained by 2030 from 100 DAA treatments in 2024, for treat all compared to targeting PWID. We calculated incremental cost-effectiveness ratios (ICERs, cost per QALY gained) relative to gross domestic product (GDP) per capita. RESULTS:QALYs gained from 100 treatments ranged from 29-55 if treat all and 25-90 if targeting PWID. Using country-level costs, Bulgaria and Russia had ICERs above GDP per capita due to high DAA costs. For other countries, ICERs ranged from 18% to 89% of GDP (treat all) and 4%-89% (PWID). Using lower Georgian costs and UNICEF costs, the treat all ICERs were below 84% and 24% of GDP for all countries, respectively, except Bosnia, while the ICERs when targeting PWID were below 64% and 16% of GDP, respectively. CONCLUSIONS:Strategies that treat all persons with HCV and target PWID are both likely to be cost-effective in middle-income EECA countries, particularly with broad access to low-cost generic treatments such as through UNICEF procurement.

Background: Subgroups of people who inject drugs (PWID) may experience differential exposure to HIV and hepatitis C (HCV). This study analyzes behavioral risk profiles associated with HIV and HCV infection among PWID, with the aim of identifying subgroups at highest risk and guiding future interventions. Methods: We recruited PWID in Kenya using respondent driven sampling. Participants completed behavioral surveys and point-of-care HCV, HIV, and hepatitis B (HBV) testing. We used latent class (LC) analysis to divide the sample into mutually exclusive classes based on nine risk-and service access-related measures. Results: Among the 3152 participants enrolled, one-fifth (N = 610, 19.4 %) were HCV antibody-positive, one-tenth were HIV-positive (N = 306, 9.7 %), and 1.3 % (N = 40) were HBV-positive. We obtained three LCs: LC1-long-term, high-frequency PWID with large networks, high access to NSP services, and moderate access to OAT (N = 1522, 48.3 %), LC2-newer, high-frequency PWID with large networks, moderate access to NSP services, and moderate access to OAT (N = 878, 27.8 %), and LC3-long-term, low-frequency PWID with small networks, high access to NSP, and moderate access to OAT (N = 752, 23.9 %). HIV and HCV prevalence and risk behaviors differed between the classes, and classes differed in demographic characteristics as well. Conclusion: Subgroups of PWID in Kenya have different risk for HIV and HCV, influenced by duration of injection, network size, service access, and other behavioral risk factors. Targeted interventions to meet each subgroup's needs are essential to prevent ongoing HCV and HIV epidemics among PWID.

Background:In 2022, a global mpox outbreak occurred among gay and bisexual men who have sex with men (GBMSM). In England, the outbreak was controlled through reductions in sexual risk behaviour and vaccination of high-risk GBMSM. However, mpox continues to circulate, including an expanding outbreak in Africa. We evaluated the most cost-effective vaccination strategy to minimise future mpox outbreaks among GBMSM in England. Methods:A mathematical model of mpox transmission among GBMSM was developed to estimate the costs per quality-adjusted-life-year (QALY) gained for different vaccination strategies starting in 2024 (10-year time-horizon; 3.5% discount rate; willingness-to-pay threshold £20,000/QALY). Reactive vaccination (only during outbreaks) and/or pre-emptive vaccination (continuous routine) strategies targeting high-risk GBMSM were compared to no vaccination. Baseline projections assumed importation of new mpox cases, and a vaccine effectiveness following 1/2 doses of 78%/89% for 5/10 years at £160/dose. Costs were estimated for case management, vaccination and public health responses during an outbreak. Findings:All vaccination strategies reduced future outbreaks, gained QALYs and reduced costs compared to no vaccination. Continuous pre-emptive vaccination (daily rate 54 doses) with reactive vaccination (daily rate 81 doses) if there is an outbreak was most cost-effective, saving £8.8 million and gaining 108.6 QALYs over 10-years. Vaccination remains cost-effective if the vaccine costs less than £330/dose. Pre-emptive with reactive vaccination remains the preferred strategy across many sensitivity analyses, with just pre-emptive vaccination at a higher rate becoming the preferred strategy in some sensitivity analyses. Just reactive vaccination only becomes the preferred strategy when public health response costs are not included, and in this case the vaccine has to cost less than £110 per dose for vaccination to be cost-effective. Interpretation:Vaccination of high-risk GBMSM is likely to be a cost-saving strategy for preventing future mpox outbreaks. Funding:NIHR and Wellcome Trust.

INTRODUCTION:Little data exists on the effectiveness of HIV prevention interventions among people who inject drugs (PWID) in Africa. We used empirical data from Kenya to fill this evidence gap. METHODS:Six rounds of bio-behavioural surveys using respondent-driven-sampling were conducted among PWID in Nairobi and Coastal Kenya over 2012-2015. Dried blood spot samples were tested for HIV and HIV viral load, and HIV incidence was estimated through linking participants between rounds. Regression analyses evaluated whether self-reported usage of opioid agonist therapy (OAT) or needle and syringe programmes (NSP) in last year were associated with reduced injecting risk behaviours, increased ART uptake and viral suppression, and reduced risk of HIV acquisition. RESULTS:Overall, 4897 PWID participated in the study, with 3903 participating in >1 round. Over the rounds, coverage increased from zero to 80-86 % for NSP and zero to 10-20 % for OAT. The proportion of people living with HIV (PLHIV) that were virally suppressed increased from 7-14 % to 39-55 %. Accessing NSP and OAT was associated with reduced syringe sharing at last injection (NSP adjusted odds ratio (aOR)=0.31; 95 %CI:0.24-0.40; OAT aOR=0.046; 95 %CI:0.034-0.061) and OAT was associated with reduced injecting frequency (adjusted rate ratio=0.21; 95 %CI:0.12-0.36). Using OAT was associated with increased ART coverage (aOR=2.76; 95 %CI:1.50-5.06) and viral suppression (aOR=2.99; 95 %CI:1.78-5.03) among PLHIV, while NSP was not. HIV incidence decreased from 6.10 (95 %CI:3.56-9.77) to 1.49 (95 %CI:0.79-2.54) per 100 person-years between the first and second half of the study. Accessing NSP was associated with lower HIV incidence (adjusted hazard ratio=0.25; 95 %CI:0.087-0.58). CONCLUSIONS:This study provides strong evidence for the benefits of NSP and OAT on varied HIV outcomes among PWID in Africa.

Hepatitis C virus (HCV) is hypothesised to be a public health problem in Ethiopia, and systematic review evidence suggested 1%-3% seroprevalence. We aimed to estimate the seroprevalence of HCV overall and across regions of Ethiopia. We estimated HCV seroprevalence using the 2016 Ethiopian Demographic and Health Survey (EDHS-2016). EDHS-2016 is a nationwide household survey conducted using two-stage cluster sampling methods. We tested all 26,753 samples from participating adult women (15-49 years) and men (15-59 years) using HCV Enzyme Immunoassay. Descriptive analyses were performed based on the Guide to Demographic Health Survey statistics. We applied sample weighting to derive representative estimates. Of the total tested, more than half (54.40%) were aged 15-29 years and 51.59% were women. Overall HCV seroprevalence was 0.18% (95% Confidence Interval: 0.10-0.32). Higher seroprevalences were found in Afar (0.92%) and South Nations Nationality Peoples Region (0.43%); people living with HIV (PLWH) (0.62%); the poorest wealth index (0.35%); people having multiple lifetime sexual partners (0.31%); and widowed/divorced individuals (0.30%). In stratified analyses by sex and residency, we found higher seroprevalences in non-Christian and non-Muslim males (1.98%) and rural population (1.00%), male PLWH (1.67%), rural PLWH (1.45%), widowed/divorced males (0.97%), and in all groups from the Afar region: males (1.30%), females (0.61%), urban (1.07%), and rural (0.86%). HCV seroprevalence among the general population in Ethiopia is much lower than from previous estimates. General population screening is unlikely to be cost-effective, and so screening programs targeted to people at greater risk of HCV will be required.

Background:Sex workers' risk of violence and ill-health is shaped by their work environments, community and structural factors, including criminalisation. Aim:We evaluated the impact of removing police enforcement on sex workers' safety, health and access to services. Design:Mixed-methods participatory study comprising qualitative research, a prospective cohort study, mathematical modelling and routine data collation. Setting:Three boroughs in London, UK. Participants:People aged ≥ 18 years, who provided in-person sexual services. Interventions:Simulated removal of police enforcement. Outcomes:Primary - recent or past experience of sexual, physical or emotional violence. Secondary - depression/anxiety symptoms, physical health, chlamydia/gonorrhoea, and service access. Results:A combination of enforcement by police, local authorities and immigration, being denied justice when reporting violence, and linked cuts to specialist health and support services created harmful conditions for sex workers. This disproportionately affected cisgender and transgender women who work on the streets, use drugs, are migrants and/or women of colour. Among women (n = 197), street-based sex workers experienced higher levels than indoor sex workers of recent violence from clients (73% vs. 36%), police (42% vs. 7%) and others (67% vs. 17%); homelessness (65% vs. 7%); anxiety and depression (71% vs 35%); physical ill-health (57% vs 31%); and recent law enforcement (87% vs. 9%). For street-based sex workers, recent arrest was associated with violence from others (adjusted odds ratio (AOR)) 2.77, 95% confidence interval (CI) 1.11 to 6.94). Displacement by police was associated with client violence (AOR 4.35; 95% CI 1.36 to 13.90) as were financial difficulties (AOR 4.66; CI 1.64 to 13.24). Among indoor sex workers, unstable residency (AOR 3.19; 95% CI 1.36 to 7.49) and financial difficulties (AOR 3.66; 95% CI 1.64 to 8.18) contributed to risk of client violence. Among all genders (n = 288), ethnically and racially minoritised sex workers (26.4%) reported more police encounters than white sex workers, partly linked to increased representation in street settings (51.4% vs. 30.7%; p = 0.002) but associations remained after adjusting for work setting. Simulated removal of police displacement and homelessness was associated with a 71% reduction in violence (95% credible interval 55% to 83%). Participants called for a redirection of funds from enforcement towards respectful, peer-led services. Limitations:Restriction to one urban locality prevents generalisability of findings. More interviews with under-represented participants (e.g. trans/non-binary sex workers) may have yielded further insights into inequities. Correlation between different risk factors restricted outcomes of interest for the modelling analyses, which were largely limited to experience of violence. Conclusion:Our research adds to international evidence on the harms of criminalisation and enforcement, particularly for women who work on street and/or are racially or ethnically minoritised. Findings add weight to calls to decriminalise sex work, tackle institutionally racist, misogynist and otherwise discriminatory practices against sex workers in police and other agencies, and to (re)commission experience-based, peer-led services by and for sex workers particularly benefiting the most marginalised communities. Future work:Realist informed trials, co-produced with sex workers, would provide rigorous evidence on effective approaches to protect sex workers' health, safety and rights. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 15/55/58.

2023 marked the 75th anniversary of the UN's Universal Declaration of Human Rights. The Universal Declaration articulates an inspiring vision of a world that is just, equitable, tolerant, and strategically focused on actions to address the most vulnerable and marginalised populations—a counterpoint to the atrocities, repression, and colonialism that characterised much of the 20th century. Endorsement of the Universal Declaration was not commensurate with reality in many cases—especially because numerous signatories still had colonies and because Cold War politics resulted in divisions of social, economic, and political rights into separate international covenants—but it nevertheless inspired decades of progress.