BACKGROUND AND AIMS:Although the evidence is uncertain, existing estimates for hepatitis C virus (HCV) in sub-Saharan Africa (SSA) indicate a high burden. We estimated HCV seroprevalence and viraemic prevalence among the general population in SSA. METHODS:We searched Medline, Embase, Web of Science, APA PsycINFO, and World Health Organization Africa Index Medicus for community-based studies. Study quality was assessed using the Joanna Briggs Institute critical appraisal tool, and heterogeneity using the index of heterogeneity (I2). Two approaches were deployed. First, we used random-effects meta-analysis to pool prevalence. Second, to derive representative estimates, we weighted each country's HCV seroprevalence using 2021 United Nations country population sizes. RESULTS:We synthesized 130 studies. Overall, SSA HCV seroprevalence from the random-effects model was 4.17% (95% confidence interval [CI]: 3.71-4.66, I2 = 99.30%). There were no differences between males (4.31%) and females (4.03%). Seroprevalence was 2.25%, 3.31%, and 16.23% for ages ≤20, 21-64, and ≥65 years, respectively, and was higher in rural (6.63%) versus urban (2.93%). There was indication of decrement overtime from 5.74% to 4.35% to 3.03% in the years 1984-2000, 2001-2014, and 2015-2023, respectively. The weighted overall SSA HCV seroprevalence was estimated to be 2.30% (95% CI: 1.59-3.00) with regional variation: Africa-Southern (.79%), Africa-Central (1.47%), Africa-Eastern (2.71%), and Africa-Western (2.88%). HCV viremia among HCV seropositives was 54.77% (95% CI: 47.80-61.66). CONCLUSIONS:HCV seroprevalence in SSA remains high. Populations aged ≥65 years, rural communities, Africa-Western, and some countries in Africa-Central and Africa-Eastern appear disproportionately affected. These results underline the need for governmental commitment to achieve the 2030 global HCV elimination targets.

INTRODUCTION:People who inject drugs (PWID) in Ukraine have high prevalences of HIV and hepatitis C virus (HCV). Non-governmental organizations (NGOs) provide PWID with needles/syringes, condoms, HIV/HCV testing and linkage to opioid agonist treatment (OAT) and antiretroviral therapy (ART). We estimated their impact and cost-effectiveness among PWID. METHODS:A dynamic HIV and HCV transmission model among PWID was calibrated using data from four national PWID surveys (2011-2017). The model assumed 37-49% coverage of NGOs among community PWID, with NGO contact reducing injecting risk and increasing condom use and recruitment onto OAT and ART. We estimated the historic (1997-2021) and future (2022-2030, compared to no NGO activities from 2022) impact of NGOs in terms of the proportion of HIV/HCV infections averted and changes in HIV/HCV incidence. We estimated the future impact of scaling-up NGOs to 80% coverage with/without scale-up in OAT (5-20%) and ART (64-81%). We estimated the cost per disability-adjusted life-year (DALY) averted of current NGO provision over 2022-2041 compared to NGO activities stopping over 2022-2026, but restarting after that till 2041. We assumed average unit costs of US$80-90 per person-year of NGO contact for PWID. RESULTS:With existing coverage levels of NGOs, the model projects that NGOs have averted 20.0% (95% credibility interval: 13.3-26.1) and 9.6% (5.1-14.1) of new HIV and HCV infections among PWID over 1997-2021, respectively, and will avert 31.8% (19.6-39.9) and 13.7% (7.5-18.1) of HIV and HCV infections over 2022-2030. With NGO scale-up, HIV and HCV incidence will decrease by 54.2% (43.3-63.8) and 30.2% (20.5-36.2) over 2022-2030, or 86.7% (82.9-89.3) and 39.8% (31.4-44.8) if OAT and ART are also scaled-up. Without NGOs, HIV and HCV incidence will increase by 51.6% (23.6-76.3) and 13.4% (4.8-21.9) over 2022-2030. Current NGO provision over 2022-2026 will avert 102,736 (77,611-137,512) DALYs when tracked until 2041 (discounted 3% annually), and cost US$912 (702-1222) per DALY averted; cost-effective at a willingness-to-pay threshold of US$1548/DALY averted (0.5xGDP). CONCLUSIONS:NGO activities have a crucial preventative impact among PWID in Ukraine which should be scaled-up to help achieve HIV and HCV elimination. Disruptions could have a substantial detrimental impact.

Background The burden of chronic hepatitis B virus (HBV) varies across the European Union (EU) and European Economic Area (EEA). Aim We aimed to update the 2017 HBV prevalence estimates in EU/EEA countries and the United Kingdom for 2018 to 2021. Methods We undertook a systematic review, adding to HBV prevalence estimates from an existing (2005–2017) database. Databases were searched for original English-language research articles including HBV surface antigen prevalence estimates among the general population, pregnant women, first-time blood donors (FTB), men who have sex with men (MSM), migrants and people in prison. Country experts contributed grey literature data. Risk of bias was assessed using a quality assessment framework. Findings The update provided 147 new prevalence estimates across the region (updated total n = 579). Median HBV prevalence in the general population was 0.5% and the highest was 3.8% (Greece). Among FTB, the highest prevalence was 0.8% (Lithuania). Estimates among pregnant women were highest in Romania and Italy (5.1%). Among migrants, the highest estimate was 31.7% (Spain). Relative to 2017 estimates, median prevalence among pregnant women decreased by 0.5% (to 0.3%) and increased by 0.9% (to 5.8%) among migrants. Among MSM, the highest estimate was 3.4% (Croatia). Prevalence among people in prison was highest in Greece (8.3%) and the median prevalence increased by 0.6% (to 2.1%). Conclusions The HBV prevalence is low in the general population and confined to risk populations in most European countries with some exceptions. Screening and treatment should be targeted to people in prison and migrants.

AbstractBackgroundHepatitis B virus (HBV) epidemiology in Europe differs by region and population risk group, and data are often incomplete. We estimated chronic HBV prevalence as measured by surface antigen (HBsAg) among general and key population groups for each country in the European Union, European Economic Area and the United Kingdom (EU/EEA/UK), including where data are currently unavailable.MethodsWe combined data from a 2018 systematic review (updated in 2021), data gathered directly by the European Centre for Disease Control (ECDC) from EU/EEA countries and the UK and further country-level data. We included data on adults from the general population, pregnant women, first time blood donors (FTBD), men who have sex with men (MSM), prisoners, people who inject drugs (PWID), and migrants from 2001 to 2021, with three exceptions made for pre-2001 estimates. Finite Mixture Models (FMM) and Beta regression were used to predict country and population group HBsAg prevalence. A separate multiplier method was used to estimate HBsAg prevalence among the migrant populations within each country, due to biases in the data available.ResultsThere were 595 included studies from 31 countries (N = 41,955,969 people): 66 were among the general population (mean prevalence ($$\stackrel{-}{p}$$) 1.3% [range: 0.0-7.6%]), 52 among pregnant women ($$\stackrel{-}{p}=$$1.1% [0.1–5.3%]), 315 among FTBD ($$\stackrel{-}{p}=$$0.3% [0.0-6.2%]), 20 among MSM ($$\stackrel{-}{p}=$$1.7% [0.0-11.2%]), 34 among PWID ($$\stackrel{-}{p}=$$3.9% [0.0-16.9%]), 24 among prisoners ($$\stackrel{-}{p}=$$2.9% [0.0-10.7%]), and 84 among migrants ($$\stackrel{-}{p}=$$7.0% [0.2–37.3%]). The FMM grouped countries into 3 classes. We estimated HBsAg prevalence among the general population to be < 1% in 24/31 countries, although it was higher in 7 Eastern/Southern European countries. HBsAg prevalence among each population group was higher in most Eastern/Southern European than Western/Northern European countries, whilst prevalence among PWID and prisoners was estimated at > 1% for most countries. Portugal had the highest estimated prevalence of HBsAg among migrants (5.0%), with the other highest prevalences mostly seen in Southern Europe.ConclusionsWe estimated HBV prevalence for each population group within each EU/EAA country and the UK, with general population HBV prevalence to be < 1% in most countries. Further evidence is required on the HBsAg prevalence of high-risk populations for future evidence synthesis.

Objective: Non-governmental organizations (NGOs) in Ukraine have provided HIV testing, treatment, and condom distribution for MSM. HIV prevalence among MSM in Ukraine is 5.6%. We estimated the impact and cost-effectiveness of MSM-targeted NGO activities in Ukraine. Design: A mathematical model of HIV transmission among MSM was calibrated to data from Ukraine (2011–2018). Methods: The model, designed before the 2022 Russian invasion of Ukraine, evaluated the impact of 2018 status quo coverage levels of 28% of MSM being NGO clients over 2016–2020 and 2021–2030 compared with no NGO activities over these time periods. Impact was measured in HIV incidence and infections averted. We compared the costs and disability adjusted life years (DALYs) for the status quo and a counterfactual scenario (no NGOs 2016–2020, but with NGOs thereafter) until 2030 to estimate the mean incremental cost-effectiveness ratio (cost per DALY averted). Results: Without NGO activity over 2016–2020, the HIV incidence in 2021 would have been 44% (95% credibility interval: 36–59%) higher than with status quo levels of NGO activity, with 25% (21–30%) more incident infections occurring over 2016–2020. Continuing with status quo NGO coverage levels will decrease HIV incidence by 41% over 2021–2030, whereas it will increase by 79% (60–120%) with no NGOs over this period and 37% (30–51%) more HIV infections will occur. Compared with if NGO activities had ceased over 2016–2020 (but continued thereafter), the status quo scenario averts 14 918 DALYs over 2016–2030 with a mean incremental cost-effectiveness ratio of US$600.15 per DALY averted. Conclusion: MSM-targeted NGOs in Ukraine have prevented considerable HIV infections and are highly cost-effective compared with a willingness-to-pay threshold of 50% of Ukraine's 2018 GDP (US$1548).

Background People who inject drugs (PWID) are at increased risk for HIV and hepatitis C virus (HCV) infection and also have high levels of homelessness and unstable housing. We assessed whether homelessness or unstable housing is associated with an increased risk of HIV or HCV acquisition among PWID compared with PWID who are not homeless or are stably housed. Methods In this systematic review and meta-analysis, we updated an existing database of HIV and HCV incidence studies published between Jan 1, 2000, and June 13, 2017. Using the same strategy as for this existing database, we searched MEDLINE, Embase, and PsycINFO for studies, including conference abstracts, published between June 13, 2017, and Sept 14, 2020, that estimated HIV or HCV incidence, or both, among community-recruited PWID. We only included studies reporting original results without restrictions to study design or language. We contacted authors of studies that reported HIV or HCV incidence, or both, but did not report on an association with homelessness or unstable housing, to request crude data and, where possible, adjusted effect estimates. We extracted effect estimates and pooled data using random-effects meta-analyses to quantify the associations between recent (current or within the past year) homelessness or unstable housing compared with not recent homelessness or unstable housing, and risk of HIV or HCV acquisition. We assessed risk of bias using the Newcastle-Ottawa Scale and between-study heterogeneity using the I-2 statistic and p value for heterogeneity. Findings We identified 14 351 references in our database search, of which 392 were subjected to full-text review alongside 277 studies from our existing database. Of these studies, 55 studies met inclusion criteria. We contacted the authors of 227 studies that reported HIV or HCV incidence in PWID but did not report association with the exposure of interest and obtained 48 unpublished estimates from 21 studies. After removal of duplicate data, we included 37 studies with 70 estimates (26 for HIV; 44 for HCV). Studies originated from 16 countries including in North America, Europe, Australia, east Africa, and Asia. Pooling unadjusted estimates, recent homelessness or unstable housing was associated with an increased risk of acquiring HIV (crude relative risk [cRR] 1.55 [95% CI 1.23-1.95; p=0.0002]; I-2 = 62.7%; n=17) and HCV (1.65 [1.44-1.90; p<0.0001]; I-2 = 44.8%; n=28]) among PWID compared with those who were not homeless or were stably housed. Associations for both HIV and HCV persisted when pooling adjusted estimates (adjusted relative risk for HIV: 1.39 [95% CI 1.06-1.84; p=0.019]; I-2 = 65.5%; n=9; and for HCV: 1.64 [1.43-1.89; p<0.0001]; I-2 = 9.6%; n=14). For risk of HIV acquisition, the association for unstable housing (cRR 1.82 [1.13-2.95; p=0.014]; n=5) was higher than for homelessness (1.44 [1.13-1.83; p=0.0036]; n=12), whereas no difference was seen between these outcomes for risk of HCV acquisition (1.72 [1.48-1.99; p<0.0001] for unstable housing, 1.66 [1.37-2.00; p<0.0001] for homelessness). Interpretation Homelessness and unstable housing are associated with increased risk of HIV and HCV acquisition among PWID. Our findings support the development of interventions that simultaneously address homelessness and unstable housing and HIV and HCV transmission in this population. Copyright (C) 2021 The Author(s). Published by Elsevier Ltd.

AbstractIntroductionPeople who inject drugs (PWID) in Ukraine have a high prevalence of hepatitis C virus (HCV). Since 2015, PWID have been receiving HCV treatment, but their impact and cost-effectiveness has not been estimated.MethodsWe developed a dynamic model of HIV and HCV transmission among PWID in Ukraine, incorporating ongoing HCV treatment (5,933 treatments) over 2015–2021; 46.1% among current PWID. We estimated the impact of these treatments and different treatment scenarios over 2021-2030: continuing recent treatment rates (2,394 PWID/year) with 42.5/100% among current PWID, or treating 5,000/10,000 current PWID/year. We also estimated the treatment rate required to decrease HCV incidence by 80% if preventative interventions are scaled-up or not. Required costs were collated from previous studies in Ukraine. We estimated the incremental cost-effectiveness ratio (ICER) of the HCV treatments undertaken in 2020 (1,059) by projecting the incremental costs and disability adjusted life years (DALYs) averted over 2020-2070 (3% discount rate) compared to a counterfactual scenario without treatment from 2020 onwards.ResultsOn average, 0.4% of infections among PWID were treated annually over 2015-2021, without which HCV incidence would have been 0.6% (95%CrI: 0.3-1.0%) higher in 2021. Continuing existing treatment rates could reduce HCV incidence by 10.2% (7.8-12.5%) or 16.4% (12.1-22.0%) by 2030 if 42.5% or 100% of treatments are given to current PWID, respectively. HCV incidence could reduce by 29.3% (20.7-44.7%) or 93.9% (54.3-99.9%) by 2030 if 5,000 or 10,000 PWID are treated annually. To reduce incidence by 80% by 2030, 19,275 (15,134-23,522) annual treatments are needed among current PWID, or 17,955 (14,052-21,954) if preventative interventions are scaled-up. The mean ICER was US$828.8/DALY averted; cost-effective at a willingness-to-pay threshold of US$3,096/DALY averted (1xGDP).ImplicationsExisting HCV treatment is cost-effective but has had little preventative impact due to few current PWID being treated. Further treatment expansion for current PWID could significantly reduce HCV incidence.

ObjectivesHepatitis C Virus (HCV) is a significant cause of chronic liver disease. Among at-risk populations, access to diagnosis and treatment is challenging. We describe an integrated model of care, Hepcare Europe, developed to address this challenge.MethodsUsing a case-study approach, we describe the cascade of care outcomes at all sites. Cost analyses estimated the cost per person screened and linked to care.ResultsA total of 2608 participants were recruited across 218 clinical sites. HCV antibody test results were obtained for 2568(98•5%); 1074(41•8%) were antibody-positive, 687(60•5%) tested positive for HCV-RNA, 650(60•5%) were linked to care, and 319(43•5%) started treatment. 196(61•4%) of treatment initiates achieved a Sustained Viral Response (SVR) at dataset closure, 108(33•9%) were still on treatment, eight (2•7%) defaulted from treatment, and seven (2•6%) had virologic failure or died. The cost per person screened varied from €194 to €635, while the cost per person linked to care varied from €364 to €2035.ConclusionsHepcare enhanced access to HCV treatment and cure, and costs were affordable in all settings, offering a framework for scale-up and reproducibility.