The status of hepatitis C virus infection among people who inject drugs in the Middle East and North Africa

Hepatitis C risk score as a tool to identify individuals with HCV infection: a demonstration and cross-sectional epidemiological study in Egypt

OBJECTIVES

Hepatitis C virus (HCV) infection poses a global health challenge. By the end of 2021, the WHO estimated that less than a quarter of global HCV infections had been diagnosed. There is a need for a public health tool that can facilitate the identification of people with HCV infection and link them to testing and treatment, and that can be customised for each country.

METHODS

We derived and validated a risk score to identify people with HCV in Egypt and demonstrated its utility. Using data from the 2008 and 2014 Egypt Demographic and Health Surveys, two risk scores were constructed through multivariable logistic regression analysis. A range of diagnostic metrics was then calculated to evaluate the performance of these scores.

RESULTS

The 2008 and 2014 risk scores exhibited similar dependencies on sex, age and type of place of residence. Both risk scores demonstrated high and similar areas under the curve of 0.77 (95% CI: 0.76 to 0.78) and 0.78 (95% CI: 0.77 to 0.80), respectively. For the 2008 risk score, sensitivity was 73.7% (95% CI: 71.5% to 75.9%), specificity was 68.5% (95% CI: 67.5% to 69.4%), positive predictive value (PPV) was 27.8% (95% CI: 26.4% to 29.2%) and negative predictive value (NPV) was 94.1% (95% CI: 93.5% to 94.6%). For the 2014 risk score, sensitivity was 64.0% (95% CI: 61.5% to 66.6%), specificity was 78.2% (95% CI: 77.5% to 78.9%), PPV was 22.2% (95% CI: 20.9% to 23.5%) and NPV was 95.7% (95% CI: 95.4% to 96.1%). Each score was validated by applying it to a different survey database than the one used to derive it.

CONCLUSIONS

Implementation of HCV risk scores is an effective strategy to identify carriers of HCV infection and to link them to testing and treatment at low cost to national programmes.

Patterns and trends of hepatitis C virus infection in Jordan: an observational study

Background

Hepatitis C virus (HCV) infection levels in Jordan remain uncertain. No HCV national population-based survey has ever been conducted in the country. To meet the World Health Organization's target of reducing HCV incidence to ≤5 per 100,000 people per year by 2030, it is essential to determine the infection levels, identify affected individuals and populations, and provide appropriate treatment using direct-acting antivirals to individuals carrying the virus.

Methods

The study utilized the HCV testing database of 28,798 attendees of Biolab Diagnostic Laboratories in Jordan, covering the period from January 19, 2010, to May 26, 2023. Cross-sectional and cohort study analyses were conducted, including estimating HCV antibody (Ab) prevalence, examining associations with HCV Ab positivity, determining the HCV viremic rate, and estimating HCV incidence rate using a retrospective cohort study design.

Results

A total of 27,591 individuals, with a median age of 31.3 and 52.9% being females, underwent HCV Ab testing, while 1,450 individuals, with a median age of 42.2 and 32.8% being females, underwent HCV RNA PCR testing. The study sample HCV Ab prevalence was 4.0% (95% CI: 3.7-4.2%). After applying probability weights, the weighted HCV Ab prevalence was 5.8% (95% CI: 4.6-7.3%). Age was strongly associated with HCV Ab positivity, particularly among individuals aged 50 years or older, who had 10-fold higher odds of being HCV Ab positive compared to those aged 10-19 years. Males had 2.41-fold higher odds of testing positive for HCV Ab compared to females. The HCV viremic rate was 54.1% (95% CI: 43.0-65.0%). The cumulative incidence of HCV infection, after 5 years of follow-up, was estimated to be 0.41% (95% CI: 0.17-0.99%). The HCV incidence rate was calculated at 1.19 per 1,000 person-years (95% CI, 0.50-2.87).

Conclusion

Prevalence and incidence of HCV infection were substantial, estimated at ~5% and 1 per 1,000 person-years, respectively, and highlighting the presence of core groups actively engaged in the virus' acquisition and transmission. The high observed viremic rate indicates the need for expanding HCV treatment efforts to effectively control HCV transmission in Jordan. Utilizing quality diagnostic laboratories and innovative testing strategies is key to identifying infection carriers and facilitating linkage to treatment and care.

Prevalence of injecting drug use and HIV, hepatitis B, and hepatitis C in people who inject drugs in the Eastern Mediterranean region: a systematic review and meta-analysis

BACKGROUND

Considerable disease burden is attributed to injecting drug use (IDU). This regional systematic review and meta-analysis aimed to assess the prevalence of IDU and the characteristics of people who inject drugs in the 22 countries of the WHO Eastern Mediterranean region.

METHODS

We conducted a systematic review and meta-analysis on the prevalence of IDU, estimation of the population size of people who inject drugs, the characteristics of people who inject drugs, commonly injected drugs, the prevalence of HIV, hepatitis C virus, and hepatitis B virus in people who inject drugs, and opioid agonist treatment and needle and syringe programme services. We searched PubMed, Web of Science, Scopus, Embase, and the Index Medicus for the Eastern Mediterranean Region for documents published between Jan 1, 2010, and April 17, 2022, with no language restrictions. We also searched government reports, civil society information, and UN websites and databases for grey literature published between Jan 1, 2010, and April 17, 2022. Documents were eligible if they reported or estimated an indicator of interest, or reported enough data to permit calculation of the indicator. We extracted data from the eligible documents and calculated national and regional estimates.

FINDINGS

We identified 38 283 documents and included 201 documents in the systematic review. A total of 115 documents were included for the four outcomes for which meta-analyses were performed. The number of people who inject drugs was estimated as 864 597 (95% CI 641 909-1 205 255), amounting to a prevalence of 20·0 per 10 000 adults (95% CI 14·9-27·9) in the region. Among people who inject drugs, the prevalence of HIV was estimated as 19·22% (95% CI 12·86-26·36), hepatitis C virus as 44·82% (29·32-61·16), and hepatitis B virus as 2·66% (0·84-7·26). Countries varied greatly regarding the variables of interest and the availability of relevant data. Nine countries provided needle and syringe programme services and seven countries provided opioid agonist treatment services, mostly with very low, low, or unclear coverage.

INTERPRETATION

The prevalence of IDU in the Eastern Mediterranean region is lower than the global mean, particularly among women. The HIV infection rate is higher than the global mean, and the hepatitis C virus infection rate is lower than the global mean. Harm-reduction services are underdeveloped. Data collection on IDU and provision of services need improvement in the region.

FUNDING

World Health Organization.

TRANSLATIONS

For the Arabic, Farsi and French translations of the abstract see Supplementary Materials section.

Treatment as prevention for hepatitis C virus in the Middle East and North Africa: a modeling study

Background

Direct-acting antivirals opened an opportunity for eliminating hepatitis C virus (HCV) infection in the Middle East and North Africa (MENA), the region most affected by HCV infection. Impact of HCV treatment as prevention (HCV-TasP) was investigated in 19 MENA countries.

Methods

An age-structured mathematical model was used to assess program impact using epidemiologic and programming measures. The model was fitted to a database of systematically gathered HCV antibody prevalence data. Two main scenarios were investigated for the treatment roll-out to achieve (i) 80% reduction in HCV incidence by 2030, and (ii) incidence rate < 1 per 100,000 person-years by 2030.

Results

In the target-80%-incidence-reduction scenario, number of treatments administrated by 2030 ranged from 2,610 in Lebanon to 180,416 in Sudan with a median of 53,079, and treatment coverage ranged between 40.2 and 78.4% with a median of 60.4%. By 2030, prevalence of chronic infection ranged between 0.0 and 0.3% with a median of 0.1%, and incidence rate, per 100,000 person-years, ranged between 0.9 and 16.3 with a median of 3.2. Program-attributed reduction in incidence rate ranged between 47.8 and 81.9% with a median of 68.5%, and number of averted infections ranged between 401 and 68,499 with a median of 8,703. Number of treatments needed to prevent one new infection ranged from 1.7 in Oman to 25.9 in Tunisia with a median of 6.5. In the target incidence rate  < 1 per 100,000 person-years scenario, number of treatments administrated by 2030 ranged from 3,470 in Lebanon to 211,912 in Sudan with a median of 54,479, and treatment coverage ranged between 55.5 and 95.9% with a median of 87.5%. By 2030, prevalence of chronic infection was less than 0.1%, and incidence rate, per 100,000 person-years, reached less than 1. Program-attributed reduction in incidence rate ranged between 61.0 and 97.5% with a median of 90.7%, and number of averted infections ranged between 559 and 104,315 with a median of 12,158. Number of treatments needed to prevent one new infection ranged from 1.3 in Oman to 25.9 in Tunisia with a median of 5.5.

Conclusion

HCV-TasP is an effective and indispensable prevention intervention to control MENA's HCV epidemic and to achieve elimination by 2030.

Seroprevalence and trends of hepatitis B virus, hepatitis C virus and human immunodeficiency virus in Syrian blood donors at Damascus University Blood Center between 2004 and 2021

Introduction

Seroprevalence of transfusion-transmitted viral infections (TTVIs) is a valuable indicator for assessing blood safety, population health and health system performance in the times of peace and conflicts. Only scarce information is available on the impact of the decade-long violent conflict on the prevalence of TTVIs in Syria. Moreover, hepatitis B vaccine was introduced to the national vaccination program in 1993; however, no data is available on the vaccine effectiveness.

Methods

In this retrospective cross-sectional study, we compiled the screening results for major TTVIs, namely hepatitis B virus (HBV), hepatitis C virus (HCV), and human immuno-deficiency virus (HIV), of volunteer donors at Damascus University Blood Center from May 2004 to October 2021. Prevalence was expressed in percentages for the entire study group and subgroups. Chi-square test and linear regression were used to examine the differences and describe trends in prevalence, respectively, based on demographic characteristics (i.e., age and gender) and time. P-value of <0.005 was considered statistically significant.

Results

Of the total 307,774 donors (82.27% males, median age 27 years), 5,929 (1.93%) had serological evidence of at least one TTVI, and 26 (0.0085%) had multiple infections. The lowest prevalence (1.09%) was detected in donors aged 18-25 years old, and a higher prevalence (2.05%) was evident in males in comparison with females (1.38%). The seroprevalence of HBV, HCV, and HIV was 1.18, 0.52, and 0.23%, respectively. Trend analyses revealed a significant regression in HBV and HIV prevalence from 2011 to 2021. HBV seropositivity depicted a temporal decline by ~80%, from 0.79% in 2011 to 0.16% in 2021 in those born in 1993 and thereafter.

Discussion

The seroprevalence of HBV, HIV, and to a lesser extent HCV dropped over the study 18-year period. Possible explanations may include implementation of the HBV vaccine, robust national health system, conservative sociocultural values, and isolation.

Sub-genotypes of hepatitis C virus in the Middle East and North Africa: Patterns of distribution and temporal changes

Infection with the hepatitis C virus (HCV) remains a considerable public health concern in the Middle East and North Africa (MENA). The objectives of this study were to analyze the HCV genotype (GT) and sub-genotype (SGT) distribution in the MENA region and to assess the temporal change in the number of sequences within the MENA region. All HCV molecular sequences collected in the MENA region had been retrieved from GenBank as of 1 August 2022. The number of HCV sequences retrieved was 6740 representing sequences from a total of 17 MENA countries with a majority from Iran (n = 1969, 29.2%), Egypt (n = 1591, 23.6%), Tunisia (n = 1305, 19.4%) and Saudi Arabia (n = 1085, 16.1%). The determination of GT/SGT was based on the NCBI genotyping and Blast tool. Genotype 1 (GT1) dominated infections in the MENA (n = 2777, 41.2%), followed by GT4 (n = 2566, 39.0%). Additionally, SGT4a (1515/6393, 23.7%) was the most common SGT in the MENA, and SGT4a was dominant in Egypt and Saudi Arabia, followed by SGT1b (n = 1308, 20.5%), which was dominant in Morocco and Tunisia, while SGT1a (n = 1275, 19.9%) was common in Iran, Iraq and Palestine. Furthermore, significant temporal increase in the number of HCV MENA sequences was observed. On the SGT level, specific patterns of HCV genetic diversity were seen in the MENA region, with the most common SGT being 4a, in addition to increasing the availability of HCV sequences in the MENA region.

An Evolving HIV Epidemic in the Middle East and North Africa (MENA) Region: A Scoping Review

Human immunodeficiency virus (HIV) in the Middle East and North Africa (MENA) region is severely understudied despite the region's increase in new HIV infections since 2010. A key population that is particularly affected, due to the lack of adequate knowledge and proper interventional implementation, includes people who inject drugs (PWID). Furthermore, the paucity of HIV data (prevalence and trends) worsens an already critical situation in this region. A scoping review was conducted to address the scarcity of information and to synthesize the available data on HIV prevalence rates within the key population of PWID throughout the MENA region. Information was sourced from major public health databases and world health reports. Of the 1864 articles screened, 40 studies discussed the various factors contributing to the under-reporting of HIV data in the MENA region among PWID. High and overlapping risk behaviors were cited as the most prevalent reason why HIV trends were incomprehensible and hard to characterize among PWID, followed by lack of service utilization, lack of intervention-based programs, cultural norms, lack of advanced HIV surveillance systems, and protracted humanitarian emergencies. Overall, the lack of reported information limits any adequate response to the growing and unknown HIV trends throughout the region.

Hepatitis C virus prevalence, determinants, and cascade of care among people who inject drugs in Iran

BACKGROUND

People who inject drugs (PWID) continue to experience the highest burden of hepatitis C virus (HCV). We aimed to characterize HCV antibody prevalence, determinants of infection, and the cascade of engagement in HCV care among PWID in Iran.

METHODS

Participants were recruited in 11 cities of Iran using respondent-driven sampling. PWID underwent a structured interview capturing measures on socio-demographics, behaviors, and the HCV cascade of care. HCV and HIV were tested using antibody rapid tests. Multivariable logistic regression models identified characteristics associated with HCV seropositivity.

RESULTS

HCV antibody prevalence was 26.0% among 2684 PWID enrolled. Of 699 participants who were HCV antibody positive, 88 (12.6%) were aware of past infections. HCV antibody prevalence was associated with older age (adjusted odds ratio [aOR] 2.09; 95% CI 1.18, 3.71), lower education (aOR 1.31; 95% CI 1.02, 1.69), >10 years of injecting (aOR 6.03; 95% CI 4.10, 8.85), methamphetamine injection (aOR 1.46; 95% CI 1.07, 1.99), daily injection drug use (aOR 1.26; 95% CI 1.01, 1.58), needle/syringe sharing (aOR 2.04; 95% CI 1.24, 3.34), recent incarceration (aOR 1.74; 95% CI 1.30, 2.32), and HIV seropositivity (aOR 7.93; 95% CI 4.12, 15.24). Additionally, 12.0% had ever tested for HCV, 4.0% had previously tested reactive for HCV antibody, and 3.7% had received an HCV diagnosis. Of diagnosed cases, 44.4% were linked to care, 15.2% initiated treatment, and 3.0% achieved sustained virologic response.

CONCLUSION

Our data show a high prevalence of HCV antibody and low engagement in HCV care, underscoring an unmet need for HCV prevention, screening, and treatment among PWID in Iran. HCV prevention and treatment programs tailored for PWID are needed to enhance harm reduction efforts and access to HCV care in Iran.

Characterizing trends and associations for hepatitis C virus antibody prevalence in the Middle East and North Africa: meta-regression analyses

This study characterized population-level trends and associations with hepatitis C virus (HCV) antibody (Ab) prevalence in the Middle East and North Africa (MENA). Data source was the standardized and systematically gathered MENA HCV Epidemiology Synthesis Project Database. Random-effects univariable and multivariable meta-regressions were conducted. 2,621 HCV Ab prevalence measures on 49,824,108 individuals were analyzed. In the analysis including all populations, 71% of the variation in prevalence was explained, mostly by at-risk population type. Compared to the general population, prevalence was 23-fold higher among people who inject drugs, and 14-fold higher among high-risk clinical populations. In the analysis including only the general population, 67% of the variation in prevalence was explained, mostly by country/subregion. Compared to Afghanistan, prevalence was highest in Egypt and Pakistan. Prevalence in the general population was declining at a rate of 4% per year, but outside the general population, the decline was at only 1% per year. HCV Ab prevalence in MENA is declining rapidly, but this decline is largely occurring in the general population following introduction of blood and injection safety measures. The decline in populations at higher risk of exposure is slow and below the level needed to achieve HCV elimination by 2030.

Epidemiology of Hepatitis C Virus Infection Among High-risk Populations in Northeastern Iran

Background: Chronic hepatitis C virus (HCV) infection affects 58 million people globally. The frequency of HCV infection in the general Iranian population is less than 0.5%; however, a concentrated epidemic was reported among people who use drugs, particularly those with a history of drug injection. Objectives: This cross-sectional study was performed to assess the prevalence of HCV infection among high-risk groups outside of prison in northeastern Iran. Methods: A total of 962 participants in Razavi Khorasan province were enrolled from 2018 to 2022. They included drug users referred to drug treatment and harm reduction centers and individuals with a history of crimes such as drug use or imprisonment who worked in a private industrial unit. Serum anti-HCV antibodies were assessed using a rapid or ELISA kit, and seroreactive samples were confirmed by single-step reverse transcriptase or qualitative real-time polymerase chain reactions. A P-value < 0.05 was considered statistically significant. Results: The mean age of 707 males and 255 females was 39.8 ± 10.2 years. Anti-HCV antibodies were detected from 129 samples (13.41%), of which 117 were available for polymerase chain reaction testing. HCV RNA was detected in 88 cases (75.2%); the total viremia rate was calculated as 9.26% (88/950). Logistic regression analysis revealed that HCV infection among drug users was significantly associated with older age (P = 0.002), being single (P = 0.009), and history of drug injection (P < 0.001) or incarceration (P = 0.04). Conclusions: The findings showed a considerably high prevalence of HCV infection among people who use drugs in northeastern Iran. To achieve the global goal of viral hepatitis elimination by 2030, we strongly recommend stricter screening and treatment of this infection among such hard-to-access populations in Iran.

Collaborative Referral Model to Achieve Hepatitis C Micro-Elimination in Methadone Maintenance Treatment Patients during the COVID-19 Pandemic

Although hepatitis C virus (HCV) prevails in patients receiving methadone maintenance treatment (MMT), most do not receive anti-HCV therapy. This single-center observational study aimed to achieve HCV micro-elimination at an MMT center during the COVID-19 pandemic using a collaborative referral model, which comprised a referral-for-diagnosis stage (January 2020 to August 2020) and an on-site-diagnosis stage (September 2020 to January 2021). A multidisciplinary team was established and all MMT center patients were enrolled. HCV micro-elimination was defined as >90% of HCV-infected patients diagnosed and >80% of HCV-viremic patients treated. A total of 305 MMT patients, including 275 (90.2%) anti-HCV seropositive patients, were enrolled. Among 189 HCV-infected patients needing referral, the accumulative percentage receiving HCV RNA testing increased from 93 (49.2%) at referral-for-diagnosis stage to 168 (88.9%) at on-site-diagnosis stage. Among 138 HCV-viremic patients, the accumulative percentage receiving direct-acting antiviral (DAA) therapy increased from 77 (55.8%) at referral-for-diagnosis stage to 129 (93.5%) at on-site-diagnosis stage. We achieved an HCV RNA testing rate of 92.4% (254/275), an HCV treatment rate of 95.8% (203/212) and a sustained virological response rate of 94.1% (191/203). The collaborative referral model is highly effective in HCV RNA testing and HCV treatment uptake among MMT patients, achieving HCV micro-elimination.

Hepatitis C virus transmission cluster among injection drug users in Pakistan

Hepatitis C virus (HCV) infections are public health problem across the globe, particularly in developing countries. Pakistan has the second highest prevalence of HCV infection worldwide. Limited data exist from Pakistan about persons who inject drugs (PWID) and are at significant risk of exposure to HCV infection and transmission. Serum specimens (n = 110) collected from PWID residing in four provinces were tested for molecular markers of HCV infection. Next generation sequencing (NGS) of the hypervariable region (HVR1) of HCV and Global Hepatitis Outbreak and Surveillance Technology (GHOST) were used to determine HCV genotype, genetic heterogeneity, and construct transmission networks. Among tested specimens, 47.3% were found anti-HCV positive and 34.6% were HCV RNA-positive and belonged to four genotypes, with 3a most prevalent followed by 1a, 1b and 4a. Variants sampled from five cases formed phylogenetic cluster and a transmission network. One case harbored infection with two different genotypes. High prevalence of infections and presence of various genotypes indicate frequent introduction and transmission of HCV among PWID in Pakistan. Identification of a transmission cluster across three provinces, involving 20% of all cases, suggests the existence of a countrywide transmission network among PWIDs. Understanding the structure of this network should assist in devising effective public health strategies to eliminate HCV infection in Pakistan.

Status of the HIV epidemic in key populations in the Middle East and north Africa: knowns and unknowns

The Middle East and north Africa is one of only two world regions where HIV incidence is on the rise, with most infections occurring among key populations: people who inject drugs, men who have sex with men, and female sex workers. In this Review, we show a trend of increasing HIV prevalence among the three key populations in the Middle East and north Africa. Although the epidemic continues at a low level in some countries or localities within a country, there is evidence for concentrated epidemics, with sustained transmission at considerable HIV prevalence among people who inject drugs and men who have sex with men in over half of countries in the region with data, and among female sex workers in several countries. Most epidemics emerged around 2003 or thereafter. The status of the epidemic among key populations remains unknown in several countries due to persistent data gaps. The HIV response in Middle East and north Africa remains far below global targets for prevention, testing, and treatment. It is hindered by underfunding, poor surveillance, and stigma, all of which are compounded by widespread conflict and humanitarian crises, and most recently, the advent of COVID-19. Investment is needed to put the region on track towards the target of eliminating HIV/AIDS as a global health threat by 2030. Reaching this target will not be possible without tailoring the response to the needs of key populations, while addressing, to the extent possible, the complex structural and operational barriers to success.

Hepatitis C virus among blood donors and general population in Middle East and North Africa: Meta-analyses and meta-regressions

BACKGROUND

Despite the Middle East and North Africa (MENA) Region reported to have the highest prevalence of hepatitis C virus (HCV) globally, HCV infection levels in the majority of MENA countries remain inadequately characterized. Blood donor data have been previously used as a proxy to assess levels and trends of HCV in the general population, however, it is unclear how comparable these populations are in MENA and whether blood donors provide an appropriate proxy.

AIM

To delineate HCV epidemiology among blood donors and the general population in the MENA.

METHODS

The data source was the systematically gathered MENA HCV Epidemiology Synthesis Project Database. Random-effects meta-analyses and meta-regressions were conducted. For comparison, analyses were conducted for Europe, utilizing the Hepatitis C Prevalence Database of the European Centre for Disease Prevention and Control.

RESULTS

One thousand two hundred and thirteen HCV antibody prevalence measures and 84 viremic rate measures were analyzed for MENA. Three hundred and seventy-seven antibody prevalence measures were analyzed for Europe. In MENA, pooled mean prevalence was 1.58% [95% confidence interval (CI): 1.48%–1.69%] among blood donors and 4.49% (95%CI: 4.10%–4.90%) in the general population. In Europe, pooled prevalence was 0.11% (95%CI: 0.10%–0.13%) among blood donors and 1.59% (95%CI: 1.25%–1.97%) in the general population. Prevalence in the general population was 1.72-fold (95%CI: 1.50–1.97) higher than that in blood donors in MENA, but it was 15.10-fold (95%CI: 11.48–19.86) higher in Europe. Prevalence was declining at a rate of 4% per year in both MENA and Europe [adjusted risk ratio: 0.96 (95%CI: 0.95–0.97) in MENA and 0.96 (95%CI: 0.92–0.99) in Europe]. Pooled mean viremic rate in MENA was 76.29% (95%CI: 67.64%–84.02%) among blood donors and 65.73% (95%CI: 61.03%–70.29%) in the general population.

CONCLUSION

Blood donor data provide a useful proxy for HCV infection in the wider population in MENA, but not Europe, and could improve HCV burden estimations and assess progress toward HCV elimination by 2030.

Hepatitis C Virus Prevalence, Medical Status Awareness and Treatment Engagement among Homeless People Who use Drugs: Results of a Street Outreach Study

Background:

Hepatitis C virus (HCV) infection is a primary health concern among people who use drugs (PWUDs). Homeless PWUDs that constitute a key population for HCV transmission remain underrepresented in many surveys.

Objectives:

We performed a proactive street outreach to evaluate HCV infection prevalence among homeless PWUDs in Tel Aviv, identify risk factors associated with HCV infection, awareness of disease status and linkage to care rate.

Results:

Thirty-eight percent of approached PWUD were willing to participate in the study. Out of 53 subjects who got tested for anti HCV by rapid test, 29 (54.72%) had a positive result, 20 of 29 anti-HCV positive (69%) patients had positive HCV PCR. Risk factors were investigated using structured questionnaires. Heroin use was reported significantly more frequently in the HCV-positive group (P = .05, CI 95%), whereas other established risk factors did not reach significance in our cohort. While 21 of 29 (72%) HCV-positive participants were aware of their condition, only 4 of 21 (19%) received treatment in the past, and 2 of 4 (50%) failed to achieve treatment goals, as assessed by HCV PCR.

Conclusions:

Our data indicate a high prevalence of HCV infection among homeless PWUDs. Importantly, despite relatively high awareness of HCV status in this population, we found strikingly low access to care. These findings motivate novel interventional approaches targeted at improving patient access, and compliance among homeless PWUDs, in an effort to reduce HCV transmission.

Understanding and Responding to Substance Use and Abuse in the Palestinian Refugee Camps in Lebanon Prior to and During COVID-19 Times

Due to its geographical proximity to the Syrian conflict and the occupied territories, Lebanon has experienced an influx of refugees in recent times. Palestinian refugees are an identified key vulnerable population, with displaced communities increasingly experiencing camp insecurity, vulnerability to drug use and related health harms. A qualitative study consisting of in-depth interviews and focus group discussions (FGDs) was undertaken as part of a regional exercise investigating Palestinian community experiences of substance and drug use in refugee camps. Thematic analysis triangulated the perspectives of 11 professional stakeholders representing United Nations, human rights and non-governmental organizations (NGOs), and eight Palestinian community members. Emerging themes centered on the interplay between socio-economic instability, lack of law enforcement and camp governance contributing to concerning levels of familial, drug and camp violence, trafficking and availability of drugs. Transactional sex and the exploitation of women and children in drug dealing, diversification toward drug manufacture and dealing of drugs with the outside community were described. There is a lack of harm reduction and rehabilitation supports for those in need. This study highlights the complexities in tackling drug dealing and related criminal activity within refugee camps and humanitarian settings, and the vulnerabilities of those living within to harmful drug use.

Hepatitis C Virus Infection in Persons Who Inject Drugs in the Middle East and North Africa: Intervention Strategies

There is a high incidence and prevalence of hepatitis C viral infection in persons with or without substance use disorders (SUDs) in the Middle East and North Africa (MENA) region, but only a small number receive comprehensive care. Highly effective direct-acting antiviral (DAA) medications are available at substantially lower costs; however, complete elimination of the hepatitis C virus (HCV) can only be achieved if integrated care strategies target those at highest risk for HCV infection and transmission and improve access to care. Due to the high prevalence of SUD in the MENA region, strategies to eliminate HCV must focus on integrated healthcare across multiple subspecialties, including addiction medicine, psychiatry, infectious diseases, hepatology, and social work. In this invited manuscript, we review the epidemiology of HCV in the MENA region and highlight intervention strategies to attain the WHO's goal of HCV eradication by 2030.

The status of hepatitis C virus infection among people who inject drugs in the Middle East and North Africa

BACKGROUND AND AIMS

People who inject drugs (PWID) are a key population at high risk of hepatitis C virus (HCV) infection. The aim of this study was to delineate the epidemiology of HCV in PWID in the Middle East and North Africa (MENA).

METHODS

Syntheses of data were conducted on the standardized and systematically assembled databases of the MENA HCV Epidemiology Synthesis Project, 1989-2018. Random-effects meta-analyses and meta-regressions were performed. Meta-regression variables included country, study site, year of data collection and year of publication [to assess trends in HCV antibody prevalence over time], sample size and sampling methodology. Numbers of chronically infected PWID across MENA were estimated. The Shannon Diversity Index was calculated to assess genotype diversity.

RESULTS

Based on 118 HCV antibody prevalence measures, the pooled mean prevalence in PWID for all MENA was 49.3% [95% confidence interval (CI) = 44.4-54.1%]. The country-specific pooled mean ranged from 21.7% (95% CI = 4.9-38.6%) in Tunisia to 94.2% (95% CI = 90.8-96.7%) in Libya. An estimated 221 704 PWID were chronically infected, with the largest numbers found in Iran at 68 526 and in Pakistan at 46 554. There was no statistically significant evidence for a decline in HCV antibody prevalence over time. Genotype diversity was moderate (Shannon Diversity Index of 1.01 out of 1.95; 52.1%). The pooled mean percentage for each HCV genotype was highest in genotype 3 (42.7%) and in genotype 1 (35.9%).

CONCLUSION

Half of people who inject drugs in the Middle East and North Africa appear to have ever been infected with hepatitis C virus, but there are large variations in antibody prevalence among countries. In addition to > 200 000 chronically infected current people who inject drugs, there is an unknown number of people who no longer inject drugs who may have acquired hepatitis C virus during past injecting drug use. Harm reduction services must be expanded, and innovative strategies need to be employed to ensure accessibility to hepatitis C virus testing and treatment.

Key associations for hepatitis C virus genotypes in the Middle East and North Africa

This study aimed to investigate the epidemiology of hepatitis C virus (HCV) genotypes in the Middle East and North Africa (MENA) through an analytical and quantitative meta-regression methodology. For the most common genotypes 1, 3, and 4, country/subregion explained more than 77% of the variation in the distribution of each genotype. Genotype 1 was common across MENA, and was more present in high-risk clinical populations than in the general population. Genotype 3 was much more present in Afghanistan, Iran, and Pakistan than the rest of countries, and was associated with transmission through injecting drug use. Genotype 4 was broadly disseminated in Egypt in all populations, with overall limited presence elsewhere. While genotype 2 was more present in high-risk clinical populations and people who inject drugs, most of the variation in its distribution remained unexplained. Genotypes 5, 6, and 7 had low or no presence in MENA, limiting the epidemiological inferences that could be drawn. To sum up, geography is the principal determinant of HCV genotype distribution. Genotype 1 is associated with transmission through high-risk clinical procedures, while genotype 3 is associated with injecting drug use. These findings demonstrate the power of such analytical approach, which if extended to other regions and globally, can yield relevant epidemiological inferences.