Micro-elimination of hepatitis C among people living with HIV in Egypt

Viral hepatitis is a global health challenge and a leading cause of death worldwide.¹ In 2016, the World Health Organization (WHO) called for the elimination of hepatitis C virus (HCV) as a public health threat by 2030, including a 90% reduction in incidence and a 65% reduction in hepatitis-related mortality globally.²

Until recently, Egypt had by far one of the highest HCV prevalence rates in the world.³ A national elimination plan, including a free, domestically funded screening and treatment campaign has recently been implemented to control this epidemic.⁴ Of the target population of 62.5 million (18 years of age or older), up to 50 million (79.4%) adults were screened, and over 2 million (4.0%) of these were diagnosed with HCV infection and linked to care over a period of 7 months, from October 2018 to April 2019. Additionally, 2 million patients were successfully treated since the introduction of direct-acting antivirals (DAAs) in 2014.

To further advance progress towards the WHO elimination goal, a micro-elimination strategy is now essential. Such a strategy would complement national, population-based screening efforts and scale up HCV diagnosis and treatment uptake among disproportionately affected and often difficult-to-reach populations.⁵

In a recent review, Hollande et al noted that, ‘…the targets for HCV micro-elimination are now well established… high-risk populations (migrant communities from high-prevalence regions, HIV-infected, [people who inject drugs] PWID, [men who have sex with men] MSM) and target groups (patients with advanced liver disease, haemophiliacs, prisoners, generational cohorts with high prevalence)…’ and emphasized the importance of achieving HCV cure among these groups to reach the WHO HCV elimination targets.⁶

As highlighted by Holland et al, one of the key target groups for HCV micro-elimination in Egypt is people living with HIV (PLHIV). Egypt has a low HIV prevalence among the general population at <0.02%.⁷ However, there is a concentrated HIV epidemic among the populations of PWID and MSM.⁸ Egypt is also reported to have the fastest growing HIV rate in the Middle East and North Africa region, with an annual increase of newly discovered cases of about 25%-30% over the past 10 years.⁹

To assess the magnitude and associated risk factors for HCV infection among PLHIV in Egypt, we conducted a prospective study of HIV-positive patients attending the main HIV/AIDS reference centre in Cairo, Egypt, between 2016 and 2019.¹⁰ The study aimed to determine the incidence of HCV infection and identify risk factors for seroconversion. Out of 460 HIV-positive patients who were initially screened for HCV, 146 had a positive HCV antibody result, representing a baseline prevalence of 31.7%. The overall incidence of HCV in HIV infected patients was 4.06 cases per 100 person-years and 83.3% of those diagnosed with a new HCV infection reported a history of ongoing injecting drug use. Among HIV-positive PWID, the incidence of new HCV infections was 7.08 cases per 100 person-years.

PWID are also a key target group for HCV micro-elimination, with an estimated HCV prevalence of 55% among the 93 400 PWID in Egypt.^{11, 12} According to the Ministry of Health's latest Bio-Behavioral Surveillance Survey (Bio-BSS 2010), PWID also had the highest HIV prevalence rate (7.7% in Cairo and 6.7% in Alexandria).⁸ This was not surprising as sharing needles in the past 30 days was a common practice among PWID in Alexandria and Cairo (40.5% and 22.9%, respectively). Furthermore, the criminalization of drug use in Egypt means PWID are frequently put in prison, placing them at higher risk of contracting HCV through high-risk behaviours, such as tattooing, sharing toiletries and unsafe injections.

Given the relationship between HIV, HCV and injecting drug use, a successful HCV elimination strategy must involve targeted testing and treatment of HIV-positive PWID. Furthermore, enhanced screening approaches must be expanded to the broader PWID population, as well as other vulnerable groups who bear disproportionate burdens of both HIV and HCV including homeless people, people with mental health issues and prisoners. This will allow for tackling both HIV and HCV infection through dual testing among at-risk populations.

Simplified models of care, including rapid point-of-care testing for both HIV and HCV and co-localization of HIV and HCV care, are ideal approaches involving multidisciplinary care teams, which provide integrated services and allow for improved linkage to care.¹³ Regular screening for reinfection is also essential to identify acute infections and treat them early to reduce the risk of transmission. Furthermore, the availability of locally produced, generic DAAs with cure rates >95%, allows for widespread scale-up of HCV treatment and provides an important tool to eliminate HCV among people with HCV/HIV co-infection.¹⁴

Completely eliminating HCV among HIV-positive PWID will require a strategic combination of treatment strategies along with harm reduction services, such as opioid substitution therapy (OST) and needle and syringe programs (NSP). OST with methadone and buprenorphine is considered the gold standard for addressing opioid dependence and both drugs are included in the WHO Essential Medication List since 2005.¹⁵ In addition to maximizing the benefits of DAA therapy for prevention, both OST and high-coverage NSP are safe and cost-effective public health interventions and when combined can reduce HCV incidence by up to 80%.¹⁶ However, OST is still not available in Egypt and NSP are limited across the country for fear of prosecution.^{12, 17}

A major barrier to HCV elimination in PLHIV is the stigmatization of HIV and AIDS in Egyptian society. For PLHIV, discrimination can occur at all levels of daily life, even within healthcare facilities. A recent study conducted in Tanta University Hospitals surveyed 310 doctors and nurses about attitudes towards PLHIV and how prepared they felt about working with them.¹⁸ The study revealed high levels of discrimination and stigma against PLHIV among healthcare workers, with 40% of them being unwilling to care for and only 36% reporting that they may get in trouble for discriminating against HIV patients. Fear of discrimination, harassment or prosecution prevents at-risk groups from revealing their high-risk behaviour or seeking healthcare. This can complicate prevention efforts and push risky behaviour further underground.

As we enter the final decade to meet the WHO HCV elimination goal, Kondili et al recently reported that WHO guidance is important in helping to define progress towards true elimination.¹⁹ However, absolute targets, rather than those based on the 2015 benchmark, identified by each country, according to their most affected populations, are more relevant for this effort.^{18, 20} Therefore, non-discriminatory, tailored interventions must be delivered quicker and more efficiently to achieve HCV elimination among PLHIV in Egypt. There should be a focus on enhanced screening, linkage to care, treatment and harm reduction provision among both co-infected individuals and the broader population at continued risk, such as PWID.

The COVID-19 pandemic has undoubtedly impacted health system priorities. However, some of the innovative interventions developed during this period, such as those related to virtual health and differentiated service delivery approaches, may be transferrable to HCV micro-elimination efforts among difficult-to-reach populations during the pandemic and beyond, to ensure that no one is left behind.¹⁹

CONFLICT OF INTEREST

The authors declare that they have no conflicts of interest related to this manuscript.

AUTHORS CONTRIBUTIONS

All authors were involved in the conceptualization, writing and editing process. RM and AC developed the first draft, which JVL and RM further revised. All authors revised and approved the final version.