Hepatitis C virus (HCV) infection is a major global health problem, with an estimated 71 million people chronically infected with hepatitis C worldwide.1 In 2015, 1·34 million deaths were attributed to viral hepatitis due to complications of cirrhosis, end-stage liver disease, and hepatocellular carcinoma, and 30% of these deaths were directly attributed to HCV infection.1, 2, 3 New oral direct-acting antivirals have transformed treatment of HCV, achieving cure rates of higher than 95%, with use of short-duration (12–24 weeks) oral regimens, some of which now have pan-genotypic efficacy.4
The seroprevalence and burden of HCV in the general population in Egypt is among the highest in the world, largely as a result of mass population-level antischistosomal campaigns in the 1950s with poor injection safety and other unsafe medical practices.5 In 2008, the estimated prevalence of chronic infection (defined as HCV RNA positivity) in Egypt was 10%,6 and by 2015 this prevalence had decreased to 7%.7 Distinctive epidemiological features of the hepatitis C epidemic in Egypt include a pronounced birth cohort effect, with a higher prevalence among people older than 50 years due to previous exposure via unsafe medical practices, and among those in rural settings, of low socioeconomic status, and with a low educational level. Most people are infected with genotype 4.8, 9, 10, 11 Another key issue has been the high incidence of new infections, estimated at 2–6 per 1000 people (equivalent to at least 170 000 new cases) per year,11 which has been attributed largely to persistent unsafe injection and health-care practices,11, 12, 13 and highlights the need for concomitant effective preventive strategies.
Research in context
Evidence before this study
The prevalence and burden of hepatitis C virus (HCV) in Egypt is one of the highest in the world, with an estimated 7% of the population living with hepatitis C viraemia. However, Egypt has established a successful national treatment programme towards the goal of HCV elimination. From 2014 to early 2017, more than 1 million people who were infected with HCV had been treated, mainly with new direct-acting antiviral regimens. However, to treat the several million people who are infected but undiag-nosed and link them to treatment requires a substantial expansion in access to testing. This substantial expansion is particularly important in rural communities that account for 57% of Egypt's population of 92 million people and have restricted access to exisitng HCV testing and treatment services. The 2017 WHO guidelines on testing for chronic viral hepatitis recommend implementing general population testing in high prevalence countries. We designed a demonstration project with the goal to eliminate HCV infection from all adults (aged 12–80 years) living in a typical village in the governorate of Gharbiah in northern Egypt (with an estimated general population HCV prevalence of 7·4%). To our knowledge, no previous studies have adopted such a systematic approach to identification and treatment of cases in a country with a high burden of HCV, or combined such an approach with a preventive educational campaign to eliminate HCV and its transmission in a rural community.
Added value of study
Our programme model combined both preventive strategies of raising awareness in the community and an educational campaign to achieve sustained behavioural change, with a systematic household testing approach to identify villagers infected with HCV, followed by prompt linkage to care and treatment. This approach achieved high uptake of HCV testing, linkage to care and treatment, and attainment of cure. Overall, the treatment coverage and cure was over 90% of the estimated HCV-infected village population. We also achieved wide coverage among those reached with the educational campaign, increased both the awareness and understanding of HCV and its transmission, and the adoption of recommended safer behaviours and practices to reduce transmission. These outcomes along the cascade of care for treatment and prevention are a marked improvement on previously reported outcomes from other population studies. In particular, few other programmes have reported on the concomitant effect of preventive educational and behavioural change initiatives.
Implications of all the available evidence
This community-based and community-led programme is an important model for delivering testing, treatment, education, and prevention for the elimination of HCV, particularly in rural communities, and complements the existing Egyptian Government national treatment programme and strategy. Countries with a similarly high HCV prevalence and burden in the general population and with a large rural-based population, such as Pakistan, Mongolia, or Indonesia, could also benefit from a similar community-based approach. This approach would need to be adapted for each country's health-care infrastructure and epidemiological context. Our programme model is currently being extended to 63 other villages in Egypt from which additional lessons will be learned to inform further scale-up.
The Egyptian Ministry of Health and Population, in collaboration with key stakeholders, developed a comprehensive plan of action for the prevention, care, and treatment of viral hepatitis in Egypt for 2008–12,11 which was updated for 2014–18 period14 and covers six main components of prevention and control: surveillance, infection control, improving blood safety, hepatitis B vaccination, health education to providers and communities, and care and treatment. In Egypt, from 2014 to early 2017, more than a million people who were chronically infected with HCV were treated, mainly with new direct-acting antiviral regimens,15, 16, 17 through the national government-funded programme and national health insurance scheme.18 Although the prevalence of chronic HCV infection in the adult population in Egypt has decreased from 10% in 20086 to 7% in 2015,7 3·5–4·2 million people are estimated to be living with the infection and in need of treatment.16
Most patients who have already been treated through the government programme were already aware of their diagnosis or had a symptomatic infection. Key challenges to further scale-up of treatment in Egypt include that most people who are infected—particularly in rural communities—remain undiagnosed and are unaware of their infection, access to testing through the national programme has been restricted, and the perceived costs of accessing care, especially among people from rural areas.18
In Egypt, to achieve the testing and treatment targets of the global hepatitis health sector strategy towards the goal of HCV elimination by 2030,19, 20 access to testing needs to be substantially expanded to identify those infected and link them to treatment. Increasing access is particularly important in rural communities, which account for 57% of Egypt's population of 92 million people, and include many who might not perceive themselves as at risk. The 2017 WHO guidelines on testing for chronic viral hepatitis included specific recommendations to implement general population testing approaches in high-prevalence countries and settings.20, 21
The overall objective of this project was to establish a comprehensive community-led model programme for the prevention, diagnosis, and treatment of hepatitis C in one Egyptian village, and identify knowledge that could inform scale up to other villages and rural settings. This approach is intended to complement the existing national treatment programme and support the national goal towards elimination of HCV in Egypt.