Articles
An educate, test, and treat programme towards elimination of hepatitis C infection in Egypt: a community-based demonstration project

https://doi.org/10.1016/S2468-1253(18)30139-0Get rights and content

Summary

Background

Egypt has one of the highest prevalences and burdens of hepatitis C virus (HCV) worldwide, and a large government treatment programme. However, identifying and treating people who are infected in rural communities can be a substantial challenge. We designed and evaluated a comprehensive community-led outreach programme for prevention, testing, and treatment of HCV infection in one village in northern Egypt, with the goal to eliminate HCV infection from all adult villagers, and as a model for potential adoption in rural settings.

Methods

A community-based education and test-and-treat project was established in Al-Othmanya village. The programme consisted of community mobilisation facilitated by a network of village promoters and establishment of partnerships; an educational campaign to raise awareness and promote behavioural changes; fundraising for public donations in the local community; and comprehensive testing, diagnosis, and treatment. For the educational campaign, we used public awareness events, house-to-house visits, and promotional materials (eg, booklets, cartoons, songs) to raise awareness of HCV and its transmission, and changes in knowledge, attitudes, and practices were measured through the use of a survey done before and after the educational campaign. Comprehensive testing, linkage to care, and treatment was offered to all eligible villagers (ie, those aged 12–80 years who had not previously been treated for HCV). Testing was done by use of HCV antibody and hepatitis B surface antigen (HBsAg) rapid diagnostic tests, with HCV-RNA PCR confirmation of positive cases, and staging of liver disease by use of transient elastography. HCV-RNA-positive participants were offered a 24-week course of sofosbuvir (400 mg orally, daily) and ribavirin (1000–1200 mg orally, daily) with an assessment of cure (sustained virological response) at 12 weeks after completion of treatment (SVR12).

Findings

Between June 6, 2015, and June 9, 2016, 4215 (89%) of 4721 eligible villagers were screened for HCV antibodies and HBsAg. Of these participants, 530 (13%) were HCV antibody positive and eight (<1%) were HBsAg positive. All HCV-antibody-positive individuals had an HCV-RNA assay, and 312 (59%) were HCV-RNA positive. All 312 completed a full baseline assessment with staging of liver disease, and 300 (96%) were given 24 weeks of sofosbuvir and ribavirin treatment within a median of 2·3 weeks (IQR 0·0–3·7) from serological diagnosis. 293 (98%) of the treated participants achieved SVR12. 42 (13%) HCV-RNA-positive participants had cirrhosis as determined by transient elastography, of whom 12 (29%) were diagnosed with hepatocellular carcinoma on the basis of α-fetoprotein measurement and ultrasound. 3575 (85%) of 4215 eligible villagers completed the baseline and after educational campaign survey, and awareness, knowledge, and adoption of safer practices to prevent HCV transmission all significantly increased (p<0·0001).

Interpretation

This community-led educate, test-and-treat demonstration project achieved high uptake of HCV testing, linkage to care and treatment, and attainment of cure in one village, as well as awareness and adoption of practices to prevent transmission in the community. This approach could be an important strategy for adoption in rural settings to complement the national government programme towards the elimination of HCV in Egypt.

Funding

Egyptian Liver Research Institute and Hospital.

Introduction

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.

Section snippets

Target community and project design

A demonstration project was established by the Egyptian Liver Research Institute and Hospital (ELRIAH), with a goal to eliminate infection with HCV from adults (aged 12–80 years) living in Al-Othmanya—one of 317 villages in the governorate of Gharbiah, which has an overall population of 4·6 million. Al-Othmanya has a population of 6997 living in about 1242 households. A chronic HCV infection prevalence of about 7·4% was assumed on the basis of the 2015 national estimates.7

In this typical

Results

Between June 6, 2015, and June 9, 2016, of the 6997 people who lived in about 1242 households in Al-Othmanya village, 4721 (67%) were within the eligible age range for inclusion in the testing programme. 506 (11%) of 4721 were then excluded from the programme because they had previously been diagnosed and treated for HCV (158 [3%]), were not living in the village at the time of testing (145 [3%]), or declined testing (203 [4%]; figure).

4215 (89%) of 4721 adult villagers were screened for HCV

Discussion

We report on one typical village in north Egypt affected by a high burden of HCV infection in the general population, and the establishment and successful implementation of a comprehensive community outreach programme to eliminate HCV infection. The project combined preventive strategies of community education on practices to reduce transmission, with systematic household testing to identify those infected, followed by prompt linkage to care and treatment. The programme achieved considerable

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