Risk of Severe COVID-19-Related Outcomes among Patients with Cirrhosis: A Population-Based Cohort Study in Canada.

We assessed the association between cirrhosis and severe COVID-19-related outcomes among people with laboratory-diagnosed COVID-19 infection in British Columbia, Canada. We used data from the British Columbia (BC) COVID-19 Cohort, a population-based cohort that integrates data on all individuals tested for COVID-19, with data on hospitalizations, medical visits, emergency room visits, prescription drugs, chronic conditions, and deaths in the Canadian province of BC. We included all individuals aged ≥18 who tested positive for SARS-CoV-2 by real-time reverse transcription-polymerase chain reaction from 1 January 2021 to 31 December 2021. Multivariable logistic regression models were used to assess the associations of cirrhosis status with COVID-19-related hospitalization and with ICU admission. Of the 162,509 individuals who tested positive for SARS-CoV-2 and were included in the analysis, 768 (0.5%) had cirrhosis. In the multivariable models, cirrhosis was associated with increased odds of hospitalization (aOR = 1.97, 95% CI: 1.58-2.47) and ICU admission (aOR = 3.33, 95% CI: 2.56-4.35). In the analyses stratified by age, we found that the increased odds of ICU admission among people with cirrhosis were present in all the assessed age-groups. Cirrhosis is associated with increased odds of hospitalization and ICU admission among COVID-19 patients.

Prevalence of hepatitis B and C infection and linkage to care among patients with Non-Communicable Diseases in three rural Rwandan districts: a retrospective cross-sectional study.

INTRODUCTION: Rwanda's Hepatitis C elimination campaign has relied on mass screening campaigns. An alternative "micro-elimination" strategy focused on specific populations, such as non-communicable disease (NCD) patients, could be a more efficient approach to identifying patients and linking them to care. METHODS: This retrospective cross-sectional study used routine data collected during a targeted screening campaign among NCD patients in Kirehe, Kayonza, and Burera districts of Rwanda and patients receiving oncology services from the Butaro District Hospital. The campaign used rapid diagnostic tests to screen for Hepatitis B surface antigen (HBsAg) and Hepatitis C antibody (anti-HCV). We reported prevalences and 95% confidence intervals for HBsAg and anti-HCV, assessed for associations between patients' clinical programs and hepatitis B and C, and reported cascade of care for the two diseases. RESULTS: Out of 7,603 NCD patients, 3398 (45.9%) self-reported a prior hepatitis screening. Prevalence of HBsAg was 2.0% (95% CI: 1.7%-2.3%) and anti-HCV was 6.7% (95% CI: 6.2%-7.3%). The prevalence of HBsAg was significantly higher among patients < 40 years (2.4%). Increased age was significantly associated with anti-HCV (12.0% among patients ≥ 70 years). Of the 148 individuals who screened positive for HbsAg, 123 had viral load results returned, 101 had detectable viral loads (median viral load: 451 UI/mL), and 12 were linked to care. Of the 507 individuals who screened positive for anti-HCV, 468 had their viral load results returned (median viral load: 1,130,000 UI/mL), 304 had detectable viral loads, and 230 were linked to care. CONCLUSION: Anti-HCV prevalence among Rwandan patients with NCD was high, likely due to their older age. NCD-HCV co-infected patients had high HCV viral loads and may be at risk of poor outcomes from hepatitis C. Hepatitis C micro-elimination campaigns among NCD patients are a feasible and acceptable strategy to enhance case detection in this high-prevalence population with elevated viral loads and may support linkage to care for hepatitis C among elderly populations.

Treatment of HCV with direct-acting antivirals on reducing mortality related to extrahepatic manifestations: a large population-based study in British Columbia, Canada.

Background: HCV infection is associated with mortality due to extrahepatic manifestations (EHM). Sustained virologic response (SVR) following direct-acting antiviral (DAA) therapy has been linked to decreased all-cause and liver-related mortality. However, evidence regarding the impact of DAA on EHM-related deaths is lacking. This study aimed to assess the impact of DAA and SVR on EHM-related mortality. Methods: The British Columbia Hepatitis Testers Cohort comprises ∼1.7 million people tested for HCV between 1990 and 2015 and is linked with administrative health data. Among individuals diagnosed with HCV by 12/31/2020, those who received at least one DAA treatment were matched to those who never received treatment by the year of their first HCV RNA positive date. We compared three groups: treated & SVR, treated & no-SVR, and untreated; and generated EHM mortality rates and incidence curves. To account for differences in baseline characteristics, we used inverse probability of treatment weights (IPTW). IPTW-weighted multivariable cause-specific Cox regression models were adjusted for competing risk and confounders. Findings: Study population included 12,815 treated (12,287 SVR, 528 no-SVR) and 12,815 untreated individuals (median follow-up 3.4 years, IQR 2.9). The untreated group had the highest EHM mortality rate (30.9 per 1000 person-years [PY], 95% CI 29.2-32.8), followed by the treated & no-SVR group (21.2 per 1000 PY, 95% CI 14.9-30.1), while the treated & SVR group had the lowest EHM mortality rate (7.9 per 1000 PY, 95% CI 7.1-8.7). In the multivariable model, EHM mortality in the treated & SVR group was significantly decreased (adjusted cause-specific hazard ratio [acsHR] 0.20, 95% CI 0.18-0.23). The treated & SVR group had significant reductions in mortality related to each of the EHMs (78-84%). Interpretation: Treatment of HCV with DAA was associated with significant reductions in EHM-related mortality. These findings emphasize the critical importance of timely diagnosis and treatment of HCV to prevent deaths associated with EHM, and have important implications for clinical practice and public health. Funding: This work was supported by the BC Centre for Disease Control and the Canadian Institutes of Health Research (CIHR) [Grant # NHC-348216, PJT-156066, and PHE-337680]. DJ has received Doctoral Research Award (#201910DF1-435705-64343) from the Canadian Institutes of Health Research (CIHR) and Doctoral fellowship from the Canadian Network on Hepatitis C (CanHepC). CanHepC is funded by a joint initiative of the Canadian Institutes of Health Research (CIHR) (NHC-142832) and the Public Health Agency of Canada (PHAC).

The association between HIV self-test awareness and recent HIV testing uptake in the male population in Gambia: data analysis from 2019-2020 demographic and health survey.

BACKGROUND: The Gambian Ministry of Health is supportive of HIV self-testing (HIVST) and HIVST initiatives are being piloted as an additional strategy to increase HIV testing for individuals not currently reached by existing services, particularly men. This study aimed to determine awareness of HIVST among Gambian men, and whether prior awareness of HIVST is associated with recent HIV testing uptake. METHODS: We used men's cross-sectional data from the 2019-2020 Gambian Demographic and Health Survey. We employed design-adjusted multivariable logistic regression to examine the association between HIVST awareness and recent HIV testing. Propensity-score weighting was conducted as sensitivity analyses. RESULTS: Of 3,308 Gambian men included in the study, 11% (372) were aware of HIVST and 16% (450) received HIV testing in the last 12 months. In the design-adjusted multivariable analysis, men who were aware of HIVST had 1.76 times (95% confidence interval: 1.26-2.45) the odds of having an HIV test in the last 12 months, compared to those who were not aware of HIVST. Sensitivity analyses revealed similar findings. CONCLUSION: Awareness of HIVST may help increase the uptake of HIV testing among men in Gambia. This finding highlights HIVST awareness-raising activities to be an important intervention for nationwide HIVST program planning and implementation in Gambia.

The Cascade of Care for Hepatitis C Treatment in Rwanda: A Retrospective Cohort Study of the 2017-2019 Mass Screening and Treatment Campaign.

Access to hepatitis C (HCV) testing and treatment is still limited globally. To address this, the Government of Rwanda launched a voluntary mass screening and treatment campaign in 2017. We studied the progression of patients through the cascade of HCV care during this campaign. We conducted a retrospective cohort study and included all patients screened at 46 hospitals between April 2017 and October 2019. We used hierarchical logistic regression to assess factors associated with HCV positivity, gaps in care, and treatment failure. A total of 860,801 people attended the mass screening during the study period. Some 5.7% tested positive for anti-HCV, and 2.9% were confirmed positive. Of those who were confirmed positive, 52% initiated treatment, and 72% of those initiated treatment, completed treatment and returned for assessment 12 weeks afterward. The cure rate was 88%. HCV positivity was associated with age, socio-economic status, sex, marital status, and HIV coinfection. Treatment failure was associated with cirrhosis, baseline viral load, and a family history of HCV. Our results suggest that future HCV screening and testing interventions in Rwanda and other similar settings should target high-risk groups. High dropout rates suggest that more effort should be put into patient follow-up to increase adherence to care.

Impact of Hepatitis B Virus Infection, Non-alcoholic Fatty Liver Disease, and Hepatitis C Virus Co-infection on Liver-Related Death among People Tested for Hepatitis B Virus in British Columbia: Results from a Large Longitudinal Population-Based Cohort Study.

Data on the contribution of hepatitis B virus (HBV) infection and related comorbidities to liver-related mortality in Canada are limited. We assessed the concurrent impact of HBV infection, non-alcoholic fatty liver disease (NAFLD), and hepatitis C virus (HCV) coinfection on liver-related deaths in British Columbia (BC), Canada. We used data from the BC Hepatitis Testers Cohort (BC-HTC). We used Fine-Gray multivariable sub-distributional hazards models to assess the effect of HBV, NAFLD, and HCV coinfection on liver-related mortality, while adjusting for confounders and competing mortality risks. The liver-related mortality rate was higher among people with HBV infection than those without (2.57 per 1000 PYs (95%CI: 2.46, 2.69) vs. 0.62 per 1000 PYs (95%CI: 0.61, 0.64), respectively). Compared with the HBV negative groups, HBV infection was associated with increased liver-related mortality risk in almost all of the subgroups: HBV mono-infection (adjusted subdistribution hazards ratio (asHR) of 3.35, 95% CI 3.16, 3.55), NAFLD with HBV infection, (asHR 12.5, 95% CI 7.08, 22.07), and HBV/HCV coinfection (asHR 8.4, 95% CI 7.62, 9.26). HBV infection is associated with a higher risk of liver-related mortality, and has a greater relative impact on people with NAFLD and those with HCV coinfection. The diagnosis and treatment of viral and fatty liver disease are required to mitigate liver-related morbidity and mortality.

Association between close interpersonal contact and vaccine hesitancy: Findings from a population-based survey in Canada.

Background: Vaccine hesitancy threatens efforts to bring the coronavirus disease 2019 (COVID-19) pandemic to an end. Given that social or interpersonal contact is an important driver for COVID-19 transmission, understanding the relationship between contact rates and vaccine hesitancy may help identify appropriate targets for strategic intervention. The purpose of this study was to assess the association between interpersonal contact and COVID-19 vaccine hesitancy among a sample of unvaccinated adults in the Canadian province of British Columbia (BC). Methods: Unvaccinated individuals participating in the BC COVID-19 Population Mixing Patterns Survey (BC-Mix) were asked to indicate their level of agreement to the statement, "I plan to get the COVID-19 vaccine." Multivariable multinomial logistic regression was used to assess the association between self-reported interpersonal contact and vaccine hesitancy, adjusting for age, sex, ethnicity, educational attainment, occupation, household size and region of residence. All analyses incorporated survey sampling weights based on age, sex, geography, and ethnicity. Results: Results were based on survey responses collected between March 8, 2021 and December 6, 2021, by a total of 4,515 adults aged 18 years and older. Overall, 56.7% of respondents reported that they were willing to get the COVID-19 vaccine, 27.0% were unwilling and 16.3% were undecided. We found a dose-response association between interpersonal contact and vaccine hesitancy. Compared to individuals in the lowest quartile (least contact), those in the fourth quartile (highest contact), third quartile and second quartile groups were more likely to be vaccine hesitant, with adjusted odd ratios (aORs) of 2.85 (95% CI: 2.02, 4.00), 1.91(95% CI: 1.38, 2.64), 1.78 (95% CI: 1.13, 2.82), respectively. Conclusion: Study findings show that among unvaccinated people in BC, vaccine hesitancy is greater among those who have high contact rates, and hence potentially at higher risk of acquiring and transmitting infection. This may also impact future uptake of booster doses.

Epidemiology of sexually transmitted infections: trends among patients screened for sexually transmitted infections in rwandan health facilities 2014-2020.

BACKGROUND: Sexually Transmitted Infections (STIs) are of great global health concern. Currently, there are limited epidemiological data characterizing STIs in the general population in Rwanda. We assessed the national and regional epidemiology of STIs in Rwanda from 2014-2020 among patients syndromically screened for STIs in all health facilities in Rwanda. METHODS: This is a retrospective analysis of the trend of STIs epidemiology among screened patients at all health facilities in Rwanda using data from the Health Management Information System (HMIS) reporting. Adult patients (15 years and over) screened for STIs between July 2014 and June 2020 were included in the analysis. Outcomes of interest were the number of individuals screened for STIs and individuals diagnosed with at least one STI with a syndromic approach only or plus a test together. RESULTS: Overall, the number of individuals screened for STIs over the study period was 5.3 million (M) in 2014-2015, 6.6 M in 2015-2016, 6.3 M in 2016-2017, 6.7 M in 2017-2018, 6.2 M in 2018-2019, and 4.9 M in 2019-2020. There was a modest increase in the number of individuals diagnosed and treated for STIs from 139,357 in 2014-15 to 202,294 (45% increase) in 2019-2020. At the national level, the prevalence of STI syndromes amongst individuals screened at health facilities in Rwanda varied between 2.37% to 4.16% during the study period. Among the provinces, Kigali city had the highest prevalence for the whole 6 years ranging from 3.46% (95%CI: 3.41, 3.51) in 2014-2015 to 8.23% (95%CI: 8.15, 8.31) in 2019-2020. CONCLUSION: From 2014 to 2020, the number of patients screened for STI syndromes in Rwanda varied between 4.9 M and 6.7 M. However, the prevalence of STIs among screened patients increased considerably over time, which could be associated with public awareness and improved data recording. The highest prevalence of all STIs was observed in urban areas and near borders, and private clinics reported more cases, suggesting the need to improve awareness in these settings and increase confidentiality and trust in public health clinics.

Impact of COVID-19 pandemic on HCV care cascade in Rwanda: Ecological study from July 2019 to June 2021.

Content available: Author Interview and Audio Recording.

Implementation of Refugees' Inclusion in National Viral Hepatitis B and Hepatitis C Screening Campaign in Mahama Refugee Camp, Rwanda.

INTRODUCTION: The World Health Organization has called for the elimination of hepatitis B virus (HBV) and hepatitis C virus (HCV) as public health threats by 2030. In response to the United Nations High Commissioner for Refugees requests, Rwanda became the first country to include refugees in its national viral hepatitis prevention and management program in 2019. We used secondary data to describe the implementation of the first HBV and HCV screening program among refugees in Rwanda. METHODS: Rapid diagnostic tests were used to screen for HBV surface antigen (HBsAg) and HCV antibody (anti-HCV). We used routine data collected during the HBV and HCV mass screening campaign among Burundian refugees living in Mahama camp and program records to estimate the screening coverage, the prevalence of HBV and HCV, and the cost of the campaign. RESULTS: Over 28 days in February and March 2020, 26,498 unique individuals were screened for HBV and HCV, reflecting a screening coverage of 77.9% (95% confidence interval [CI]=76.5%, 78.4%). Coverage was greater than 90% among women aged 30-64 years, but younger age groups and men were less likely to be screened. On average, 946 clients were screened per day. The prevalence of anti-HCV was 1.1% (95% CI=1.0%, 1.3%), and the prevalence of HBsAg was 3.8% (95% CI=3.6%, 4.0%). We estimate that the total cost of the campaign was US$177,336.60, reflecting a per-person-screened cost of US$6.69. CONCLUSION: Conducting a mass screening was a feasible and effective strategy to achieve high screening coverage and identify refugees who were eligible for HBV and HCV treatment. This screening program in the Mahama refugee camp can serve as a reference for other refugee camps in Rwanda and elsewhere.

Time to complete hepatitis C cascade of care among patients identified during mass screening campaigns in rural Rwanda: a retrospective cohort study.

BACKGROUND: Since the discovery of direct-acting antivirals, treatment for hepatitis C virus (HCV) is increasingly accessible in low-resource settings, but quality of care in these settings is not known. We described progression through the cascade of care among individuals who screened positive for HCV antibodies during a mass screening campaign in Kirehe and Kayonza, two rural Rwandan districts, in September 2019. METHODS: This retrospective cohort study used routine clinical data to assess proportions of participants completing each stage of the cascade of care, including: (a) screening positive on rapid diagnostic test; (b) return of initial viral load results; (c) detectable viral load; (d) treatment assessment; (e) treatment initiation; (f) return of sustained virological response (SVR12) results; and (g) achieving SVR12. We proposed three indicators to assess timely care provision and used medians and interquartile ranges (IQR) to describe the time to complete the cascade of care. RESULTS: Overall, 666 participants screened HCV positive, among them, 452 (68.1%) were female and median age was 61 years (IQR: 47, 70). Viral load results were returned for 537 (80.6%) participants of whom 448 (83.4%) had detectable viral loads. Of these, 398 (88.8%) were assessed for treatment, 394 (99%) were initiated, but only 222 (56.3%) had results returned for SVR12. Among those with SVR12 results, 208 (93.7%) achieved SVR12. When assessing timely care provision, we found 65.9% (95% CI: 62.0, 69.7) of initial viral load results were returned ≤ 30 days of screening; 45% (95% CI: 40.1, 49.8) of people with detectable viral load completed treatment assessment ≤ 90 days of initial viral load results; and 12.5% (95% CI: 9.2, 16.3) of SVR12 results were returned ≤ 210 days of treatment initiation among those who initiated treatment. The overall median time from screening to SVR12 assessment was 437 days. CONCLUSION: Despite high rates of SVR12 among those who completed all stages of the cascade of care, we identified gaps and delays in the treatment cascade. Improving communication between viral load testing hubs and health facilities could reduce the turn-around time for viral load testing, and actively monitor timeliness of care provision could improve quality of HCV care.

Safety and efficacy of sofosbuvir-velpatasvir-voxilaprevir for re-treatment of chronic hepatitis C virus infection in patients with previous direct-acting antiviral treatment failure in Rwanda (SHARED-3): a single-arm trial.

BACKGROUND: Hepatitis C virus (HCV) genotype 4 non-a/d subtypes, which frequently have NS5A resistance-associated substitutions, are highly prevalent in sub-Saharan Africa. These subtypes, particularly genotype 4r, have been associated with higher rates of failure of treatment regimens containing the NS5A inhibitors ledipasvir or daclatasvir, which are the most accessible direct-acting antivirals in low-income countries. Clinical evidence regarding the efficacy of re-treatment options for these subtypes is limited. We aimed to evaluate the safety and efficacy of sofosbuvir-velpatasvir-voxilaprevir for the treatment of adults in Rwanda with chronic HCV infection, predominantly of genotype 4, and a history of direct-acting antiviral treatment failure. METHODS: In this single-arm prospective trial, we enrolled adults (aged ≥18 years) with a HCV RNA titre of at least 1000 IU/mL, and a documented history of direct-acting antiviral failure. Patients were assessed for eligibility at a single study site after referral from hospitals with HCV treatment programmes throughout Rwanda, and participants for whom sofosbuvir-ledipasvir treatment had failed in the previous SHARED trial were also included. Participants with decompensated liver disease or hepatitis B virus co-infection were excluded. Participants were treated once daily with an oral fixed-dose combination tablet containing sofosbuvir (400 mg), velpatasvir (100 mg), and voxilaprevir (100 mg) for 12 weeks. The primary endpoint was the proportion of participants with a sustained virological response 12 weeks after completion of treatment (SVR12) in the intention-to-treat population. Viral sequencing of NS3, NS5A, and NS5B genes was done at baseline in all participants and at end of follow-up (week 24) in participants with treatment failure. The study is registered with ClinicalTrials.gov (NCT03888729) and is completed. FINDINGS: Between Sept 23, 2019, and Jan 10, 2020, 49 individuals were screened and 40 participants were enrolled. 20 (50%) were female, 20 (50%) were male, median age was 63 years (IQR 56-68), and median HCV viral load was 6·2 log10 IU/mL (5·8-6·5) at baseline. The genotype subtypes identified were 4r (18 [45%] participants), 4k (six [15%]), 4b (five [13%]), 4q (four [10%]), 4l (two [5%]), 4a (one [3%]), 4m (one [3%]), and 3h (one [3%]). One (3%) genotype 4 isolate could not be subtyped, and one (3%) isolate was of unknown genotype. All successfully sequenced isolates (33 [83%]) had at least two NS5A resistance-associated substitutions and 25 (63%) had three or more. 39 (98% [95% CI 87-100]) participants had SVR12. Seven (18%) participants had a total of ten grade 3, 4, or 5 adverse events, including three (8%) cases of hypertension, and one (3%) case each of cataract, diabetes, gastrointestinal bleeding, joint pain, low back pain, vaginal cancer, and sudden death. Four of these events were categorised as serious adverse events resulting in hospitalisation. The one sudden death occurred at home from an unknown cause 4 weeks after the completion of treatment. No serious adverse event was determined to be related to the study drug or resulted in treatment discontinuation. INTERPRETATION: A 12 week course of sofosbuvir-velpatasvir-voxilaprevir is safe and efficacious for the re-treatment of individuals infected with HCV genotype 4 non-a/d subtypes with frequent baseline NS5A resistance-associated substitutions, following failure of previous direct-acting antiviral treatment. Improved affordability and access to sofosbuvir-velpatasvir-voxilaprevir in regions with these subtypes is crucial. FUNDING: Gilead Sciences.

Safety and efficacy of sofosbuvir-velpatasvir to treat chronic hepatitis C virus infection in treatment-naive patients in Rwanda (SHARED-3): a single-arm trial.

BACKGROUND: Hepatitis C virus (HCV) genotype 4 is the predominant type of HCV found in sub-Saharan Africa. Various genotype 4 subtypes, such as 4r, frequently have resistance-associated substitutions that can increase rates of treatment failure with common direct-acting antiviral regimens. In-vitro studies suggest that the NS5A inhibitor velpatasvir is effective against viral isolates containing such resistance-associated substitutions, but its clinical efficacy against genotype 4 non-a/d subtypes in sub-Saharan Africa remains to be confirmed. We aimed to evaluate the safety and efficacy of sofosbuvir-velpatasvir among adults chronically infected with HCV and naive to direct-acting antiviral treatment in Rwanda, where genotype 4 non-a/d subtypes predominate. METHODS: In this single-arm prospective trial, we enrolled adults (age ≥18 years) in Rwanda who had chronic HCV infection and a plasma HCV RNA titre of at least 1000 IU/mL. Patients were referred from hospitals with HCV treatment programmes throughout Rwanda and were sequentially enrolled and assessed for eligibility at a single study site. Individuals with decompensated liver disease or hepatitis B virus co-infection were excluded. Participants were given an oral fixed-dose combination tablet of sofosbuvir (400 mg) and velpatasvir (100 mg) once-daily for 12 weeks. The primary endpoint was the proportion of participants with a sustained virological response 12 weeks after completion of treatment (SVR12) in the intention-to-treat population. Viral sequencing of the NS5A and NS5B genes was done at baseline for all participants and end of follow-up (week 24) for participants who did not have SVR12. This study is registered with ClinicalTrials.gov (NCT03888729) and is completed. FINDINGS: Between Sept 23, 2019, and Jan 10, 2020, 73 individuals were screened for eligibility, of whom 12 (16%) were excluded and 61 (84%) were enrolled. 40 (66%) participants were female, 21 (34%) were male, median age was 64 years (IQR 51-74), and median baseline HCV viral load was 5·7 log10 IU/mL (5·2-6·2). The genotypes identified among the participants were 4k (28 [46%] participants), 4r (11 [18%]), 4v (eight [13%]), 4q (five [8%]), 4l (three [5%]), 4b (one [2%]), 4c (one [2%]), and one undetermined genotype 4 subtype. Three isolates could not be sequenced and were of indeterminate genotype. Of the 55 HCV isolates that were successfully sequenced, all had at least two NS5A resistance-associated substitutions. 59 (97% [95% CI 89-99]) participants had SVR12. 18 (30%) participants had grade 3 adverse events (including 12 [20%] with hypertension), and none had grade 4 adverse events. Four (7%) participants had serious adverse events, including one asthma exacerbation, one abscess, one uterine myoma, and one pelvic fracture related to a motor vehicle accident. No serious adverse events were attributed to the study drug and no adverse event resulted in discontinuation of the study drug. INTERPRETATION: A 12-week regimen of sofosbuvir-velpatasvir is safe and efficacious in treating chronic HCV genotype 4 infection in patients in Rwanda. This regimen could be an effective treatment option in regions known to have a high prevalence of HCV genotype 4 of diverse non-a/d subtypes. FUNDING: Gilead Sciences.

Cross-sectional assessment of determinants of STIs among men who have sex with men and transgender women in Kigali, Rwanda.

BACKGROUND: STIs among men who have sex with men (MSM) and transgender women (TGW) continue to increase. In Rwanda, STI management relies on syndromic management with limited empirical data characterising the burden of specific STIs among MSM/TGW. This study evaluated the prevalence of syphilis, Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) and associated factors among MSM/TGW in Kigali. METHODS: From March to August 2018, 737 MSM/TGW >18 years were enrolled using respondent-driven sampling (RDS). Structured interviews and HIV/STI screening were conducted. Syphilis was screened with rapid plasma reagin confirmed by Treponema pallidum hemagglutination assay. CT/NG were tested by Cepheid GeneXpert. RDS-adjusted multivariable Poisson regression models with robust variance estimation were used to evaluate factors associated with any STI, and determinants of urethral and rectal STIs separately. RESULTS: Prevalence of any STI was 20% (RDS adjusted: 16.7% (95% CI: 13.2% to 20.2%)). Syphilis was 5.7% (RDS adjusted: 6.8% (95% CI: 4.3% to 9.4%)). CT was 9.1% (RDS adjusted: 6.1% (95% CI: 3.9% to 8.4%)) and NG was 8.8% (RDS adjusted: 7.1% (95% CI: 4.9% to 9.2%)). STIs were more common among older MSM and those with HIV (p<0.05). Of CT infections, 67% were urethral, 27% rectal and 6% were dual site. For NG infections, 52% were rectal, 29% urethral and 19% were dual site. Overall, 25.8% (23 of 89) of those with confirmed STI and returned for their results were symptomatic at time of testing.STI symptoms in the previous year (adjusted prevalence ratio (aPR): 1.94 (95% CI: 1.26 to 2.98)) were positively associated with any STI. Being circumcised was negatively associated with any STI (aPR: 0.47 (95% CI: 0.31 to 0.73)). HIV was positively associated with rectal STIs (aPR: 3.50 (95% CI: 1.09 to 11.21)) but negatively associated with urethral STIs. CONCLUSION: MSM/TGW, especially those living with HIV, are at high risk of STIs in Rwanda with the vast majority being asymptomatic. These data suggest the potential utility of active STI surveillance strategies using highly sensitive laboratory methods among those at high risk given the anatomical distribution and limited symptomatology of STIs observed among Rwandan MSM/TGW.

Injection drug use practices and HIV infection among people who inject drugs in Kigali, Rwanda: a cross-sectional study.

BACKGROUND: In Rwanda, epidemiological data characterizing people who inject drugs (PWID) and their burden of HIV are limited. We examined injection drug use (IDU) history and practices, and HIV infection in a sample of PWID in Kigali. METHODS: From October 2019 to February 2020, 307 PWID aged ≥ 18 were enrolled in a cross-sectional study using convenience sampling in Kigali. Participants completed interviewer-administered questionnaires on IDU history and practices and HIV testing. We used Poisson regression with robust variance estimation to assess IDU practices associated with HIV infection and assessed factors associated with needle sharing in the six months preceding the study. RESULTS: The median age was 28 years (IQR 24-31); 81% (251) were males. Female PWID were more likely to report recent IDU initiation, selling sex for drugs, and to have been injected by a sex partner (p < 0.05). In the prior six months, heroin was the primary drug of choice for 99% (303) of participants, with cocaine and methamphetamine also reported by 10% (31/307) and 4% (12/307), respectively. In total, 91% (280/307) of participants reported ever sharing needles in their lifetime and 43% (133) knew someone who died from a drug-related overdose. HIV prevalence was 9.5% (95% CI 8.7-9.3). Sharing needles at least half of the time in the previous six months was positively associated with HIV infection (adjusted prevalence ratio (aPR) 2.67; 95% CI 1.23-5.78). Overall, 31% (94/307) shared needles and 33% (103/307) reused needles in the prior six months. Female PWID were more likely to share needles compared to males (aPR 1.68; 95% CI 1.09-2.59). Additionally, bisexual PWID (aPR 1.68; 95% CI 1.09-2.59), those who shared needles at the first injection (aPR 2.18; 95% CI 1.59-2.99), reused needles recently (aPR 2.27; 95% CI 1.51-3.43) and shared other drug paraphernalia (aPR 3.56; 95% CI 2.19-5.81) were more likely to report recent needle sharing. CONCLUSION: HIV infection was common in this study. The high prevalence of needle reuse and sharing practices highlights significant risks for onward transmission and acquisition of HIV and viral hepatitis. These data highlight the urgent need for PWID-focused harm reduction services in Rwanda, including syringe services programs, safe injection education, naloxone distribution, and substance use disorder treatment programs and optimizing these services to the varied needs of people who use drugs in Rwanda.

Prevalence and associated risk factors for hepatitis B and C viruses among refugee populations living in Mahama, Rwanda: A cross-sectional study.

INTRODUCTION: As part of the integration of refugees into Rwanda's national hepatitis C elimination agenda, a mass screening campaign for hepatitis B (HBV) and hepatitis C (HCV) was conducted among Burundian refugees living in Mahama Camp, Eastern Rwanda. This cross-sectional survey used data from the screening campaign to report on the epidemiology of viral hepatitis in this setting. METHODS: Rapid diagnostic tests (RDTs) were used to screen for hepatitis B surface antigen (HBsAg) and hepatitis C antibody (anti-HCV) among people of ≥15years old. We calculated seroprevalence for HBsAg and anti-HCV by age and sex and also calculated age-and-sex adjusted risk ratios (ARR) for other possible risk factors. RESULTS: Of the 26,498 screened refugees, 1,006 (3.8%) and 297 (1.1%) tested positive for HBsAg and Anti-HCV, respectively. HBsAg was more prevalent among men than women and most common among people 25-54 years old. Anti-HCV prevalence increased with age group with no difference between sexes. After adjusting for age and sex, having a household contact with HBsAg was associated with 1.59 times higher risk of having HBsAg (95% CI: 1.27, 1.99) and having a household contact with anti-HCV was associated with 3.66 times higher risk of Anti-HCV (95% CI: 2.26, 5.93). Self-reporting having HBV, HCV, liver disease, or previously screened for HBV and HCV were significantly associated with both HBsAg and anti-HCV, but RDT-confirmed HBsAg and anti-HCV statuses were not associated with each other. Other risk factors for HBsAg included diabetes (ARR = 1.97, 95% CI: 1.08, 3.59) and family history of hepatitis B (ARR = 1.32, 95% CI: 1.11, 1.56) and for anti-HCV included heart disease (ARR = 1.91, 95% CI: 1.30, 2.80) and history of surgery (ARR = 1.70, 95% CI: 1.24, 2.32). CONCLUSION: Sero-prevalence and risks factors for hepatitis B and C among Burundian were comparable to that in the Rwandan general population. Contact tracing among household members of identified HBsAg and anti-HCV infected case may be an effective approach to targeted hepatitis screening given the high risk among self-reported cases. Expanded access to voluntary testing may be needed to improve access to hepatitis treatment and care in other refugee settings.

Knowledge among patients with Hepatitis C initiating on direct-acting antiviral treatment in rural Rwanda: A prospective cohort study.

BACKGROUND: Curative direct-acting antiviral treatment (DAA) has made it plausible to implement hepatitis C elimination interventions. However, poor hepatitis C knowledge among patients could impede the effectiveness of screening and treatment programs. OBJECTIVE: We assessed knowledge on hepatitis C among rural Rwandans initiating DAA treatment for hepatitis C in a prospective cohort. METHODS: We administered 15 true-false statements before treatment initiation and during one follow-up visit occurring either 1 or 2 months after treatment initiation. We assessed the average number of correct responses per patient, the proportion of correct responses to individual statements, pre-treatment predictors of knowledge, and whether post-initiation knowledge was associated with time since treatment initiation, quality of care, or adherence. RESULTS: Among 333 patients who answered knowledge questions before treatment initiation, 325 (97.6%) were re-assessed at a post-initiation visit. Pre-initiation, 72.1% knew hepatitis C was curable, 61.9% knew that hepatitis C could cause liver damage or cancer, and 42.3% knew that people with hepatitis C could look and feel fine. The average number of correct responses was 8.1 out of 15 (95% CI: 7.8-8.5), but was significantly lower among those with low educational attainment or with low literacy. Post-initiation, correct responses increased by an average of 2.0 statements (95% CI: 1.6, 2.4, p-value <0.001). Many patients still mistakenly believed that hepatitis C could be transmitted through kissing (66.5%), eating utensils (44.1%), handshakes (34.8%), and hugs (34.8%). Post-initiation knowledge is inversely associated with self-reported quality of care and unassociated with self-reported adherence. CONCLUSION: Although knowledge improved over time, key gaps persisted among patients. Accessible public education campaigns targeted to low-literacy populations emphasizing that hepatitis C can be asymptomatic, has severe consequences, and is curable could promote participation in mass screening campaigns and linkage to care. Visual tools could facilitate clinician-provided patient education.