HIV and hepatitis B, C co-infection and correlates of HIV infection among men who have sex with men in Rwanda, 2021: a respondent-driven sampling, cross-sectional study.

BACKGROUND: Men who have sex with men (MSM) are a key population group disproportionately affected by HIV and other sexually transmitted infections (STIs) worldwide. In Rwanda, the HIV epidemic remains a significant public health concern, and understanding the burden of HIV and hepatitis B and C coinfections among MSM is crucial for designing effective prevention and control strategies. This study aims to determine the prevalence of HIV, hepatitis B, and hepatitis C infections among MSM in Rwanda and identify correlates associated with HIV infection within this population. METHODS: We used respondent-driven sampling (RDS) to recruit participants between November and December 2021. A face-to-face, structured questionnaire was administered. Testing for HIV infection followed the national algorithm using two rapid tests: Alere Combo and STAT PAK as the first and second screening tests, respectively. Hepatitis B surface antigen (HBsAg) and anti-HCV tests were performed. All statistics were adjusted for RDS design, and a multivariable logistic regression model was constructed to identify factors associated with HIV infection. RESULTS: The prevalence of HIV among MSM was 6·9% (95% CI: 5·5-8·6), and among HIV-positive MSM, 12·9% (95% CI: 5·5-27·3) were recently infected. The prevalence of hepatitis B and C was 4·2% (95% CI: 3·0-5·7) and 0·7% (95% CI: 0·4-1·2), respectively. HIV and hepatitis B virus coinfection was 0·5% (95% CI: 0·2-1·1), whereas HIV and hepatitis C coinfection was 0·1% (95% CI: 0·0-0·5), and no coinfection for all three viruses was observed. MSM groups with an increased risk of HIV infection included those who ever suffered violence or abuse because of having sex with other men (AOR: 3·42; 95% CI: 1·87-6·25), those who refused to answer the question asking about 'ever been paid money, goods, or services for sex' (AOR: 10·4; 95% CI: 3·30-32·84), and those not consistently using condoms (AOR: 3·15; 95% CI: 1·31-7·60). CONCLUSION: The findings suggest more targeted prevention and treatment approaches and underscore the importance of addressing structural and behavioral factors contributing to HIV vulnerability, setting interventions to reduce violence and abuse against MSM, promoting safe and consensual sexual practices, and expanding access to HIV prevention tools such as condoms and preexposure prophylaxis (PrEP).

Strategies for Removal of Barriers to Hepatitis C Elimination in Sub-Saharan Africa.

Hepatitis C virus (HCV) infection is a major global health threat, with serious consequences including liver cirrhosis and cancer. Despite efforts to combat HCV, an estimated 1.5 million new infections occur each year and HCV was the sixth leading cause of death in 2017. Nevertheless, political leaders are increasingly interested in the fight against HCV, and the achievements of countries such as Rwanda, Egypt, India, Mongolia, Pakistan, Georgia, and Ukraine have given hope that the elimination plan to reduce new infections to 90% and mortality to 65% by 2030 is possible. It is true that some African countries can attest to the difficulty of operationalizing the HCV program with expensive testing platforms and HCV drugs that few could afford in the past, let alone the logistics involved, given that active case detection is an asset for HCV elimination. The inability to add direct-acting antivirals (DAAs) to the national essential drug list and negotiate DAA cost subsidies remains a major challenge in Africa. The lessons learned from implementing and scaling up the human immunodeficiency virus program can provide a strong framework to deliver comprehensive HCV services. We present the strategies used by some African countries to move toward HCV elimination, describe the challenges they have faced, and suggest realistic solutions.

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.

Long-term effect of chronic hepatitis B on mortality in HIV-infected persons in a differential HBV transmission setting.

BACKGROUND: There remain gaps in quantifying mortality risk among individuals co-infected with chronic hepatitis B (HBV) and human immunodeficiency virus (HIV) in sub-Saharan African contexts. Among a cohort of HIV-positive individuals in Rwanda, we estimate the difference in time-to mortality between HBV-positive (HIV/HBV co-infected) and HBV-negative (HIV mono-infected) individuals. METHODS: Using a dataset of HIV-infected adults screened for hepatitis B surface antigen (HBsAg) from January to June 2016 in Rwanda, we performed time-to-event analysis from the date of HBsAg results until death or end of study (31 December 2019). We used the Kaplan-Meier method to estimate probability of survival over time and Cox proportional hazard models to adjust for other factors associated with mortality. RESULTS: Of 21,105 available entries, 18,459 (87.5%) met the inclusion criteria. Mean age was 42.3 years (SD = 11.4) and 394 (2.1%) died during follow-up (mortality rate = 45.7 per 100,000 person-months, 95% confidence interval (CI) 41.4-50.4) Mortality rate ratio for co-infection was 1.7, 95% CI 1.1-2.6, however, Cox regression analysis did not show any association with mortality between compared groups. The adjusted analysis of covariates stratified by co-infection status showed that males, residing outside of the capital Kigali, drinking alcohol, WHO-HIV-clinical stage 3 and 4 were associated with increased mortality in this HIV cohort. CONCLUSIONS: HBV infection does not significantly influence mortality among HIV-infected individuals in Rwanda. The current cohort is likely to have survived a period of high-risk exposure to HBV and HIV mortality and limited health care until their diagnosis.

Effectiveness of Direct-acting Antivirals for the Treatment of Chronic Hepatitis C in Rwanda: A Retrospective Study.

BACKGROUND: Direct-acting antivirals (DAAs) are becoming accessible in sub-Saharan Africa. This study examined the effectiveness of DAAs in patients treated through the Rwandan national health system and identified factors associated with treatment outcomes. METHODS: This retrospective study used data from the national hepatitis C virus (HCV) program for patients who initiated DAAs between November 2015 and March 2017. Sustained virological response at 12 weeks after treatment (SVR12) was the primary outcome. Logistic regression models were fit to estimate the relationship between patients' clinical and demographic characteristics and treatment outcome. RESULTS: 894 patients started treatment during the study period; 590 completed treatment and had SVR12 results. Among the 304 patients without SVR12 results, 48 were lost to follow-up and 256 had no SVR12 results but clinical data indicated they likely completed treatment; these patients were classified as nonvirological failure because viral clearance could not be determined. In a per-protocol analysis of 590 patients with SVR12 results, SVR12 was achieved in 540 (92%), and virological failure occurred in 50 (8%). Pretreatment HCV RNA above the median split was associated with virological failure. Intention-to-treat analyses including all patients showed that SVR12 was achieved in 540 (60%), with nonvirological failure in 304 (34%) and virological failure in 50 (6%). Patients in Western Province were more likely to experience nonvirological failure than patients in Kigali, likely owing to the 5-7-hour travel required to access testing and treatment. CONCLUSIONS: DAAs were effective when implemented through the Rwandan national health system. Decentralization and enhanced financing are underway in Rwanda, which could improve access to treatment and follow-up as the country prepares for HCV elimination.

Patient and healthcare provider experiences of hepatitis C treatment with direct-acting antivirals in Rwanda: a qualitative exploration of barriers and facilitators.

BACKGROUND: Direct-acting antivirals (DAAs) are increasingly accessible to patients with hepatitis C (HCV) worldwide and are being introduced through national health systems in sub-Saharan Africa. DAAs are highly efficacious when tested in controlled trials, yet patients treated outside of study settings often encounter challenges in completing the full treatment and follow-up sequence. Little information is available on the influences of successful DAA implementation in sub-Saharan Africa. This qualitative study explored the individual- and system-level barriers and enablers of DAA treatment in Rwanda between March 2015 and November 2017. METHODS: Face-to-face interviews were conducted with 39 patients who initiated care at one of four referral hospitals initially offering DAAs. Ten healthcare providers who managed HCV treatment participated in face-to-face interviews to examine system-level barriers and facilitators. Interview data were analyzed using a general inductive approach in alignment with the a priori objective of identifying barriers and facilitators of HCV care. RESULTS: Barriers to successful treatment included patients' lack of knowledge surrounding HCV and its treatment; financial burdens associated with paying for medication, laboratory testing, and transportation; the cumbersome nature of the care pathway; the relative inaccessibility of diagnostics technology; and heavy workloads of healthcare providers accompanied by a need for additional HCV-specific training. Patients and healthcare providers were highly aligned on individual- and system-level barriers to care. The positive patient-provider relationship, strong support from community and family members, lack of stigma, and mild side effect profile of DAAs all positively influenced patients' engagement in treatment. CONCLUSIONS: Several interrelated factors acted as barriers and facilitators to DAA treatment in Rwanda. Patients' and healthcare providers' perceptions were in agreement, suggesting that the impeding and enabling factors were well understood by both groups. These results can be used to enact evidence-informed interventions to help maximize the impact of DAAs as Rwanda moves towards HCV elimination.

Risk factors for viral hepatitis C infection in Rwanda: results from a nationwide screening program.

BACKGROUND: The epidemiology and risk factors for hepatitis C virus (HCV) infection in Rwanda are not well known; however, this information is crucial to shaping the country's public health approach to hepatitis C control. METHODS: A HCV screening campaign was conducted in the general population in 24 districts previously identified to have a high HCV disease burden. At the time of sample collection, sociodemographic information and self-reported risk factors were collected. Bivariate and multivariate logistic regressions were conducted to assess risk factors independently associated with hepatitis C antibodies (HCVAb) seroprevalence. RESULTS: Out of a total of 326,263 individuals screened for HCVAb, 22,183 (6.8%) were positive. In multivariate analysis, risk factors identified as statistically associated with HCVAb Seroprevalence include history of traditional operation or scarification (OR = 1.09, 95% CI: 1.05-1.14), presence of viral hepatitis in the family (OR = 1.27, 95% CI: 1.15-1.40), widowed or separated/divorced (OR = 1.36, 95% CI: 1.26-1.47), Southern province (OR = 1.98, 95% CI: 1.88-2.08) and aged 65 years and older (OR = 4.86, 95% CI: 4.62-5.11). Ubudehe category 3 (OR = 0.97, 95% CI: 0.93-1.01) and participants using RAMA (Health insurances for employees of public and private sectors) insurance (OR = 0.76, 95% CI: 0.70-0.85) had lower odds of HCV seroprevalence. CONCLUSIONS: Our findings provide important information for Rwanda's strategy on prevention and case-finding. Future prevention interventions should aim to reduce transmission through targeted messaging around traditional healing practices and case-finding targeting individuals with a history of exposure or advanced age.

Screening a nation for hepatitis C virus elimination: a cross-sectional study on prevalence of hepatitis C and associated risk factors in the Rwandan general population.

OBJECTIVES: We analysed data collected during programmatic screening activities conducted in 2017 to describe hepatitis C virus (HCV) seroprevalence in the general population and identify associated factors. DESIGN: We analysed data collected between June and September 2017. For both seroprevalence and viraemia, variations across demographic and geographic factors were assessed and multivariate regression models were fit to identify factors independently associated with each marker. Geospatial data were examined for visualisation. SETTING: HCV screening was organised within each of the 30 districts in Rwanda. One designated location in each district was selected as the screening site and screening took place for 1 week at each site. PARTICIPANTS: This study included 124 223 male and female volunteers. Anti-HCV-positive individuals were followed up with HCV RNA viral load (VL) testing for infection confirmation. MAIN OUTCOME MEASURES: Two markers were examined: the presence of HCV antibodies and HCV RNA VL. RESULTS: Among 124 223 individuals screened, 11 003 (8.86%, 95% CIs: 8.70% to 9.02%) were positive for anti-HCV. Anti-HCV prevalence varied by age with the oldest age group (>55 year olds) having a prevalence of 16.46% (95% CIs: 16.14% to 16.80%) and the youngest age group (<25 year olds) having a prevalence of 2.20% (95% CIs: 1.93% to 2.50%) (crude OR=8.78). After adjustment for covariates, an association remained between anti-HCV prevalence and age (p<0.001), province (p<0.001) and socioeconomic status (p<0.001). Of the 3771 anti-HCV-positive individuals who had an available HCV RNA VL result, 2099 (55.66%, 95% CI: 54.06% to 57.25%) had a detectable HCV RNA VL. Age was also associated with HCV viraemia (p<0.001). CONCLUSION: Results suggest that over 55% of individuals who screened positive for HCV-antibodies were chronically infected. Targeted screening for HCV among older individuals is recommended, given the association between age and infection. Further geographical hotspots of HCV infection can also inform targeted screening as Rwanda moves towards HCV elimination.

Prevalence of hepatitis B surface antigen (HBsAg) positivity and its associated factors in Rwanda.

BACKGROUND: The epidemiology of hepatitis B virus (HBV) infection in the general population in Rwanda is not well known. This study examined the prevalence of HBV surface antigen (HBsAg) positivity and associated risk factors among people aged 25 years and over in an organized national screening campaign. METHODS: This is a cross-sectional study using data from a nationwide HBV screening campaign organized by the Rwanda Biomedical Centre from March to October 2018. This campaign targeted individuals aged > 25 years old from 24 of 30 districts of Rwanda. Sensitization was done through multimedia announcements, community health workers and local church leaders. During the campaign, a structured interview was administered by trained healthcare workers to collect information on socio-demographic, clinical and behavioral characteristics of participants; HBV screening was performed with HBsAg using enzyme-linked immunosorbent assays (ELISA) testing. Bivariate and multivariate logistic regressions were used to assess factors associated with HBsAg positivity in the screened participants. RESULTS: A total of 327,360 individuals were screened during the campaign. Overall 12,865(3.9%) were HBsAg positive. The highest prevalence (4.2%) was found in the 35-44-year-old group, but the difference from other groups was not significant (Odds Ratio [OR = 1.057, 95% Confidence Interval(CI) (0.904-1.235)]. Being male [OR = 1.348, 95% CI (1.30,1.40)]; being single [OR = 1.092, 95% CI (1.10-1.16)] compared to married; a previous positive TB screening test [OR = 2.352, 95% CI (1.63-3.39)]; history of surgical operation [OR = 1.082, 95% CI (1.00,1.17)]; exposure to traditional operational practices and scarification [OR = 1.187, 95% CI (1.13, 1.24)]; and having a person in the family with viral hepatitis [OR = 1.367, 95% CI (1.21, 1.53)] were significantly associated with HBV infection. CONCLUSIONS: These data provide the first national estimate of the prevalence of HBsAg seropositivity and its associated factors in Rwanda. The study identified people with the highest risk of HBV infection who should be the priority of future prevention efforts in Rwanda and in similar settings.

Controlling hepatitis C in Rwanda: a framework for a national response.

With the introduction of direct-acting antiviral drugs, treatment of hepatitis C is both highly effective and tolerable. Access to treatment for patients, however, remains limited in low- and middle-income countries due to the lack of supportive health infrastructure and the high cost of treatment. Poorer countries are being encouraged by international bodies to organize public health responses that would facilitate the roll-out of care and treatment on a national scale. Yet few countries have documented formal plans and policies. Here, we outline the approach taken in Rwanda to a public health framework for hepatitis C control and care within the World Health Organization hepatitis health sector strategy. This includes the development and implementation of policies and programmes, prevention efforts, screening capacity, treatment services and strategic information systems. We highlight key successes by the national programme for the control and management of hepatitis C: establishment of national governance and planning; development of diagnostic capacity; approval and introduction of direct-acting antiviral treatments; training of key personnel; generation of political will and leadership; and fostering of key strategic partnerships. Existing challenges and next steps for the programme include developing a detailed monitoring and evaluation framework and tools for monitoring of viral hepatitis. The government needs to further decentralize care and integrate hepatitis C management into routine clinical services to provide better access to diagnosis and treatment for patients. Introducing rapid diagnostic tests to public health-care facilities would help to increase case-finding. Increased public and private financing is essential to support care and treatment services.

Grâce à l'introduction d'antiviraux à action directe, le traitement de l'hépatite C est à la fois très efficace et bien toléré. Néanmoins, l'accès des patients au traitement demeure limité dans les pays à revenu faible et intermédiaire en raison du manque d'infrastructures sanitaires de soutien et du coût élevé du traitement. Les pays pauvres sont encouragés par des organismes internationaux à élaborer des mesures de santé publique qui faciliteraient la mise en place de soins et de traitements à l'échelle nationale. Peu de pays ont cependant établi des politiques et des plans officiels. Dans cet article, nous présentons l'approche adoptée au Rwanda à l'égard d'un cadre de santé publique pour le contrôle de l'hépatite C et les soins qui lui sont associés dans le contexte de la stratégie du secteur de la santé contre l'hépatite de l'Organisation mondiale de la Santé. Cela inclut le développement et la mise en œuvre de politiques et de programmes, d'efforts de prévention, de capacités de dépistage, de services de traitement et de systèmes d'information stratégiques. Nous mettons en avant les principaux succès du programme national pour le contrôle et la gestion de l'hépatite C: l'établissement d'une gouvernance et d'une planification nationales; le renforcement des capacités de diagnostic; l'approbation et l'introduction de traitements antiviraux à action directe; la formation de personnel d'encadrement; le développement d'une volonté et d'un leadership politiques; et la promotion de partenariats stratégiques clés. Les enjeux actuels et les prochaines étapes du programme incluent l'élaboration d'un cadre détaillé de suivi et d'évaluation, ainsi que des outils pour le suivi de l'hépatite virale. Le gouvernement doit favoriser la décentralisation des soins et intégrer la gestion de l'hépatite C aux services cliniques courants afin de fournir aux patients un meilleur accès au diagnostic et au traitement. L'utilisation de tests de diagnostic rapide dans les établissements publics de santé permettrait d'améliorer le dépistage. Il est essentiel d'augmenter les financements publics et privés pour soutenir les services de soins et de traitement.

Con la introducción de los fármacos antivíricos de acción directa, el tratamiento de la hepatitis C es altamente eficaz y tolerable. Sin embargo, el acceso al tratamiento por parte de los pacientes sigue siendo limitado en los países de ingresos medios y bajos, debido a la falta de infraestructuras sanitarias de apoyo y a los altos costos del tratamiento. Los organismos internacionales alientan a los países más pobres a organizar respuestas de salud pública que podrían facilitar la puesta en marcha de atención y tratamiento a escala nacional. Sin embargo, son pocos los países que han documentado planes y políticas formales. En el presente estudio, esbozamos el enfoque adoptado en Rwanda para un marco de salud pública para el control y la atención de la hepatitis C dentro de la estrategia del sector de la salud contra la hepatitis de la Organización Mundial de la Salud. Este incluye la elaboración y aplicación de políticas y programas, medidas preventivas, capacidad de cribado, servicios de tratamiento y sistemas de información estratégica. Destacamos los éxitos clave del programa nacional para el control y tratamiento de la hepatitis C: establecimiento de la gobernanza y planificación nacional; desarrollo de capacidad diagnóstica; aprobación e introducción de tratamientos antivíricos de acción directa; formación de personal clave; generación de voluntad política y liderazgo; y promoción de asociaciones estratégicas clave. Los desafíos actuales y los próximos pasos del programa incluyen el desarrollo de un marco de seguimiento y evaluación detallado, así como herramientas para el seguimiento de la hepatitis viral. El gobierno necesita descentralizar todavía más la atención e integrar la gestión de la hepatitis C en los servicios clínicos corrientes para proporcionar un mejor acceso al diagnóstico y tratamiento de los pacientes. La introducción de pruebas diagnósticas rápidas en los centros de atención de salud pública ayudaría a aumentar la búsqueda de casos. El aumento de la financiación pública y privada es esencial para apoyar los servicios de atención y tratamiento.

Prevalence of hepatitis B and C infection in persons living with HIV enrolled in care in Rwanda.

BACKGROUND: Hepatitis B (HBV) and C (HCV) are important causes of morbidity and mortality in people living with human immunodeficiency virus (HIV). The burden of these co-infections in sub-Saharan Africa is still unclear. We estimated the prevalence of the hepatitis B surface antigen (HBsAg) and hepatitis C antibody (HCVAb) among HIV-infected individuals in Rwanda and identified factors associated with infection. METHODS: Between January 2016 and June 2016, we performed systematic screening for HBsAg and HCVAb among HIV-positive individuals enrolled at public and private HIV facilities across Rwanda. Results were analyzed to determine marker prevalence and variability by demographic factors. RESULTS: Overall, among 117,258 individuals tested, the prevalence of HBsAg and HCVAb was 4.3% (95% confidence interval [CI] (4.2-4.4) and 4.6% (95% CI 4.5-4.7) respectively; 182 (0.2%) HIV+ individuals were co-infected with HBsAg and HCVAb. Prevalence was higher in males (HBsAg, 5.4% [5.1-5.6] vs. 3.7% [3.5-3.8]; HCVAb, 5.0% [4.8-5.2] vs. 4.4% [4.3-4.6]) and increased with age; HCVAb prevalence was significantly higher in people aged ≥65 years (17.8% [16.4-19.2]). Prevalence varied geographically. CONCLUSION: HBV and HCV co-infections are common among HIV-infected individuals in Rwanda. It is important that viral hepatitis prevention and treatment activities are scaled-up to control further transmission and reduce the burden in this population. Particular efforts should be made to conduct targeted screening of males and the older population. Further assessment is required to determine rates of HBV and HCV chronicity among HIV-infected individuals and identify effective strategies to link individuals to care and treatment.