Knowledge, attitudes, practices and prevalence of hepatitis B and C and hepatitis B vaccination coverage among public sector healthcare workers in Cambodia.

Healthcare workers (HCWs) are a key population at high risk for hepatitis B (HBV) and hepatitis C (HCV) infections. We aim to study HBV vaccination coverage, seroprevalence, knowledge, attitudes, and practices towards HBV and HCV infections among HCWs in public sector in Cambodia. A nationally representative cross-sectional study was implemented in 2019, among Cambodian HCWs. A standardized questionnaire was administered to randomly selected HCWs whose blood was then sampled. We used univariate and multivariate regression to determine predictors of outcomes. Among 755 participants, we found 4.9% positive HBsAg and 2.3% positive anti-HCV Ab. HBV vaccination coverage was 59.3%. Lack of knowledge was found on the route of transmission, HBV vaccination, diagnosis and treatment of HBV and HCV. 67% of HCWs thought that all patients should be screened for HBV and HCV and about 30% of them would refuse to take care of infected patients. 58% of HCWs always recapped the needle after use. In univariate analysis, older age-group (> 50 years) is more likely to have positive anti-HCV (OR: 9.48; 95% CI: 2.36-38.18). HCWs who were younger, female or having higher education or having ever been tested, were more likely to have gotten HBV vaccinated. Multivariate analysis reconfirmed these predictors of getting vaccinated. Study findings indicated an urgent need of a national policy for Cambodian HCWs given the high prevalence of hepatitis among this group. Policy should include an effective in-service training program to improve knowledge and practices, a testing and vaccination program for HCWs and it should emphasize stigma intervention towards people living with HBV/HCV.

Shared-care models are highly effective and cost-effective for managing chronic hepatitis B in China: reinterpreting the primary care and specialty divide.

Background: We evaluate the impact and cost-effectiveness of shared primary-specialty chronic hepatitis B (CHB) care models in China. Methods: We constructed a decision-tree Markov model to simulate hepatitis B virus (HBV) disease progression in a cohort of 100,000 CHB individuals aged ≥18 years over their lifetime (aged 80). We evaluated the population impacts and cost-effectiveness in three scenarios: (1) status quo; (2) shared-care model with HBV testing and routine CHB follow-ups in primary care and antiviral treatment initiation in specialty care; and (3) shared-care model with HBV testing, treatment initiation and routine CHB follow-up in primary care and treatment for predetermined conditions in specialty care. We evaluated from a healthcare provider's perspective with 3% discounting rate and a willingness-to-pay (WTP) threshold of 1-time China's GDP. Findings: Compared with status quo, scenario 2 would result in an incremental cost of US$5.79-132.43m but a net gain of 328-16,993 quality-adjusted life years (QALYs) and prevention of 39-1935 HBV-related deaths over cohort's lifetime. Scenario 2 was not cost-effective with a WTP of 1-time GDP per capita, but became cost-effective when treatment initiation rate increased to 70%. In contrast, compared with status quo, secnario 3 would save US$144.59-192.93m in investment and achieve a net gain of 23,814-30,476 QALYs and prevention of 3074-3802 HBV-related deaths. Improving HBV antiviral treatment initiation among eligible CHB individuals substantially improved the cost-effectiveness of the shared-care models. Interpretation: Shared-care models with HBV testing, follow up and referring of predetermined conditions to specialty care at an appropriate time, especially antiviral treatment initiation in primary care, are highly effective and cost-effective in China. Funding: National Natural Science Foundation of China.

Progress towards triple elimination of mother-to-child transmission of HIV, hepatitis B and syphilis in Pacific Island Countries and Territories: a systematic review.

The diverse geographic, demographic, and societal factors in the Pacific Island Countries and Territories (PICTs) have contributed to unique epidemiological patterns of HIV, syphilis, and hepatitis B. Transmission can be during pregnancy, at the time of birth or via breastfeeding for HIV, and can have long-term adverse outcomes. Given the similarities in prevention of mother-to-child transmission of these infections, coordinated interventions for triple elimination are used. This systematic review has evaluated the peer-reviewed literature, grey literature, and global databases to assess the availability of data to report against elimination targets in the WHO Regional Framework for the Triple Elimination of Mother-to-Child Transmission of HIV, Hepatitis B and Syphilis in Asia and the Pacific 2018-2030. The secondary objective is to report on progress towards these targets. The findings show that none of the PICTs are on track to achieve triple elimination by 2030. Amongst the limited publicly available indicator data, there is suboptimal coverage for most indicators. It is important that there is an increase in availability of and access to antenatal care, testing, and treatment for pregnant women. Increased efforts are needed to collect data on key indicators and integrate reporting into existing systems to avoid extra burden. Funding: Leila Bell was supported by an Australian Government Research Training Program (RTP) Scholarship, Australia. Funding sources had no role in paper design, data collection, data analysis, interpretation, or writing of the paper.

Global reporting of progress towards elimination of hepatitis B and hepatitis C.

BACKGROUND: The 69th World Health Assembly endorsed the global health sector strategy on viral hepatitis to eliminate viral hepatitis as a public health threat by 2030. Achieving and measuring the 2030 targets requires a substantial increase in the capacity to test and treat viral hepatitis infections and a mechanism to monitor the progress of hepatitis elimination. This study aimed to identify the gaps in data availability or quality and create a new mechanism to monitor the progress of hepatitis elimination. METHODS: In 2020, using a questionnaire, we collected empirical, systematic, modelled, or surveyed data-reported by WHO country and WHO regional offices-on indicators of progress towards elimination of viral hepatitis, including burden of infection, incidence, mortality, and the cascade of care, and validated these data. FINDINGS: WHO received officially validated country-provided data from 130 countries or territories, and used partner-provided data for 70 countries or territories. We estimated that in 2019, globally, 295·9 million (3·8%) people were living with chronic hepatitis B virus (HBV) infection and 57·8 million (0·8%) people were living with chronic hepatitis C virus (HCV) infection. Globally, there were more than 3·0 million new infections with HBV and HCV and more than 1·1 million deaths due to the viruses in 2019. In 2019, 30·4 million (95% CI 24·3-38·0) individuals living with hepatitis B knew their infection status and 6·6 million (5·3-8·3) people diagnosed with hepatitis B received treatment. Among people with HCV infection, 15·2 million (95% CI 12·1-19·0) had been diagnosed between 2015 and 2019, and 9·4 million (7·5-11·7) people diagnosed with hepatitis C infection were treated with direct-acting antiviral drugs between 2015 and 2019. INTERPRETATION: There has been notable global progress towards hepatitis elimination. In 2019, 30·4 million (10·3%) people living with hepatitis B knew their infection status, which was slightly higher than in 2015 (22·0 million; 9·0%), and 6·6 million (22·7%) of those diagnosed with hepatitis B received treatment, compared with 1·7 million (8·0%) in 2015. Mortality from hepatitis C has declined since 2019, driven by an increase in HCV treatment ten times that of the strategy baseline. However, an estimated 89·7% of HBV infections and 78·6% of HCV infections remain undiagnosed. A new global strategy for 2022-30, based on these new estimates, should be implemented urgently to scale up the screening and treatment of viral hepatitis. FUNDING: World Health Organization.

A randomized controlled trial enhancing viral hepatitis testing in primary care via digital crowdsourced intervention.

Despite the availability of hepatitis B virus (HBV) and hepatitis C virus (HCV) testing in primary care, testing rates in China remain low. Social media is an inexpensive means of disseminating information and could facilitate hepatitis testing promotion. We evaluated the capacity of digitally crowdsourced materials to promote HBV/HCV testing uptake via a randomized controlled trial (identifier: ChiCTR1900025771), which enrolled 750 Chinese primary care patients. We randomized patients (1:1) to receive crowdsourced HBV/HCV promotion materials through social media or facility-based care without promotional materials for four weeks. Exposure to all intervention materials was associated with increased odds of HBV (aOR = 1.79, 95% CI: 1.09-3.00) and HCV (aOR = 1.95, 95% CI: 1.29-2.99) testing compared to facility-based care. There was a significant reduction in hepatitis stigma among intervention group participants (HBV slope: -0.15, p < 0.05; and HCV slope: -0.13, p < 0.05). Digitally crowdsourced promotion messages could enhance hepatitis testing uptake and should be considered in hepatitis reduction strategies.Trial registration: Chinese Clinical Trial Registry (ChiCTR1900025771) on September 9, 2019. Available from: http://www.chictr.org.cn/showproj.aspx?proj=42788.

Systematic Review of Hepatitis C Virus Prevalence in the WHO Western Pacific Region.

BACKGROUND: This review aimed to identify hepatitis C virus (HCV) prevalence estimates among the general population and six key populations (people who inject drugs, men who have sex with men, sex workers, prisoners/detainees, Indigenous people, and migrants) in the World Health Organization Western Pacific Region (WHO WPR). METHODS: Original research articles published between 2016 and 2020 were identified from bibliographic databases. Publications were retrieved, replicas removed, and abstracts screened. Retained full texts were assessed and excluded if inclusion criteria were not met. Methodological quality was assessed using the Johanna Briggs Institute critical appraisal checklist for prevalence data. Data on HCV exposure and active infection were extracted and aggregated and forest plots generated for each population by country. RESULTS: There were no HCV prevalence estimates in any population for more than half of WPR countries and territories. Among the 76 estimates, 97% presented prevalence of exposure and 33% prevalence of active infection. General population viraemic prevalence was 1% or less, except in Mongolia. Results confirm the endemic nature of HCV among people who inject drugs, with estimates of exposure ranging from 30% in Cambodia to 76% in Hong Kong. CONCLUSIONS: Countries require detailed knowledge of HCV prevalence in diverse populations to evaluate the impact of efforts to support WHO HCV elimination goals. Results provide baseline estimates from which to monitor and evaluate progress and by which to benchmark future elimination efforts.

A quasi-randomised controlled trial of online distribution of home-based hepatitis C self-testing for key populations in Malaysia: a study protocol.

BACKGROUND: Malaysia has an estimated hepatitis C virus (HCV) prevalence of 1.9% among its adult population and a history of providing HCV treatment in the public sector. In 2019, Malaysia launched a 5-year national strategic plan for viral hepatitis control and has been expanding HCV testing and treatment to the primary care and community levels, while actively engaging key populations in services for hepatitis care. The Ministry of Health (MoH) is seeking to specifically understand how to better target HCV services at men who have sex with men (MSM); HCV self-testing could increase the uptake of HCV testing among this group. METHODS: We aim to integrate HCV antibody self-testing into an existing online platform used for HIV self-testing, to evaluate the acceptability and impact of an online HCV self-testing programme in Malaysia. This is a non-blinded parallel group quasi-randomised superiority study comparing HCV self-testing via an online distribution model with the standard care, which involves attending a clinic for facility-based HCV antibody testing (control, 2:1). Participants will be randomised to either the HCV self-testing via online distribution arm, in which either an oral fluid- or blood-based HCV self-test kit will be mailed to them, or the control arm, where they will be provided with information about the nearest centre with HCV testing. The primary outcome is the number and proportion of participants who report completion of testing. Secondary outcomes include the number and proportion of participants who (a) receive a positive result and are made aware of their status, (b) are referred to and complete HCV RNA confirmatory testing, and (c) start treatment. Acceptability, feasibility, attitudes around HCV testing, and cost will also be evaluated. The target sample size is 750 participants. DISCUSSION: This study is one of the first in the world to explore the real-world impact of HCV self-testing on key populations using online platforms and compare this with standard HCV testing services. The outcomes of this study will provide critical evidence about testing uptake, linkage to care, acceptability, and any social harms that may emerge due to HCV self-testing. TRIAL REGISTRATION: ClinicalTrials.gov NCT04982718.

Regional progress towards hepatitis C elimination in the Western Pacific Region, 2015-2020.

Chronic hepatitis C (HCV) infection is a major global public health threat and in 2019 there were an estimated 58 million infected globally and 290,000 deaths. Elimination of viral hepatitis B/C as a public health threat by 2030 is defined as a 90% incidence reduction and a 65% mortality reduction. The Western Pacific region is one of the most affected regions with 10 million people living with HCV, one-fifth of the global burden. We review progress towards HCV elimination in the Western Pacific region since 2015. Key developments in the region, which comprises of 37 high-and-middle-income countries, include the following: 20 countries have national hepatitis action plans, 19 have conducted recent disease burden and investment cases, 10 have scaled-up hepatitis services at primary health care level, and in 11 countries, domestic financing including social health insurance support DAA costs. We highlight six countries' experience in navigating the path towards HCV elimination: Cambodia, China, Malaysia, Mongolia, Philippines, and Viet Nam. Future initiatives to accelerate elimination are expanding access to community-based testing using HCV point-of-care tests among at-risk and general populations; adopting decentralized and integrated HCV one-stop services at harm reduction sites, detention settings and primary care; expanding treatment to include children and adolescents; address stigma and discrimination; and ensuring sustainable financing through domestic resources to scale-up testing, treatment and prevention. The COVID-19 pandemic has a significant impact on hepatitis response across the region on community and facility-based testing, treatment initiation, monitoring and cancer screening, which is projected to delay elimination goals.

A Real-world Prospective Study of Mother-to-child Transmission of HBV in China Using a Mobile Health Application (Shield 01).

Background and Aims: The World Health Organization (WHO) Western Pacific Region set a target of eliminating mother-to-child transmission (MTCT) of hepatitis B virus (HBV) by 2030. To assess the feasibility of this target in China, we carried out an epidemiological study to investigate the status quo of MTCT in the real-world setting. Methods: One thousand and eight hepatitis B surface antigen-positive pregnant women were enrolled at 10 hospitals. Immunoprophylaxis was administered to infants. In addition, mothers with HBV DNA level >2,000,000 IU/mL were advised to initiate antiviral therapy during late pregnancy. A health application called SHIELD was used to manage the study. Results: Nine hundred and five of the enrolled mothers, with 924 infants, completed the follow-up. Birth-dose hepatitis B vaccine and hepatitis B immunoglobulin were received by 99.7% and 99.7% of infants, respectively, within 24 h after birth. There were 446 mothers who received antiviral therapy, including 72.3% of the mothers with HBV DNA level >2,000,000 IU/mL and 21.0% of the mothers with HBV DNA level <2,000,000 IU/mL. Eight infants were infected with HBV. The overall rate of MTCT was 0.9%. Birth defects were rare (0.5% among infants with maternal antiviral exposure versus 0.7% among infants without exposure; p=1.00). Conclusions: The MTCT rate was lower than the WHO Western Pacific Region elimination MTCT target in this real-world study, indicating that a comprehensive management composed of immunoprophylaxis to infants and antiviral prophylaxis to mothers may be a feasible strategy to achieve the 2030 WHO elimination goal.

A crowdsourced intervention to promote hepatitis B and C testing among men who have sex with men in China: A nationwide online randomized controlled trial.

BACKGROUND: Crowdsourcing may be an effective strategy to develop test promotion materials. We conducted an online randomized controlled trial (RCT) to evaluate a crowdsourced intervention to promote hepatitis B virus (HBV) and hepatitis C virus (HCV) testing among men who have sex with men (MSM) in China. METHODS: MSM never previously tested for hepatitis were recruited through social media. Eligible men were randomized to receive an online crowdsourced intervention or no testing promotion materials. Outcomes including self-reported and confirmed HBV and HCV test uptake were assessed after four weeks. Odds ratios (OR) with 95% confidence intervals (95% CI) of men achieving primary and secondary outcomes between the intervention and control arms were calculated. FINDINGS: 556 eligible men were enrolled. Overall, 17•4% (97/556) of men self-reported HBV and HCV testing and 7•9% (44/556) confirmed HBV and HCV test uptake. The intervention was seen by 72•1% and 29•0% of men in the intervention and control arms, respectively. In intention-to-treat analysis, confirmed HBV and HCV test uptake was similar between the two arms, both when using a missing=failure approach (OR 0•98, 95% CI 0•53-1•82) or multiple imputation (OR 1•46, 95% CI 0•72-2•95). INTERPRETATION: This RCT extends the literature by developing and evaluating an intervention to spur hepatitis testing in a middle-income country with a high burden of hepatitis. Overall test uptake among MSM in China was similar to previous interventions promoting hepatitis testing in high-income countries. We found frequent intervention sharing, complicating interpretation of the results, and the role of crowdsourcing to promote hepatitis testing remains unclear.

Compliance among infants exposed to hepatitis B virus in a post-vaccination serological testing program in four provinces in China.

BACKGROUND: Mother to child transmission of hepatitis B virus (HBV) remains the most common form of HBV infection in China. Prevention of HBV vertical transmission involves timely administration of the complete hepatitis B vaccine (HepB) series and hepatitis B immunoglobulin. Post-vaccination serological testing (PVST) is utilized to determine an infant's outcome after HBV exposure and completion of HepB series. We aim to determine the frequency of compliance with a PVST testing cascade for HBV infected mothers and analyze factors associated with infant lost to follow up (LTFU). METHODS: We conducted a retrospective cohort review of previously collected data in Fujian, Jiangxi, Zhejiang and Chongqing provinces in China from 1 June 2016-31 December 2017. The study population included all HBV-exposed infants and their mothers. SAS software was used for statistical analyses. Bivariate and multivariate regression analyses (presented in odds ratio [OR] with 95% confidence intervals [CI]) were used to compare the proportional differences of factors associated with PVST not being completed. RESULTS: Among enrolled 8474 target infants, 40% of them transferred out of the study provinces without further information and 4988 were eligible for PVST. We found 20% (994) of infants were not compliant with the testing cascade: 55% of LTFU occurred because parents refused venous blood sample collection or failure of sample collection in the field, 16% transferred out after 6 months of age, and 10% of families chose to have independent, confidential PVST completed without reporting results. High PVST noncompliance rates were more likely to be from Fujian (aOR = 17.0, 95% CI: 9.7-29.9), Zhejiang (aOR = 5.7, 95% CI: 3.2-10.1) and Jiangxi (aOR = 1.9, 95% CI: 1.0-3.4), and from HBV e antigen positive mother (aOR = 1.2, 95% CI: 1.1-1.4). CONCLUSIONS: This study found that the LTFU rate reached 20% in PVST program, which was a significant problem. We recommend implementing a national electronic information system for tracking HBV at risk mother-infant pairs; encourage further research in developing a less invasive means of completing PVST, and take effective measures nationally to reduce HBV stigma. Without reducing the loss to follow up rate among infants eligible for PVST, elimination of vertical HBV transmission will be impossible.

Hepatitis B vaccination coverage among health care workers in China.

OBJECTIVES: Nation-wide hepatitis B vaccination coverage among healthcare workers (HCWs) is not well researched in China. This study aims to investigate the self-reported hepatitis B vaccination status among HCWs in China. METHODS: We conducted a cross-sectional survey of health_care workers' vaccination statuses in 120 hospitals in China by collecting demographic and vaccination data. Univariate and multivariate logistic regression analysis were used to assess factors associated with hepatitis B vaccination coverage. RESULTS: Eighty-six percent (2,666/3,104) of respondents reported having received at least one dose of the hepatitis B vaccination and 60% (1,853/3,104) reported having completed ≥3 doses of the hepatitis B vaccination. Factors associated with completing ≥3 doses of the hepatitis B vaccination included workplaces offering free hepatitis B vaccination with vaccination management, age, medical occupation, hospital level, acceptable hepatitis B knowledge and having received training on hepatitis B. HCWs in workplaces offering a free hepatitis B vaccine with vaccination management were 1.4 times more likely (OR = 1.4, 95% CI: 1.1-1.8) to complete their hepatitis B vaccination compared to HCWs in workplaces that did not offer a free hepatitis B vaccine. Either the possession of acceptable hepatitis B knowledge or an age of 30-39 years increased the odds of complete hepatitis B vaccination by 1.3-fold (95% CIs: 1.1-1.5 and 1.1-1.7, respectively) over their referent category. The receipt of training on hepatitis B was also associated with a higher percentage of completing the hepatitis B vaccination (OR = 1.5, 95% CI: 1.2-1.8). The main self-reported reason for incomplete hepatitis B vaccination was "forgot to complete follow-up doses" among 43% (234/547) of respondents. Among those who never received any hepatitis B vaccination, only 30% (131/438) intended to be vaccinated. Obtaining immunity from work (40%) and hospitals that did not provide hepatitis B vaccination activities (40%) were the top reasons mentioned for refusing hepatitis B vaccination. CONCLUSIONS: The complete hepatitis B vaccination rate among HCWs in China is low, and the desire of HCWs for vaccination is indifferent; therefore, education campaigns are needed. In addition, a free national hepatitis B vaccination policy for HCWs that includes vaccination management should be prioritized to improve hepatitis B coverage among HCWs who are at-risk for HBV infection.

Hepatitis C virus infection in children and adolescents.

Hepatitis C virus (HCV) infection is a major cause of chronic liver disease and associated morbidity and mortality worldwide. Short-course, oral, curative, direct-acting antiviral regimens have transformed treatment for HCV infection. Since the 2016 launch of the first global strategy towards elimination of viral hepatitis as a public health threat by 2030, the predominant focus of the global response has been on the treatment of adults, who bear the greatest burden of morbidity and mortality of HCV-related chronic liver disease. Compared with adults, there has been little attention paid to addressing the response to HCV in children and adolescents, in part because of the scarcity of data to inform specific paediatric management practices and policy. In this Series paper, we summarise knowledge on the epidemiology, natural history, and treatment of chronic HCV infection in adolescents and children, and we highlight key differences from infection acquired in adulthood. The estimated global prevalence and burden of HCV infection in children aged 1-19 years is 0·15%, corresponding to 3·5 million people (95% CI 3·1-3·9 million). HCV infection is usually asymptomatic during childhood, and cirrhosis and hepatocellular carcinoma are rare. Sofosbuvir with ledipasvir and sofosbuvir with ribavirin have received regulatory approval and guidelines recommend their use in adolescents aged 12 years and older with HCV infection. In April, 2019, glecaprevir with pibrentasvir also received regulatory approval for adolescents aged 12-17 years. Key actions to address the current policy gaps and achieve treatment scale-up that is comparable to that in adults include: establishment of a campaign on access to testing and treatment that is targeted at children and adolescents; fast-track evaluation of pan-genotypic regimens; and accelerated approval of paediatric formulations. Research gaps that need to be addressed include: age-specific prevalence studies of HCV viraemia in priority countries; further validation of non-invasive tests for staging of liver disease in children; and establishment of paediatric treatment registries and international consortia to promote collaborative research agendas.

Hepatitis B virus infection in children and adolescents.

Hepatitis B virus (HBV) infection is a major cause of acute and chronic liver disease and associated morbidity and mortality worldwide. Vertical (mother-to-child) and horizontal early childhood transmission are the main routes of HBV transmission and are responsible for most chronic infections, including among adults who bear the greatest burden of morbidity and mortality. Universal hepatitis B immunisation at birth and in infancy is the key strategy for global elimination of HBV infection, and has been highly effective in reducing new vertical infections. However, global progress in scale-up of HBV testing and treatment has been slow in adults and children. In this Series paper, we summarise knowledge on the epidemiology, natural history, and treatment of chronic HBV infection in adolescents and children, and we highlight key differences from HBV infection in adults. The estimated global prevalence of HBV infection in children aged 5 years or younger is 1·3%. Most children are in the high-replication, low-inflammation phase of infection, with normal or only slightly raised aminotransferases; cirrhosis and hepatocellular carcinoma are rare. Although entecavir is approved and recommended for children aged 2-17 years, and tenofovir for those aged 12-18 years, a conservative approach to treatment initiation in children is recommended. Key actions to address current policy gaps include: validation of non-invasive tests for liver disease staging; additional immunopathogenesis studies in children with HBV infection; long-term follow-up of children on nucleoside or nucleotide analogue regimens to inform guidance on when to start treatment; evaluation of different treatment strategies for children with high rates of HBV replication; and establishment of paediatric treatment registries and international consortia to promote collaborative research.

Prevalence of hepatitis C virus infection among key populations in China: A systematic review.

BACKGROUND AND AIM: Chronic hepatitis C is a major global health challenge. China has the world's largest burden of hepatitis C and related liver disease, with several groups having an increased risk of acquiring hepatitis C virus (HCV) infection. We undertook a systematic review in Chinese and English literature to determine the seroprevalence of anti-HCV among men who have sex with men (MSM), sex workers, people who use drugs (PWUD) and migrant workers in China. METHODS: We searched three Chinese databases (CNKI, Wanfang and Chongqing VIP Information) and four English databases (Pubmed, EMBASE, Global Health and CINAHL) for studies published between 2010 and 2015. Included were 89 studies for MSM, 112 for sex workers, 11 for migrant workers, 94 for people who inject drugs (PWID) and 67 for non-injectors. Random-effect models pooled estimates of anti-HCV seroprevalence in each population and a meta-regression model examined the relationship between anti-HCV seroprevalence and injecting drug use. RESULTS: The overall pooled seroprevalence of anti-HCV among MSM was 0.67% (CI 95 0.51-0.86); for sex workers 0.65% (CI 95 0.53-0.77); for migrant workers 0.48 (CI 95 0.20-0.85); for IDUs 72.41% (CI 95 68.71-75.97); among non-injectors 25.07% (CI 95 21.51%-28.80%). Our meta-regression model predicted that the seroprevalence of anti-HCV among PWID increased by 8.6% for each 10% increase seroprevalence of reporting ever having injected drugs. CONCLUSIONS: Overall, seroprevalence of HCV infection is high among PWUD, especially those who inject. Lower HCV seroprevalence (<1%) was found among MSM, sex workers and migrant workers. Our estimates for IDU seroprevalence are higher than that from the national surveillance system, though estimates for other at-risk populations are similar.

A crowdsourced intervention to promote hepatitis B and C testing among men who have sex with men in China: study protocol for a nationwide online randomized controlled trial.

BACKGROUND: The World Health Organization recommends all men who have sex with men (MSM) receive Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) testing. MSM in China are a high-risk group for HBV and HCV infection, but test uptake is low. Crowdsourcing invites a large group to solve a problem and then shares the solution with the public. This nationwide online randomized controlled trial will evaluate the effectiveness of a crowdsourced intervention to increase HBV and HCV testing among MSM in China. METHODS: Seven hundred MSM will be recruited through social media operated by MSM organizations in China. Eligible participants will be born biologically male, age 16 years or older, report previous anal sex with another man, and reside in China. After completing a baseline online survey, participants will be randomly assigned to intervention or control arms with a 1:1 allocation ratio. The intervention will include two components: (1) a multimedia component will deliver two videos and two images promoting HBV and HCV testing developed through a crowdsourcing contest in China; (2) a participatory component will invite men to submit suggestions for how to improve crowdsourced videos and images. The control arm will not view any images or videos and will not be invited to submit suggestions. All participants will be offered reimbursement for HBV and HCV testing costs. The primary outcome is HBV and HCV test uptake confirmed through electronic submission of test report photos within four weeks of enrolment. Secondary outcomes include self-reported HBV and HCV test uptake, HBV vaccination uptake, and change in stigma toward people living with HBV after four weeks. Primary and secondary outcomes will be calculated using intention to treat and as-exposed analyses and compared using two-sided 95% confidence intervals. DISCUSSION: Few previous studies have evaluated interventions to increase HBV and HCV testing in middle-income countries with a high burden of hepatitis. Delivering a crowdsourced intervention using social media is a novel approach to increasing hepatitis testing rates. HBV and HCV test uptake will be confirmed through test report photos, avoiding the limitations of self-reported testing outcomes. TRIAL REGISTRATION: NCT03482388 (29 March 2018).

Acceptability and feasibility of dual HIV and syphilis point-of-care testing for early detection of infection among pregnant women in China: a prospective study.

OBJECTIVE: To assess the feasibility and acceptability of using WHO prequalified combined dual HIV/syphilis rapid diagnostic tests (RDT) for same-day results in antenatal care (ANC) clinics. METHODS: This is a pragmatic implementation study using quantitative approach to evaluate outcomes. Antenatal clinic attendees from 21 rural and urban township hospitals in two provinces of China were offered with free dual RDTs testing that included HIV and syphilis, in addition to the routine blood tests. Study outcomes included testing uptake before and during dual RDT use, test feasibility and acceptability among pregnant women. Regression model was used to assess acceptance of RDT testing. RESULTS: In total, 1787 out of 1828 pregnant women attending ANC received the RDT testing. Testing uptake among pregnant women in their first and second trimester increased from 76.0% (2438/3269) using standard blood testing to 90.1% (1626/1787) with concurrent RDT use (χ2=197.1, p<0.001). Among 1787 pregnant women who received RDT tests, 98.3% (1757/1787) participants were given test result the same day. Positive proportions of HIV and syphilis screened with RDT were 0.06% (1/1787) and 1.0% (18/1787), respectively. Regression analysis indicated that women who did not receive syphilis or HIV testing before were less likely to accept dual RDT (OR 0.28, 95% CI 0.10 to 0.75). Acceptance for dual RDT testing at second or third antenatal visit was lower compared with the first visit (OR 0.37, 95% CI 0.15 to 0.94). CONCLUSION: Combined dual HIV/syphilis RDT with same-day results increased uptake of HIV and syphilis testing among pregnant women at primary healthcare facilities. Given the diversity of testing capacities among health services especially in rural areas in China, the dual RDT kit is feasible tool to improve testing uptake among pregnant women.

Improving the hepatitis cascade: assessing hepatitis testing and its management in primary health care in China.

Objective: The study aimed to decentralize hepatitis testing and management services to primary care in China. Methods: A nationwide representative provider survey amongst community health centres (CHCs) using randomized stratified sampling methods was conducted between September and December 2015. One hundred and eighty CHCs and frontline primary care practitioners from 20 cities across three administrative regions of Western, Central and Eastern China were invited to participate. Results: One hundred and forty-nine clinicians-in-charge (79%), 1734 doctors and 1846 nurses participated (86%). Majority of CHCs (80%, 95% CI: 74-87) offered hepatitis B testing, but just over half (55%, 95% CI: 46-65) offered hepatitis C testing. The majority of doctors (87%) and nurses (85%) felt that there were benefits for providing hepatitis testing at CHCs. The major barriers for not offering hepatitis testing were lack of training (54%) and financial support (23%). Multivariate analysis showed that the major determinants for CHCs to offer hepatitis B and C testing were the number of nurses (AOR 1.1) and written policies for hepatitis B diagnosis (AOR 12.7-27.1), and for hepatitis B the availability of reproductive health service. Conclusions: Primary care providers in China could play a pivotal role in screening, diagnosing and treating millions of people with chronic hepatitis B and C in China.

The experience of discrimination of individuals living with chronic hepatitis B in four provinces of China.

OBJECTIVES: To assess chronic hepatitis B (CHB) patients' knowledge about hepatitis B and their experience of discrimination with regard to study, work, and daily life. METHODS: We administered a questionnaire to 797 CHB patients in four provinces of China and used one-way analysis of variance (ANOVA) and a generalized linear model (GLM) to identify factors associated with discrimination. RESULTS: CHB patients had low levels of knowledge about hepatitis B. Patients under 40 years of age with a junior college education or above knew more about hepatitis B than CHB patients over 40 years of age who had only a high school education. Three-fourths of patients had experienced discrimination because of their hepatitis B infection, with no differences in the proportion experiencing discrimination by sex or age. People with more education reported less discrimination. Patients in Beijing and Henan province perceived less discrimination than those in Shaanxi and Guangdong provinces. Discrimination was significantly associated with negative emotions. CHB patients had little awareness of China's anti-discrimination laws and policies. Among patients who had experienced discrimination, fewer than 10% knew organizations or institutions that could offer help. Over 60% of CHB patients who experienced discrimination chose not to respond. CONCLUSION: CHB patients in China commonly experienced discrimination, which was associated with significant, negative emotional stress. To mitigate the damaging effects of discrimination, our study suggests raising general population knowledge about hepatitis B, raising awareness of the availability of legal protection and organizations that can fight discrimination, and providing psychological support for CHB patients.

Feasibility of implementing an integrated tool for improvement of treatment quality and early-warning indicators for HIV drug resistance: a pilot study of centres in India.

With the rapid scale-up in use of antiretroviral therapy (ART), monitoring the quality of care and factors that may lead to emergence of HIV drug resistance (HIVDR) is an important focus point for programme managers. The National AIDS Control Organisation of India embarked on strengthening the ART programme for continuous quality improvement (CQI), using defined quality-of-care indicators (QCIs), including World Health Organization (WHO) early-warning indicators (EWIs) for HIVDR. In this feasibility study, done during July 2014, an integrated QCI and EWI tool developed by WHO India was pilot tested across 18 purposively selected ART centres. At seven ART centres, the EWI 1 target of >90% on-time pill pick-up was achieved for adult patients, while among the paediatric age group (<15 years old) it was not achieved by any centre. EWI 2 (retention of patients in ART care at 12 months after initiation) showed that two centres had retention of both adult and paediatric patients of >85% at 12 months of ART, while 11 centres had retention between 75% and 85%. EWI 3 (pharmacy stock-out) for adult and paediatric patients showed that 11 ART centres reported a minimum of one stock-out for the first-line ART drugs in the reporting period, while EWI 4 targets (pharmacy dispensing practices) were achieved by all the centres, for both adults and children. Average retention in care at 6, 12 and 24 months after ART initiation was 82%, 77% and 71%, respectively. This feasibility study showed that EWI analyses were much simpler to conduct if information was sought only for patients receiving ART, for whom the quality of record-keeping is better and more consistent. The activity has highlighted the need for improved quality of record-keeping at the facilities and implementation of specific interventions to ensure better patient follow-up. After modifications, use of the tool will be phased in across all the ART centres in India.