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.

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.

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.