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.

Role of unsafe medical practices and sexual behaviours in the hepatitis B and C syndemic and HIV co-infection in Rwanda: a cross-sectional study.

OBJECTIVES: This study describes the burden of the hepatitis B, C and HIV co-infections and assesses associated risk factors. SETTING: This analysis used data from a viral hepatitis screening campaign conducted in six districts in Rwanda from April to May 2019. Ten health centres per district were selected according to population size and distance. PARTICIPANTS: The campaign collected information from 156 499 participants (51 496 males and 104 953 females) on sociodemographic, clinical and behavioural characteristics. People who were not Rwandan by nationality or under 15 years old were excluded. PRIMARY AND SECONDARY OUTCOMES: The outcomes of interest included chronic hepatitis C virus (HCV) infection, chronic hepatitis B virus (HBV) infection, HIV infection, co-infection HIV/HBV, co-infection HIV/HCV, co-infection HBV/HCV and co-infection HCV/HBV/HIV. Multivariable logistic regressions were used to assess factors associated with HBV, HCV and HIV, mono and co-infections. RESULTS: Of 156 499 individuals screened, 3465 (2.2%) were hepatitis B surface antigen positive and 83% (2872/3465) of them had detectable HBV desoxy-nucleic acid (HBV DNA). A total of 4382 (2.8%) individuals were positive for antibody-HCV (anti-HCV) and 3163 (72.2%) had detectable HCV ribo-nucleic acid (RNA). Overall, 36 (0.02%) had HBV/HCV co-infection, 153 (0.1%) HBV/HIV co-infection, 238 (0.15%) HCV/HIV co-infection and 3 (0.002%) had triple infection. Scarification or receiving an operation from traditional healer was associated with all infections. Healthcare risk factors-history of surgery or transfusion-were associated with higher likelihood of HIV infection with OR 1.42 (95% CI 1.21 to 1.66) and OR 1.48 (1.29 to 1.70), respectively, while history of physical traumatic assault was associated with a higher likelihood of HIV and HBV/HIV co-infections with OR 1.69 (95% CI 1.51 to 1.88) and OR 1.82 (1.08 to 3.05), respectively. CONCLUSIONS: Overall, mono-infections were common and there were differences in significant risk factors associated with various infections. These findings highlight the magnitude of co-infections and differences in underlying risk factors that are important for designing prevention and care programmes.

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.