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Background and Aims: Although the evidence is uncertain, existing estimates for hepatitis C virus (HCV) in sub‐Saharan Africa (SSA) indicate a high burden. We estimated HCV seroprevalence and viraemic prevalence among the general population in SSA. Methods: We searched Medline, Embase, Web of Science, APA PsycINFO, and World Health Organization Africa Index Medicus for community‐based studies. Study quality was assessed using the Joanna Briggs Institute critical appraisal tool, and heterogeneity using the index of heterogeneity (I2). Two approaches were deployed. First, we used random‐effects meta‐analysis to pool prevalence. Second, to derive representative estimates, we weighted each country's HCV seroprevalence using 2021 United Nations country population sizes. Results: We synthesized 130 studies. Overall, SSA HCV seroprevalence from the random‐effects model was 4.17% (95% confidence interval [CI]: 3.71–4.66, I2 = 99.30%). There were no differences between males (4.31%) and females (4.03%). Seroprevalence was 2.25%, 3.31%, and 16.23% for ages ≤20, 21–64, and ≥65 years, respectively, and was higher in rural (6.63%) versus urban (2.93%). There was indication of decrement overtime from 5.74% to 4.35% to 3.03% in the years 1984–2000, 2001–2014, and 2015–2023, respectively. The weighted overall SSA HCV seroprevalence was estimated to be 2.30% (95% CI: 1.59–3.00) with regional variation: Africa‐Southern (.79%), Africa‐Central (1.47%), Africa‐Eastern (2.71%), and Africa‐Western (2.88%). HCV viremia among HCV seropositives was 54.77% (95% CI: 47.80–61.66). Conclusions: HCV seroprevalence in SSA remains high. Populations aged ≥65 years, rural communities, Africa‐Western, and some countries in Africa‐Central and Africa‐Eastern appear disproportionately affected. These results underline the need for governmental commitment to achieve the 2030 global HCV elimination targets. [ABSTRACT FROM AUTHOR]

Pakistan harbours a large burden of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection. We utilised repeat sero‐surveys to assess progress achieved towards hepatitis elimination in Pakistan. Multilevel logistic regression evaluated the change in HBV infection (HBV surface antigen (HBsAg)‐positive) prevalence and HCV exposure (HCV antibody (HCV‐Ab)‐positive) prevalence between two sero‐surveys from 2007 and 2019 for Sindh province and associated risk factors. Adjusted odds ratios (aORs) were estimated and population‐attributable fractions (PAF) for modifiable risk factors for HCV exposure. The 2007 and 2019 surveys included 8855 and 6672 individuals. HBsAg prevalence decreased from 2.6% (95% confidence intervals (95% CI): 2.2–2.9) in 2007 to 1.1% (95% CI: 0.8–1.3) in 2019, while HCV‐Ab prevalence increased from 5.1% (95% CI: 4.6%–5.5%) to 6.2% (95% CI: 5.6%–6.8%). The age and gender‐adjusted HBsAg prevalence decreased by 80% (aOR = 0.2, 95% CI: 0.1–0.4) among children and 60% (aOR = 0.4, 95% CI: 0.3–0.6) among adults over 2007–2019, while HCV‐Ab prevalence decreased by 60% (aOR = 0.4, 95%CI:0.2–0.7) in children and increased by 40% (aOR = 1.4, 95% CI: 1.2–1.7) in adults. HCV‐Ab prevalence was lower in adults with secondary (aOR = 0.6, 95% CI: 0.5–0.8) and higher (aOR = 0.5, 95%CI:0.3–0.8) education compared to illiterates and higher among adults reporting blood transfusion (aOR = 1.7, 95% CI: 1.2–2.4), family history of hepatitis (aOR = 2.5, 95% CI: 1.9–3.3), past year medical injection (aOR = 2.1, 95% CI: 1.6–2.7), being tattooed (aOR = 1.4, 95% CI: 1.0–1.9) and shaved by traditional barber (aOR = 1.2, 95% CI: 1.0–1.5). Modifiable risk factors accounted for 45% of HCV exposure, with medical injection(s) accounting for 38% (95%CI,25.7–48.4%). Overall HCV has increased over 2007–2019 in Sindh province, while HBV prevalence has decreased. Medical injections should be an important focus of prevention activities. [ABSTRACT FROM AUTHOR]

The document is a response to a letter to the editor regarding a systematic review on the prevalence of Hepatitis C Virus in Sub-Saharan Africa. The authors discuss their methodology, including random-effects analysis and sensitivity analyses, to determine prevalence estimates. They also address issues of heterogeneity in meta-analyses and the challenges of assessing publication bias in prevalence studies. The main finding of the study is a population-weighted pooled seroprevalence estimate of 2.30%. [Extracted from the article]

Background: Syringe vending machines (SVM) can improve access to sterile injecting equipment, but they have not been widely implemented or evaluated. We evaluate the cost of SVM installed between July 2019–December 2020 in Tbilisi, Georgia. Methods: The SVM were stocked with several kit types, including injecting equipment for opioid or stimulant users, naloxone, male and female condoms, and pregnancy tests. We gathered financial data from the project to estimate fixed (staff time, start-up costs, equipment, running costs, and consumables) and variable (harm reduction kits) costs. We calculated the full cost of the SVM intervention, cost per user, cost per additional syringe accessed by SVM users, and cost per kit distributed (2020 Euros). Results: SVM access cards were issued to 1132 users, and 29,238 kits were distributed through SVM, total cost €204,358. Staff costs were 51% of total, consumable costs 28%, equipment 10%, and start up, recurrent costs, and overheads 5% or less each. Opioid and stimulant kits were most accessed (35% and 32% of total). Cost per user was €66/year, and cost per transaction €7, of which €5 fixed costs and €2 variable. If monthly transactions increased from the average of 1622/month to highest monthly usage (4714), fixed costs per transaction would decrease to < €1. It cost €0.55 per additional syringe accessed/user/month. Conclusions: This study provides evidence for governments about the cost of SVM, a novel harm reduction intervention. This is particularly relevant where Global Fund is withdrawing and harm reduction services need to be incorporated into national budgets. [ABSTRACT FROM AUTHOR]

Background & Aims: In 2016, Médecins Sans Frontières established the first general population Hepatitis C virus (HCV) screening and treatment site in Cambodia, offering free direct‐acting antiviral (DAA) treatment. This study analysed the cost‐effectiveness of this intervention. Methods: Costs, quality adjusted life years (QALYs) and cost‐effectiveness of the intervention were projected with a Markov model over a lifetime horizon, discounted at 3%/year. Patient‐level resource‐use and outcome data, treatment costs, costs of HCV‐related healthcare and EQ‐5D‐5L health states were collected from an observational cohort study evaluating the effectiveness of DAA treatment under full and simplified models of care compared to no treatment; other model parameters were derived from literature. Incremental cost‐effectiveness ratios (cost/QALY gained) were compared to an opportunity cost‐based willingness‐to‐pay threshold for Cambodia ($248/QALY). Results: The total cost of testing and treatment per patient for the full model of care was $925(IQR $668‐1631), reducing to $376(IQR $344‐422) for the simplified model of care. EQ‐5D‐5L values varied by fibrosis stage: decompensated cirrhosis had the lowest value, values increased during and following treatment. The simplified model of care was cost saving compared to no treatment, while the full model of care, although cost‐effective compared to no treatment ($187/QALY), cost an additional $14 485/QALY compared to the simplified model, above the willingness‐to‐pay threshold for Cambodia. This result is robust to variation in parameters. Conclusions: The simplified model of care was cost saving compared to no treatment, emphasizing the importance of simplifying pathways of care for improving access to HCV treatment in low‐resource settings. [ABSTRACT FROM AUTHOR]

Abstract: Transmission of parasites between host species affects host population dynamics, interspecific competition, and ecosystem structure and function. In areas where wild and domestic herbivores share grazing land, management of parasites in livestock may affect or be affected by sympatric wildlife due to cross‐species transmission. We develop a novel method for simulating transmission potential based on both biotic and abiotic factors in a semi‐arid system in Botswana. Optimal timing of antiparasitic treatment in livestock is then compared under a variety of alternative host scenarios, including seasonally migrating wild hosts. In this region, rainfall is the primary driver of seasonality of transmission, but wildlife migration leads to spatial differences in the effectiveness of treatment in domestic animals. Additionally, competent migratory wildlife hosts move parasites across the landscape. Simulated transmission potential matches observed patterns of clinical disease in livestock in the study area. Increased wildlife contact is correlated with a decrease in disease, suggesting that non‐competent wild hosts may attenuate transmission by removing infective parasite larvae from livestock pasture. Optimising the timing of treatment according to within‐year rainfall patterns was considerably more effective than treating at a standard time of year. By targeting treatment in this way, efficient control can be achieved, mitigating parasite spillover from wildlife where it does occur. Synthesis and applications. This model of parasite transmission potential enables evidence‐based management of parasite spillover between wild and domestic species in a spatio‐temporally dynamic system. It can be applied in other mixed‐use systems to mitigate parasite transmission under altered climate scenarios or changes in host ranges. [ABSTRACT FROM AUTHOR]

Parasites vary widely in the diversity of hosts they infect: some parasite species are specialists—infecting just a single host species, while others are generalists, capable of infecting many. Understanding the factors that drive parasite host-generalism is of basic biological interest, but also directly relevant to predicting disease emergence in new host species, identifying parasites that are likely to have unidentified additional hosts, and assessing transmission risk. Here, we use mathematical models to investigate how variation in host body size and environmental temperature affect the evolution of parasite host-generalism. We predict that parasites are more likely to evolve a generalist strategy when hosts are large-bodied, when variation in host body size is large, and in cooler environments. We then explore these predictions using a newly updated database of over 20 000 fish–macroparasite associations. Within the database we see some evidence supporting these predictions, but also highlight mismatches between theory and data. By combining these two approaches, we establish a theoretical basis for interpreting empirical data on parasites’ host specificity and identify key areas for future work that will help untangle the drivers of parasite host-generalism. [ABSTRACT FROM AUTHOR]

For many parasites, the full set of hosts that are susceptible to infection is not known, and this could lead to a bias in estimates of transmission. We used counts of individual adult parasites from historical parasitology studies in southern Africa to map a bipartite network of the nematode parasites of herbivore hosts that occur in Botswana. Bipartite networks are used in community ecology to represent interactions across trophic levels. We used a Bayesian hierarchical model to predict the full set of host–parasite interactions from existing data on parasitic gastrointestinal nematodes of wild and domestic ungulates given assumptions about the distribution of parasite counts within hosts, while accounting for the relative uncertainty of less sampled species. We used network metrics to assess the difference between the observed and predicted networks, and to explore the connections between hosts via their shared parasites using a host–host unipartite network projected from the bipartite network. The model predicts a large number of missing links and identifies red hartebeest, giraffe and steenbok as the hosts that have the most uncertainty in parasite diversity. Further, the unipartite network reveals clusters of herbivores that have a high degree of parasite sharing, and these clusters correspond closely with phylogenetic distance rather than with the wild/domestic boundary. These results provide a basis for predicting the risk of cross-species transmission of nematode parasites in areas where livestock and wildlife share grazing land. [ABSTRACT FROM AUTHOR]

The One Health initiative is a global effort fostering interdisciplinary collaborations to address challenges in human, animal, and environmental health. While One Health has received considerable press, its benefits remain unclear because its effects have not been quantitatively described. We systematically surveyed the published literature and used social network analysis to measure interdisciplinarity in One Health studies constructing dynamic pathogen transmission models. The number of publications fulfilling our search criteria increased by 14.6% per year, which is faster than growth rates for life sciences as a whole and for most biology subdisciplines. Surveyed publications clustered into three communities: one used by ecologists, one used by veterinarians, and a third diverse-authorship community used by population biologists, mathematicians, epidemiologists, and experts in human health. Overlap between these communities increased through time in terms of author number, diversity of co-author affiliations, and diversity of citations. However, communities continue to differ in the systems studied, questions asked, and methods employed. While the infectious disease research community has made significant progress toward integrating its participating disciplines, some segregation—especially along the veterinary/ecological research interface—remains. [ABSTRACT FROM AUTHOR]

Due to the threat of anthelmintic resistance, livestock farmers worldwide are encouraged to selectively apply treatments against gastrointestinal nematodes (GINs). Targeted selective treatment (TST) of individual animals would be especially useful for smallholder farmers in low-income economies, where cost-effective and sustainable intervention strategies will improve livestock productivity and food security. Supporting research has focused mainly on refining technical indicators for treatment, and much less on factors influencing uptake and effectiveness. We used a mixed method approach, whereby qualitative and quantitative approaches are combined, to develop, implement and validate a TST system for GINs in small ruminants, most commonly goats, among smallholder farmers in the Makgadikgadi Pans region of Botswana, and to seek better understanding of system performance within a cultural context. After the first six months of the study, 42 out of 47 enrolled farmers were followed up; 52% had monitored their animals using the taught inspection criteria and 26% applied TST during this phase. Uptake level showed little correlation with farmer characteristics, such as literacy and size of farm. Herd health significantly improved in those herds where anthelmintic treatment was applied: anaemia, as assessed using the five-point FAMACHA © scale, was 0.44–0.69 points better (95% confidence interval) and body condition score was 0.18–0.36 points better (95% C.I., five-point scale) in treated compared with untreated herds. Only targeting individuals in greatest need led to similar health improvements compared to treating the entire herd, leading to dose savings ranging from 36% to 97%. This study demonstrates that TST against nematodes can be implemented effectively by resource-poor farmers using a community-led approach. The use of mixed methods provides a promising system to integrate technical and social aspects of TST programmes for maximum uptake and effect. [ABSTRACT FROM AUTHOR]

Abstract: Several prominent and economically important diseases of livestock in East Africa are caused by multi-host pathogens that also infect wildlife species, but management strategies are generally livestock focused and models of these diseases tend to ignore the role of wildlife. We investigate the dynamics of a multi-host tick-borne disease in order to assess the efficacy of tick control from an ecological perspective. We examined the efficacy of a widespread measure of tick control and developed a model to explore how changes in the population of ticks due to control measures on cattle impact dynamics of Theileria parva infection in a system with two primary host species, cattle and Cape buffalo (Syncerus caffer). We show that the frequency of acaricide application has a significant impact on the tick population both on the host and in the environment, which can greatly reduce the pathogen load in cattle. We also demonstrate that reducing the tick population through cattle-related control measures is not sufficient to diminish disease transmission in buffalo. Our results suggest that under current control strategies, which target ticks on cattle only, T. parva is likely to remain a significant problem in East Africa, and require the continued use of acaricides, which has significant economic and ecological consequences. [Copyright &y& Elsevier]

Introduction: People who inject drugs (PWID) in Ukraine have high prevalences of HIV and hepatitis C virus (HCV). Non‐governmental organizations (NGOs) provide PWID with needles/syringes, condoms, HIV/HCV testing and linkage to opioid agonist treatment (OAT) and antiretroviral therapy (ART). We estimated their impact and cost‐effectiveness among PWID. Methods: A dynamic HIV and HCV transmission model among PWID was calibrated using data from four national PWID surveys (2011–2017). The model assumed 37–49% coverage of NGOs among community PWID, with NGO contact reducing injecting risk and increasing condom use and recruitment onto OAT and ART. We estimated the historic (1997–2021) and future (2022–2030, compared to no NGO activities from 2022) impact of NGOs in terms of the proportion of HIV/HCV infections averted and changes in HIV/HCV incidence. We estimated the future impact of scaling‐up NGOs to 80% coverage with/without scale‐up in OAT (5–20%) and ART (64–81%). We estimated the cost per disability‐adjusted life‐year (DALY) averted of current NGO provision over 2022–2041 compared to NGO activities stopping over 2022–2026, but restarting after that till 2041. We assumed average unit costs of US$80–90 per person‐year of NGO contact for PWID. Results: With existing coverage levels of NGOs, the model projects that NGOs have averted 20.0% (95% credibility interval: 13.3–26.1) and 9.6% (5.1–14.1) of new HIV and HCV infections among PWID over 1997–2021, respectively, and will avert 31.8% (19.6–39.9) and 13.7% (7.5–18.1) of HIV and HCV infections over 2022–2030. With NGO scale‐up, HIV and HCV incidence will decrease by 54.2% (43.3–63.8) and 30.2% (20.5–36.2) over 2022–2030, or 86.7% (82.9–89.3) and 39.8% (31.4–44.8) if OAT and ART are also scaled‐up. Without NGOs, HIV and HCV incidence will increase by 51.6% (23.6–76.3) and 13.4% (4.8–21.9) over 2022–2030. Current NGO provision over 2022–2026 will avert 102,736 (77,611–137,512) DALYs when tracked until 2041 (discounted 3% annually), and cost US$912 (702–1222) per DALY averted; cost‐effective at a willingness‐to‐pay threshold of US$1548/DALY averted (0.5xGDP). Conclusions: NGO activities have a crucial preventative impact among PWID in Ukraine which should be scaled‐up to help achieve HIV and HCV elimination. Disruptions could have a substantial detrimental impact. [ABSTRACT FROM AUTHOR]

ABSTRACT Hepatitis C virus (HCV) is hypothesised to be a public health problem in Ethiopia, and systematic review evidence suggested 1%–3% seroprevalence. We aimed to estimate the seroprevalence of HCV overall and across regions of Ethiopia. We estimated HCV seroprevalence using the 2016 Ethiopian Demographic and Health Survey (EDHS‐2016). EDHS‐2016 is a nationwide household survey conducted using two‐stage cluster sampling methods. We tested all 26,753 samples from participating adult women (15–49 years) and men (15–59 years) using HCV Enzyme Immunoassay. Descriptive analyses were performed based on the Guide to Demographic Health Survey statistics. We applied sample weighting to derive representative estimates. Of the total tested, more than half (54.40%) were aged 15–29 years and 51.59% were women. Overall HCV seroprevalence was 0.18% (95% Confidence Interval: 0.10–0.32). Higher seroprevalences were found in Afar (0.92%) and South Nations Nationality Peoples Region (0.43%); people living with HIV (PLWH) (0.62%); the poorest wealth index (0.35%); people having multiple lifetime sexual partners (0.31%); and widowed/divorced individuals (0.30%). In stratified analyses by sex and residency, we found higher seroprevalences in non‐Christian and non‐Muslim males (1.98%) and rural population (1.00%), male PLWH (1.67%), rural PLWH (1.45%), widowed/divorced males (0.97%), and in all groups from the Afar region: males (1.30%), females (0.61%), urban (1.07%), and rural (0.86%). HCV seroprevalence among the general population in Ethiopia is much lower than from previous estimates. General population screening is unlikely to be cost‐effective, and so screening programs targeted to people at greater risk of HCV will be required. [ABSTRACT FROM AUTHOR]

Background: Modelling suggests that achieving the WHO incidence target for hepatitis C virus (HCV) elimination in Pakistan could cost US$3.87 billion over 2018 to 2030. However, the economic benefits from integrating services or improving productivity were not included.Methods and Findings: We adapt a HCV transmission model for Pakistan to estimate the impact, costs, and cost-effectiveness of achieving HCV elimination (reducing annual HCV incidence by 80% by 2030) with stand-alone service delivery, or partially integrating one-third of initial HCV testing into existing healthcare services. We estimate the net economic benefits by comparing the required investment in screening, treatment, and healthcare management to the economic productivity gains from reduced HCV-attributable absenteeism, presenteeism, and premature deaths. We also calculate the incremental cost-effectiveness ratio (ICER) per disability-adjusted life year (DALY) averted for HCV elimination versus maintaining current levels of HCV treatment. This is compared to an opportunity cost-based willingness-to-pay threshold for Pakistan (US$148 to US$198/DALY). Compared to existing levels of treatment, scaling up screening and treatment to achieve HCV elimination in Pakistan averts 5.57 (95% uncertainty interval (UI) 3.80 to 8.22) million DALYs and 333,000 (219,000 to 509,000) HCV-related deaths over 2018 to 2030. If HCV testing is partially integrated, this scale-up requires an investment of US$1.45 (1.32 to 1.60) billion but will result in US$1.30 (0.94 to 1.72) billion in improved economic productivity over 2018 to 2030. This elimination strategy is highly cost-effective (ICER = US$29 per DALY averted) by 2030, with it becoming cost-saving by 2031 and having a net economic benefit of US$9.10 (95% UI 6.54 to 11.99) billion by 2050. Limitations include uncertainty around what level of integration is possible within existing primary healthcare services as well as a lack of Pakistan-specific data on disease-related healthcare management costs or productivity losses due to HCV.Conclusions: Investment in HCV elimination can bring about substantial societal health and economic benefits for Pakistan. [ABSTRACT FROM AUTHOR]

The second sentence of the Acknowledgments is incomplete. The complete sentence reads: AGL, JW, and PV also acknowledge funding from the Wellcome Trust under grant number 220866/Z/20/Z.By Aaron G. Lim; Nick Scott; Josephine G. Walker; Saeed Hamid; Margaret Hellard and Peter VickermanReported by Author; Author; Author; Author; Author; Author [Extracted from the article]

Climate change and emerging drug resistance make the control of many infectious diseases increasingly challenging and diminish the exclusive reliance on drug treatment as sole solution to the problem. As disease transmission often depends on environmental conditions that can be modified, such modifications may become crucial to risk reduction if we can assess their potential benefit at policy-relevant scales. However, so far, the value of environmental management for this purpose has received little attention. Here, using the parasitic disease of fasciolosis in livestock in the UK as a case study, we demonstrate how mechanistic hydro-epidemiological modelling can be applied to understand disease risk drivers and the efficacy of environmental management across a large heterogeneous domain. Our results show how weather and other environmental characteristics interact to define disease transmission potential and reveal that environmental interventions such as risk avoidance management strategies can provide a valuable alternative or complement to current treatment-based control practice. [ABSTRACT FROM AUTHOR]

Background: Hepatitis B virus (HBV) epidemiology in Europe differs by region and population risk group, and data are often incomplete. We estimated chronic HBV prevalence as measured by surface antigen (HBsAg) among general and key population groups for each country in the European Union, European Economic Area and the United Kingdom (EU/EEA/UK), including where data are currently unavailable. Methods: We combined data from a 2018 systematic review (updated in 2021), data gathered directly by the European Centre for Disease Control (ECDC) from EU/EEA countries and the UK and further country-level data. We included data on adults from the general population, pregnant women, first time blood donors (FTBD), men who have sex with men (MSM), prisoners, people who inject drugs (PWID), and migrants from 2001 to 2021, with three exceptions made for pre-2001 estimates. Finite Mixture Models (FMM) and Beta regression were used to predict country and population group HBsAg prevalence. A separate multiplier method was used to estimate HBsAg prevalence among the migrant populations within each country, due to biases in the data available. Results: There were 595 included studies from 31 countries (N = 41,955,969 people): 66 were among the general population (mean prevalence () 1.3% [range: 0.0-7.6%]), 52 among pregnant women ( 1.1% [0.1–5.3%]), 315 among FTBD ( 0.3% [0.0-6.2%]), 20 among MSM ( 1.7% [0.0-11.2%]), 34 among PWID ( 3.9% [0.0-16.9%]), 24 among prisoners ( 2.9% [0.0-10.7%]), and 84 among migrants ( 7.0% [0.2–37.3%]). The FMM grouped countries into 3 classes. We estimated HBsAg prevalence among the general population to be < 1% in 24/31 countries, although it was higher in 7 Eastern/Southern European countries. HBsAg prevalence among each population group was higher in most Eastern/Southern European than Western/Northern European countries, whilst prevalence among PWID and prisoners was estimated at > 1% for most countries. Portugal had the highest estimated prevalence of HBsAg among migrants (5.0%), with the other highest prevalences mostly seen in Southern Europe. Conclusions: We estimated HBV prevalence for each population group within each EU/EAA country and the UK, with general population HBV prevalence to be < 1% in most countries. Further evidence is required on the HBsAg prevalence of high-risk populations for future evidence synthesis. [ABSTRACT FROM AUTHOR]

Background and Aims: In 2015, the country of Georgia launched an elimination program aiming to reduce the prevalence of Hepatitis C virus (HCV) infection by 90% from 5.4% prevalence (~150 000 people). During the first 2.5 years of the program, 770 832 people were screened, 48 575 were diagnosed with active HCV infection, and 41 483 patients were treated with direct‐acting antiviral (DAA)‐based regimens, with a >95% cure rate. Methods: We modelled the incremental cost‐effectiveness ratio (ICER) of HCV screening, diagnosis and treatment between April 2015 and November 2017 compared to no treatment, in terms of cost per quality‐adjusted life year (QALY) gained in 2017 US dollars, with a 3% discount rate over 25 years. We compared the ICER to willingness‐to‐pay (WTP) thresholds of US$4357 (GDP) and US$871 (opportunity cost) per QALY gained. Results: The average cost of screening, HCV viremia testing, and treatment per patient treated was $386 to the provider, $225 to the patient and $1042 for generic DAAs. At 3% discount, 0.57 QALYs were gained per patient treated. The ICER from the perspective of the provider including generic DAAs was $2285 per QALY gained, which is cost‐effective at the $4357 WTP threshold, while if patient costs are included, it is just above the threshold at $4398/QALY. All other scenarios examined in sensitivity analyses remain cost‐effective except for assuming a shorter time horizon to the end of 2025 or including the list price DAA cost. Reducing or excluding DAA costs reduced the ICER below the opportunity‐cost WTP threshold. Conclusions: The Georgian HCV elimination program provides valuable evidence that national programs for scaling up HCV screening and treatment for achieving HCV elimination can be cost‐effective. [ABSTRACT FROM AUTHOR]

To date, studies examining HCV treatment outcomes among PWID using DAA therapy have been conducted predominantly in higher income settings. Individuals who had a detectable HCV viral load at post-treatment week 12 or those who were missing an HCV viral load at post-treatment week 12 were classified as a treatment failure. Keywords: Africa; DAA; HCV; LMIC; PWID EN Africa DAA HCV LMIC PWID 691 694 4 07/13/22 20220801 NES 220801 Abbreviations APRI Aspartate Aminotransferase to Platelet Ratio Index CTP Child-Turcotte-Pugh DAA Direct-acting antivirals DOT Directly observed therapy FIB-4 Fibrosis-4 HBV Hepatitis B virus HCV Hepatitis C virus KSH Kenyan shilling LDV Ledipasvir LMICs Low- and middle-income countries MAT Medication-assisted treatment NSP Needle and syringe programmes PCM Peer case manager PWID People who inject drugs SOF Sofosbuvir SSA Sub-Saharan Africa SVR Sustained virologic response INTRODUCTION Although between 10 and 15 million of the estimated 71 million people worldwide living with the hepatitis C virus (HCV) live in sub-Saharan Africa (SSA),1 recent data suggest only 1% of these individuals have accessed HCV treatment.1 Diminished access has been attributed to the financial and geographical barriers to general medical care, and limited regional availability of direct-acting antivirals (DAA). [Extracted from the article]

Introduction: People who inject drugs (PWID) in Dar es Salaam, Tanzania, have a high prevalence of HIV and hepatitis C virus (HCV). While needle and syringe programmes (NSP), opioid agonist therapy (OAT) and anti‐retroviral therapy (ART) are available in Tanzania, their coverage is sub‐optimal. We assess the impact of existing and scaled up harm reduction (HR) interventions on HIV and HCV transmission among PWID in Dar es Salaam. Methods: An HIV and HCV transmission model among PWID in Tanzania was calibrated to data over 2006–2018 on HIV (∼30% and ∼67% prevalence in males and females in 2011) and HCV prevalence (∼16% in 2017), numbers on HR interventions (5254 ever on OAT in 2018, 766–1479 accessing NSP in 2017) and ART coverage (63.1% in 2015). We evaluated the impact of existing interventions in 2019 and impact by 2030 of scaling‐up the coverage of OAT (to 50% of PWID), NSP (75%, both combined termed "full HR") and ART (81% with 90% virally suppressed) from 2019, reducing sexual HIV transmission by 50%, and/or HCV‐treating 10% of PWID infected with HCV annually. Results: The model projects HIV and HCV prevalence of 19.0% (95% credibility interval: 16.4–21.2%) and 41.0% (24.4–49.0%) in 2019, respectively. For HIV, 24.6% (13.6–32.6%) and 70.3% (59.3–77.1%) of incident infections among male and female PWID are sexually transmitted, respectively. Due to their low coverage (22.8% for OAT, 16.3% for NSP in 2019), OAT and NSP averted 20.4% (12.9–24.7%) of HIV infections and 21.7% (17.0–25.2%) of HCV infections in 2019. Existing ART (68.5% coverage by 2019) averted 48.1% (29.7–64.3%) of HIV infections in 2019. Scaling up to full HR will reduce HIV and HCV incidence by 62.6% (52.5–74.0%) and 81.4% (56.7–81.4%), respectively, over 2019–2030; scaled up ART alongside full HR will decrease HIV incidence by 66.8% (55.6–77.5%), increasing to 81.5% (73.7–87.5%) when sexual risk is also reduced. HCV‐treatment alongside full HR will decrease HCV incidence by 92.4% (80.7–95.8%) by 2030. Conclusions: Combination interventions, including sexual risk reduction and HCV treatment, are needed to eliminate HCV and HIV among PWID in Tanzania. [ABSTRACT FROM AUTHOR]

University students have unique living, learning and social arrangements which may have implications for infectious disease transmission. To address this data gap, we created CONQUEST (COroNavirus QUESTionnaire), a longitudinal online survey of contacts, behaviour, and COVID-19 symptoms for University of Bristol (UoB) staff/students. Here, we analyse results from 740 students providing 1261 unique records from the start of the 2020/2021 academic year (14/09/2020–01/11/2020), where COVID-19 outbreaks led to the self-isolation of all students in some halls of residences. Although most students reported lower daily contacts than in pre-COVID-19 studies, there was heterogeneity, with some reporting many (median = 2, mean = 6.1, standard deviation = 15.0; 8% had ≥ 20 contacts). Around 40% of students' contacts were with individuals external to the university, indicating potential for transmission to non-students/staff. Only 61% of those reporting cardinal symptoms in the past week self-isolated, although 99% with a positive COVID-19 test during the 2 weeks before survey completion had self-isolated within the last week. Some students who self-isolated had many contacts (mean = 4.3, standard deviation = 10.6). Our results provide context to the COVID-19 outbreaks seen in universities and are available for modelling future outbreaks and informing policy. [ABSTRACT FROM AUTHOR]

Despite the availability of effective direct‐acting antiviral (DAA) treatments for Hepatitis C virus (HCV) infection, many people remain undiagnosed and untreated. We assessed the cost‐effectiveness of a Médecins Sans Frontières (MSF) HCV screening and treatment programme within a primary health clinic in Karachi, Pakistan. A health state transition Markov model was developed to estimate the cost‐effectiveness of the MSF programme. Programme cost and outcome data were analysed retrospectively. The incremental cost‐effectiveness ratio (ICER) was calculated in terms of incremental cost (2016 US$) per disability‐adjusted life year (DALY) averted from the provider's perspective over a lifetime horizon. The robustness of the model was evaluated using deterministic and probabilistic sensitivity analyses (PSA). The ICER for implementing testing and treatment compared to no programme was US$450/DALY averted, with 100% of PSA runs falling below the per capita Gross Domestic Product threshold for cost‐effective interventions for Pakistan (US$1,422). The ICER increased to US$532/DALY averted assuming national HCV seroprevalence (5.5% versus 33% observed in the intervention). If the cost of liver disease care was included (adapted from resource use data from Cambodia which has similar GDP to Pakistan), the ICER dropped to US$148/DALY, while it became cost‐saving if a recently negotiated reduced drug cost of $75/treatment course was assumed (versus $282 in base‐case) in addition to cost of liver disease care. In conclusion, screening and DAA treatment for HCV infection are expected to be highly cost‐effective in Pakistan, supporting the expansion of similar screening and treatment programmes across Pakistan. [ABSTRACT FROM AUTHOR]

Introduction: People who inject drugs (PWID) in Ukraine have high prevalences of HIV and hepatitis C (HCV). Since the turn of the century, various organizations have funded non‐governmental organizations (NGOs) in Ukraine to provide PWID with needles and syringes, condoms, HIV and HCV testing, and improve linkage to opioid agonist therapy (OAT) and HIV treatment. We investigated whether contact with these NGOs was associated with improved HIV prevention and treatment outcomes among PWID. Methods: Five rounds of respondent‐driven sampled integrated bio‐behavioural survey data (2009 [N = 3962], 2011 [N = 9069], 2013 [N = 9502], 2015 [N = 9405], and 2017 [N = 10076]) among PWID in Ukraine (including HIV/HCV testing and questionnaires) were analysed using mixed‐effect logistic regression models (mixed‐effects: city, year). These regression models assessed associations between being an NGO client and various behavioural, OAT, HIV testing and HIV treatment outcomes, adjusting for demographic characteristics (age, gender, lifetime imprisonment, registration in a drug abuse clinic, education level). We also assessed associations between being an NGO client and being HIV positive or HCV positive, likewise adjusting for demographic characteristics (as above). Results: NGO clients were more likely to have received HIV testing ever (adjusted odds ratio [aOR] 5.37, 95% confidence interval [95% CI]: 4.97 to 5.80) or in the last year (aOR 3.37, 95% CI: 3.20 to 3.54), to have used condoms at last sexual intercourse (aOR 1.37, 95% CI: 1.30 to 1.44) and sterile needles at last injection (aOR 1.37, 95% CI: 1.20 to 1.56), to be currently (aOR 4.19, 95% CI: 3.48 to 5.05) or ever (aOR 2.52, 95% CI: 2.32 to 2.74) on OAT, and to have received syringes (aOR 109.89, 95% CI: 99.26 to 121.66) or condoms (aOR 54.39, 95% CI: 50.17 to 58.96) in the last year. PWID who were HIV positive (aOR 1.40, 95% CI: 1.33 to 1.48) or HCV positive (aOR 1.57, 95% CI: 1.49 to 1.65) were more likely to have contact with NGOs, with HIV positive PWID in contact with NGOs being more likely to be registered at AIDS centres (aOR 2.34, 95% CI: 1.88 to 2.92) and to be on antiretroviral therapy (aOR 1.60, 95% CI: 1.40 to 1.83). Conclusions: Contact with PWID targeted NGOs in Ukraine is associated with consistently better preventive, HIV testing and HIV treatment outcomes, suggesting a beneficial impact of harm reduction NGO programming. [ABSTRACT FROM AUTHOR]

The World Health Organization (WHO) recently produced guidelines advising a treat‐all policy for HCV to encourage widespread treatment scale‐up for achieving HCV elimination. We modelled the prevention impact achieved (HCV infections averted [IA]) from initiating this policy compared with treating different subgroups at country, regional and global levels. We assessed what country‐level factors affect impact. A dynamic, deterministic HCV transmission model was calibrated to data from global systematic reviews and UN data sets to simulate country‐level HCV epidemics with ongoing levels of treatment. For each country, the model projected the prevention impact (in HCV IA per treatment undertaken) of initiating four treatment strategies; either selected randomly (treat‐all) or targeted among people who inject drugs (PWID), people aged ≥35, or those with cirrhosis. The IA was assessed over 20 years. Linear regression was used to identify associations between IA per treatment and demographic factors. Eighty‐eight countries (85% of the global population) were modelled. Globally, the model estimated 0.35 (95% credibility interval [95%CrI]: 0.16‐0.61) IA over 20 years for every randomly allocated treatment, 0.30 (95%CrI: 0.12‐0.53) from treating those aged ≥35 and 0.28 (95%CrI: 0.12‐0.49) for those with cirrhosis. Globally, treating PWID achieved 1.27 (95%CrI: 0.68‐2.04) IA per treatment. The IA per randomly allocated treatment was positively associated with a country's population growth rate and negatively associated with higher HCV prevalence among PWID. In conclusion, appreciable prevention benefits could be achieved from WHO's treat‐all strategy, although greater benefits per treatment can be achieved through targeting PWID. Higher impact will be achieved in countries with high population growth. [ABSTRACT FROM AUTHOR]

Many of the largest COVID-19 outbreaks in the United States have occurred at carceral facilities. Criminal legal system (CLS)-involved individuals typically face structural barriers accessing medical care post-release. Improving COVID-19 testing and education for CLS-involved individuals could improve health outcomes for this vulnerable population and the communities to which they return. Community-based organizations (CBO) and community health workers (CHWs) fill care gaps by connecting CLS-involved individuals with essential re-entry services. The MOSAIC study will: 1) test an onsite CHW-led SARS-CoV-2 testing and education intervention in a reentry CBO and 2) model the cost-effectiveness of this intervention compared to standard care. We will recruit 250 CLS-involved individuals who have left incarceration in the prior 90 days. Participants will be randomized to receive onsite Point-of-Care testing and education (O-PoC) or Standard of Care (SoC). Over one year, participants will complete quarterly questionnaires and biweekly short surveys through a mobile application, and be tested for SARS-CoV-2 quarterly, either at the CBO (O-PoC) or an offsite community testing site (SoC). O-PoC will also receive COVID-19 mitigation counseling and education from the CHW. Our primary outcome is the proportion of SARS-CoV-2 tests performed with results received by participants. Secondary outcomes include adherence to mitigation behaviors and cost-effectiveness of the intervention. The MOSAIC study will offer insight into cost effective strategies for SARS-CoV-2 testing and education for CLS-involved individuals. The study will also contribute to the growing literature on CHW's role in health education, supportive counseling, and building trust between patients and healthcare organizations. [ABSTRACT FROM AUTHOR]

Environmental effects on the transmission of many high burden infectious diseases are increasingly recognized, especially for transmission routes through water and vectors, or intermediate hosts, that live in the environment. Control of such diseases, which is currently largely based on treatment, is increasingly challenging due to climate-induced changes in infection patterns and the rapid emergence of drug resistance. Therefore, prevention through simulation of future disease risk and the devising of more comprehensive strategies, rather than exclusively relying on treatment, are becoming key. This requires mechanistic understanding of the link between disease transmission and underlying drivers, including heterogeneous on-the-ground environmental characteristics, which are those it may be possible to manipulate locally to reduce disease burdens. However, currently assumed drivers on the variability of disease risk are often only climatic, and environmental interventions to supplement drug treatment still under-recognised. In this work, we use the widespread parasitic disease of fasciolosis, and emerging zoonosis, as a case study. First, we apply the previously developed hydro-epidemiological model for liver fluke to investigate the variability of climatic and environmental drivers on disease risk across the UK. This allows exploring opportunities for environmental control strategies to complement treatment. Second, we evaluate how future risk of infection might respond to climate change across the country, including potential shifts in disease risk and its drivers, using climate projection data. Our results show shifts from modal to bimodal seasonality across the UK going forwards, and that environmental management may provide benefits in risk reduction in certain areas, offering a more sustainable and cost-effective approach in the long run. [ABSTRACT FROM AUTHOR]

Background: People who inject drugs (PWID) experience a high prevalence of incarceration and might be at high risk of HIV and hepatitis C virus (HCV) infection during or after incarceration. We aimed to assess whether incarceration history elevates HIV or HCV acquisition risk among PWID.Methods: In this systematic review and meta-analysis, we searched MEDLINE, Embase, and PsycINFO databases for studies in any language published from Jan 1, 2000 until June 13, 2017 assessing HIV or HCV incidence among PWID. We included studies that measured HIV or HCV incidence among community-recruited PWID. We included only studies reporting original results and excluded studies that evaluated incident infections by self-report. We contacted authors of cohort studies that met the inclusion or exclusion criteria, but that did not report on the outcomes of interest, to request data. We extracted and pooled data from the included studies using random-effects meta-analyses to quantify the associations between recent (past 3, 6, or 12 months or since last follow-up) or past incarceration and HIV or HCV acquisition (primary infection or reinfection) risk among PWID. We assessed the risk of bias of included studies using the Newcastle-Ottawa Scale. Between-study heterogeneity was evaluated using the I2 statistic and the P-value for heterogeneity.Findings: We included published results from 20 studies and unpublished results from 21 studies. These studies originated from Australasia, western and eastern Europe, North and Latin America, and east and southeast Asia. Recent incarceration was associated with an 81% (relative risk [RR] 1·81, 95% CI 1·40-2·34) increase in HIV acquisition risk, with moderate heterogeneity between studies (I2=63·5%; p=0·001), and a 62% (RR 1·62, 95% CI 1·28-2·05) increase in HCV acquisition risk, also with moderate heterogeneity between studies (I2=57·3%; p=0·002). Past incarceration was associated with a 25% increase in HIV (RR 1·25, 95% CI 0·94-1·65) and a 21% increase in HCV (1·21, 1·02-1·43) acquisition risk.Interpretation: Incarceration is associated with substantial short-term increases in HIV and HCV acquisition risk among PWID and could be a significant driver of HCV and HIV transmission among PWID. These findings support the need for developing novel interventions to minimise the risk of HCV and HIV acquisition, including addressing structural risks associated with drug laws and excessive incarceration of PWID.Funding: Engineering and Physical Sciences Research Council, National Institute for Health Research, National Institutes of Health. [ABSTRACT FROM AUTHOR]

Background: The World Health Organization (WHO) has developed a global health strategy to eliminate viral hepatitis. We project the treatment and prevention requirements to achieve the WHO HCV elimination target of reducing HCV incidence by 80% and HCV-related mortality by 65% by 2030 in Pakistan, which has the second largest HCV burden worldwide.Methods: We developed an HCV transmission model for Pakistan, and calibrated it to epidemiological data from a national survey (2007), surveys among people who inject drugs (PWID), and blood donor data. Current treatment coverage data came from expert opinion and published reports. The model projected the HCV burden, including incidence, prevalence and deaths through 2030, and estimated the impact of varying prevention and direct-acting antiviral (DAA) treatment interventions necessary for achieving the WHO HCV elimination targets.Results: With no further treatment (currently ∼150 000 treated annually) during 2016-30, chronic HCV prevalence will increase from 3.9% to 5.1%, estimated annual incident infections will increase from 700 000 to 1 100 000, and 1 400 000 HCV-associated deaths will occur. To reach the WHO HCV elimination targets by 2030, 880 000 annual DAA treatments are required if prevention is not scaled up and no treatment prioritization occurs. By targeting treatment toward persons with cirrhosis (80% treated annually) and PWIDs (double the treatment rate of non-PWIDs), the required annual treatment number decreases to 750 000. If prevention activities also halve transmission risk, this treatment number reduces to 525 000 annually.Conclusions: Substantial HCV prevention and treatment interventions are required to reach the WHO HCV elimination targets in Pakistan, without which Pakistan's HCV burden will increase markedly. [ABSTRACT FROM AUTHOR]

• Harm reduction settings allow access to care for people who inject drugs (PWID). • We studied co-located HCV therapy for PWID in harm reduction settings in Kenya. • Directly observed therapy (DOT) with peer support was feasible and effective. • Adherence was the most important driver of HCV cure. • DOT and peer support can overcome other factors that might limit adherence. Directly observed therapy (DOT) maximizes adherence and minimizes treatment gaps. Peer case managers (PCM) have also shown promise as a component of integrated HCV treatment strategies. DOT and PCM-support have been underexplored, particularly in low- and middle-income countries (LMICs). The objective of this study was to evaluate predictors of sustained virologic response (SVR) among people who inject drugs (PWID) attending medication-assisted treatment (MAT) and needle and syringe programs (NSP) sites in Kenya. We recruited PWID accessing MAT and NSP in Nairobi and Coastal Kenya. PWID were treated with ledipasvir/sofosbuvir using DOT supported by PCMs. We used bivariate and multivariate logistic regression to examine the impact of sociodemographic, behavioral, and clinical factors on SVR. Among 92 PWID who initiated HCV treatment, 79 (86%) were male with mean age of 36.3 years (SD=±6.5); 38 (41%) were HIV-positive, and 87 (95%) reported injecting drugs in the last 30 days. Just over half of participants were genotype 1a (55%), followed by genotype 4a (41%) and mixed 1a/4a (3%). Most participants, 85 (92%) completed treatment and 79 (86%) achieved SVR. While sociodemographic and behavioral factors including recent injection drug use were not significantly associated with achieving SVR, being fully adherent (p=0.042), number of doses taken (p=0.008) and treatment completion (p= 0.001) were associated with higher odds of achieving SVR. DOT with PCM-support was an effective model for HCV treatment among PWID in this LMIC setting. Adherence was the most important driver of SVR suggesting DOT and PCM support can overcome other factors that might limit adherence. Further research is necessary to ascertain the effectiveness of other models of HCV care for PWID in LMICs given NSP and MAT access is variable, and DOT may not be sustainable with limited resources. [ABSTRACT FROM AUTHOR]