A decentralized point of service triple prevention and treatment model for hepatitis B, C and HIV in people who inject drugs in South Africa.

Background: The burden of viral hepatitis and HIV in sub-Saharan Africa is substantial with an estimated 64.7 million living with hepatitis B virus (HBV), 8 million with hepatitis C virus (HCV) and 20.8 million people living with HIV infection. HBV is endemic in South Africa. People who inject drugs (PWID) are disproportionately burdened with HIV and HCV infection. In Pretoria, South Africa, an HCV infection epicenter for PWID, co-infection with HIV is steadily increasing. Given this growing burden, we established and evaluated a decentralized triple prevention and management intervention for PWID.

Methods: A point of service model recruited PWID who reside in Pretoria through convenience sampling and were screened utilizing point-of-care testing for HBsAg (Determine™), anti-HCV and anti-HIV (OraQuick®). The presence of HCV-viraemia was confirmed using an onsite GeneXpert-IV® (Cepheid) PCR system. In those eligible, tenofovir/emtricitabine combination was offered as HIV PrEP and initiated in those who were HBsAg positive and HIV negative. If HIV positive or HIV-HBV co-infected, tenofovir/lamivudine/dolutegravir combination as ART was commenced. In those with confirmed HCV-viraemia, 12-weeks of sofosbuvir and daclatasvir as HCV DAA therapy were initiated in those with HCV mono-infection, or with HIV and/or HBV co-infection, if stable on treatment.

Results: A total of n = 213 participants, 86 % (n = 184) male with median age of 34 [IQR 31-37] years, were recruited. Of these, 82 % (n = 174) were anti-HCV positive, of which 62 % (n = 131) were HIV-HCV co-infected. Most results were available within 2 [1-3] hours of initial screening with 90 % (n = 138) viraemic. Of these, 73 % (n = 100) met eligibility criteria, with 95 % (n = 95) initiating DAA therapy. Of these 84 % (n = 80) completed 12 weeks of therapy and 86 % (n = 48) achieved a sustained virological response (SVR). All 7 %, (n = 14) HBsAg positive participants were initiated on appropriate therapy. HBV-vaccine were administered to 86 % (n = 172) of HBsAg screen negative participants. HIV was diagnosed in 70 % (n = 150) and 92 % (n = 138) were initiated on ART, 75 % (n = 67) were retained for 6-months, and of those, at 12-months 81 % (n = 21) were virally suppressed. A higher PrEP uptake and 12-week retention was observed for those on DAA therapy. Our approach simplified treatment algorithms, employed task sharing, and use of point-of-care technology to enable single-visit interventions and reduce input costs.

Conclusion: A comprehensive, simplified and decentralized point of service triple disease prevention and management intervention model demonstrates a feasible approach to improve access for PWID in South Africa to viral hepatitis and HIV care.

Ethics Approval: The authors declare that they have obtained ethics approval University of Cape Town HREC R0145/2014; R793/2022 from an appropriately constituted ethics committee/institutional review board where the research entailed animal or human participation.