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Half of people who inject drugs in Middle East have hepatitis C

Keith Alcorn
24 February 2020
Image: Liz Masoner/Pixabay

Half of people who inject drugs in the Middle East and north Africa have been infected with hepatitis C, and researchers from Weill Cornell Medicine Qatar estimate that around 221,000 people who inject drugs in the region have chronic hepatitis C infection, a review published in the journal Addiction reports.

Hepatitis C infection is endemic in north Africa and the Middle East. One in five of the global population with hepatitis C live in the region, with Egypt severely affected. The region comprises 24 countries stretching from Pakistan to Morocco and includes some of the world’s major drug production sites and trafficking routes.

Several countries in the region are already engaged in ambitious efforts to eliminate hepatitis C but to achieve elimination, targeted testing and treatment will be needed, as well as enhanced prevention measures.

Another research paper published recently by Weill Cornell Medicine Qatar suggests that in countries in the region that have generalised hepatitis C epidemics (Egypt and Pakistan), people who inject drugs are seven times more likely to test positive for hepatitis C antibodies, while in countries with concentrated epidemics they are almost one hundred times more likely to test positive.

Reaching people who inject drugs in the region is therefore a priority for hepatitis C elimination but until now, a comprehensive picture of hepatitis C prevalence in people who inject drugs has been missing.

Weill Cornell Medicine Qatar researchers carried out a systematic review of all studies documenting hepatitis C prevalence among people who inject drugs in the region that were conducted between 1989 and 2018. They found 118 measurements of hepatitis C prevalence in 46,493 people who inject drugs, carried out in 12 countries (mainly in Iran – 60 studies – and Pakistan – 19 studies).

The researchers estimated national prevalence wherever three studies were available to supply pooled data. Prevalence among drug users ranged from 21% in Tunisia and 25% in Lebanon to 56% in Pakistan, 52% in Iran and 94% in Libya. Insufficient data were available to produce estimates for Algeria, Bahrain, Djibouti, Iraq, Jordan, Kuwait, Mauritania, Somalia, Sudan, United Arab Emirates or Yemen.

Across the region the average prevalence of hepatitis C was 49% and the investigators used this average and country-level estimates to calculate that 221,000 people who inject drugs in the region have chronic hepatitis C. The countries with the largest number of chronic infections are Algeria (14,220), Morocco (6718), Iran (68,526) and Pakistan (46,444). The much lower numbers in many other countries is an opportunity for affordable elimination.

However, the researchers were not able to estimate how many ex-drug users might have chronic hepatitis C infection.  

The researchers also looked at the prevalence of hepatitis C genotypes in the Middle East and north Africa, finding that the predominant genotypes in the region are genotype 1 (35%), genotype 3 (42%) and genotype 4 (11%).

Drug users were five times more likely to test positive for hepatitis C in Pakistan when compared to Afghanistan and three and a half times more likely to test positive in Saudi Arabia when compared to Afghanistan.

The meta-analysis also showed that drug users tested in prison were two and a half times more likely to test positive than drug users tested through a community sample, showing the importance of test and treat interventions in prisons in the region for hepatitis C elimination.

The researchers warn that the very high prevalence of hepatitis C suggests potential for concentrated epidemics of HIV among drug users too.

Lack of harm reduction services in the region means that hepatitis C will continue to spread among people who inject drugs. Non-governmental organisations in Morocco, Iran and Lebanon have developed harm reduction services but these services need to be scaled up and backed by national policies on harm reduction provision. Testing and treatment also need to be scaled up, especially in prisons, say the investigators.