Prevalence of hepatitis C virus infection among high-risk groups in Iran: a systematic review and meta-analysis

Epidemiology of Hepatitis C Virus Infection Among High-risk Populations in Northeastern Iran

Background: Chronic hepatitis C virus (HCV) infection affects 58 million people globally. The frequency of HCV infection in the general Iranian population is less than 0.5%; however, a concentrated epidemic was reported among people who use drugs, particularly those with a history of drug injection. Objectives: This cross-sectional study was performed to assess the prevalence of HCV infection among high-risk groups outside of prison in northeastern Iran. Methods: A total of 962 participants in Razavi Khorasan province were enrolled from 2018 to 2022. They included drug users referred to drug treatment and harm reduction centers and individuals with a history of crimes such as drug use or imprisonment who worked in a private industrial unit. Serum anti-HCV antibodies were assessed using a rapid or ELISA kit, and seroreactive samples were confirmed by single-step reverse transcriptase or qualitative real-time polymerase chain reactions. A P-value < 0.05 was considered statistically significant. Results: The mean age of 707 males and 255 females was 39.8 ± 10.2 years. Anti-HCV antibodies were detected from 129 samples (13.41%), of which 117 were available for polymerase chain reaction testing. HCV RNA was detected in 88 cases (75.2%); the total viremia rate was calculated as 9.26% (88/950). Logistic regression analysis revealed that HCV infection among drug users was significantly associated with older age (P = 0.002), being single (P = 0.009), and history of drug injection (P < 0.001) or incarceration (P = 0.04). Conclusions: The findings showed a considerably high prevalence of HCV infection among people who use drugs in northeastern Iran. To achieve the global goal of viral hepatitis elimination by 2030, we strongly recommend stricter screening and treatment of this infection among such hard-to-access populations in Iran.

Prevalence of HIV, hepatitis B virus, and hepatitis C virus among incarcerated people in Iran: a systematic review and meta-analysis

OBJECTIVES

Incarcerated people are at higher risk for HIV, Hepatitis B Virus (HBV), and Hepatitis C Virus (HCV) infections. This review systematically summarized the evidence on the prevalence of these infections among incarcerated people in Iran.

STUDY DESIGN

A systematic review and meta-analysis.

METHODS

We searched Embase, PubMed, Web of Science, Scopus, PsychInfo, Iranian databases, including IranMedex, Magiran, Scientific Information Database (SID), and IranDoc. A grey literature review was conducted to find unpublished reports from the Ministry of Health and experts throughout the country. Included studies reported data on the prevalence of HIV, HBV, or HCV infections. A random-effects meta-analysis was performed to estimate the pooled prevalence. A meta-regression analysis was also conducted.

RESULTS

Of 1461 screened records, 23 records were eligible (total participants = 199,855). The pooled prevalence of HIV (17 studies), HBV (6 studies), and HCV (10 studies) was 2.77% (95% CI: 1.96, 3.70), 2.89% (95% CI: 2.28, 3.56), and 21.57% (95% CI: 13.62, 30.76), respectively. Meta-regression analyses showed that HIV (P-value = 0.05) and HCV (P-value = 0.02) were reduced over time using survey year as the interested variable in the model. Also, lifetime history of drug injection had a significant association with the HIV infection (P-value = 0.03).

CONCLUSION

The findings suggest that the prevalences of these infections are relatively considerable among Iranian incarcerated people. These findings support developing interventions to reduce the risk of the acquisition and circulation of these infections among incarcerated people, and continued harm reduction programs among most at-risk incarcerated people, as well as HCV treatment.

Prevalence of HBV and HCV Infections in Iranian Blood Donors; An Updated Systematic Review and Meta-Analysis

BACKGROUND Awareness of the prevalence of hepatitis B (HBV) and hepatitis C virus (HCV) infections, as blood transmitted infections, among blood donors can help policymakers improve the guidelines, share experiences, and estimate the blood safety over the country and in the region. We aimed to determine the prevalence of HBV and HCV infection in Iranian blood donors based on the present published literature. METHODS A meta-analysis was carried out based on the results of an electronic literature search in the international and national databases for all articles published until October 2020. We selected studies that had appropriate sampling and valid statistical analysis as well as proper measurement methods. The heterogenic indices of the studies were determined using Cochran's (Q) and I-square (I2) tests. According to the heterogeneity results, a fixed or random-effects model was implemented to estimate the pooled prevalence of HBV and HCV. Meta-regression was conducted to explore the suspected sources of heterogeneity. RESULTS We included 61 and 58 eligible studies related to HBV and HCV, respectively. The pooled prevalence of HBV was 0.57% (95% confidence interval (CI): 0.47 - 0.67, I2: 99.9%) among the blood donors. The range of prevalence rates of HBV was between 0.10% and 2.34% in different areas of Iran. The pooled prevalence of HCV was 0.22% (95% CI: 0.20 - 0.24, I2: 98.64%) in blood donors, which varied between 0.02% and 1.09% in separate locations. Subgroup and meta-regression analyses revealed that the year of publication, geographical location, and quality of the studies probably generated the heterogeneity. CONCLUSION The prevalence of HBV and HCV decreased steadily in Iranian blood donors during the past two decades. It should be asserted that most of the health policies and safety measures taken in recent years in Iran have been effective and promising.

Harm reduction program and hepatitis C prevalence in people who inject drugs (PWID) in Iran: an updated systematic review and cumulative meta-analysis

BACKGROUND

Prevalence of hepatitis C virus (HCV) infection among people who inject drugs (PWID) in Iran is high. Since 2005, the Iranian government has implemented a harm reduction program to control HCV. We aimed to describe the prevalence of HCV antibody (Ab) in Iranian PWID before and after the implementation of harm reduction with cumulative meta-analysis.

METHODS

Following PRISMA guidelines, we conducted a systematic review and meta-analysis of studies published on the seroprevalence of HCV among PWID. We systematically reviewed the literature to identify eligible studies up to December 2018 in international and national databases. Pooled prevalence and 95% confidence intervals were calculated using Der Simonian and Laird method, taking into account conceptual heterogeneity. Subgroup analyses were performed by harm reduction implementation and studies' characteristics to assess the sources of heterogeneity. We used Cochran-Armitage test for the linear trend of the prevalence of HCV Ab among PWID.

RESULTS

We reviewed 5966 papers and reports and extracted data from 62 eligible records. The pooled HCV Ab prevalence among PWID in Iran was 46.5% (95% confidence interval [95% CI] 41.1-52.0%). Overall, the Cochran-Armitage test for trend indicated a significant decreasing trend of HCV Ab prevalence (P = 0.04). The cumulative meta-analysis showed a slight decline in the prevalence of HCV Ab between the years 2005 and 2018.

CONCLUSIONS

The HCV Ab prevalence among PWID in Iran is high, with a considerable geographical variation. The prevalence of HCV Ab among PWID in Iran slightly decreased after 2005 which could be, at least to some extent, related to the implementation of extensive harm reduction programs in the country.

A simple risk-based strategy for hepatitis C virus screening among incarcerated people in a low- to middle-income setting

Background

Hepatitis C virus (HCV) is among the highest priority diseases in custodial settings; however, the diagnosis remains suboptimal among people in custody. This study aimed to validate a short survey for identifying people with HCV infection in a provincial prison in Iran.

Methods

Between July and December 2018, residents and newly admitted inmates of Gorgan central prison completed a questionnaire, including data on the history of HCV testing, drug use, injecting drug use, sharing injecting equipment, and imprisonment. Participants received rapid HCV antibody testing, followed by venipuncture for RNA testing (antibody-positive only). Each enrollment question (yes/no) was compared with the testing results (positive/negative).

Results

Overall, 1892 people completed the questionnaire, including 621 (34%) who were currently on opioid agonist therapy (OAT); 30% of participants had been tested for HCV previously. About 71% had a history of drug use, of whom 13% had ever injected drugs; 52% had ever shared injecting equipment. The prevalence of HCV antibody and RNA was 6.9% (n = 130) and 4.8% (n = 90), respectively. The antibody prevalence was higher among people on OAT compared to those with no history of OAT (11.4% vs. 4.0%). History of drug use was the most accurate predictor of having a positive HCV antibody (sensitivity: 95.2%, negative predictive value: 98.9%) and RNA testing (sensitivity: 96.7%, negative predictive value: 99.5%). The sensitivity of the drug use question was lowest among people with no OAT history and new inmates (87% and 89%, respectively). Among all participants, sensitivity and negative predictive value of the other questions were low and ranged from 34 to 54% and 94 to 97%, respectively.

Conclusions

In resource-limited settings, HCV screening based on having a history of drug use could replace universal screening in prisons to reduce costs. Developing tailored screening strategies together with further cost studies are crucial to address the current HCV epidemic in low- to middle-income countries.

Barriers and motivators to participation and retention in HIV/HCV cohort studies among people who inject drugs: a community consultation in Iran

BACKGROUND

The lack of robust estimates of HIV/HCV incidence among people who inject drugs (PWID) in Iran calls for well-designed prospective cohort studies. Successful recruitment and follow-up of PWID in cohort studies may require formative assessment of barriers PWID are faced with in participation and retention in cohort studies and factors they think may facilitate their engagement in such studies. Using a focus group discussion (FGD) format, we conducted a consultation with PWID in southeast Iran to recognize those barriers and motivators.

METHODS

Using targeted sampling and through snowball referrals, we recruited PWID (aged≥18, injected in last 6 months) from community-based drop-in centers (DICs), homeless shelters, and through outreach efforts to participate in four FGDs (one women-only). Socio-demographic characteristics, injection behaviors and self-reported HCV/HIV testing and diagnosis history were obtained. Then, a semi-structured FGD guide was applied to explore barriers and motivators to participation and retention in cohort studies among study participants. All FGD sessions were recorded and transcribed verbatim, removing any identifying information. The content of FGDs were analyzed by thematic analysis using an inductive approach.

RESULTS

In total, 30 individuals (10 women) participated in the study. The median age of participants was 35 (IQR 31-40), with majority (73.3%) reporting injecting drug use within the last month. Only 40.0% reported ever being tested for HCV whereas a larger proportion (63.4%) reported ever being tested for HIV. While the majority were willing to participate in cohort studies, breach of confidentiality, fear of positive test results, perceived required commitment, and marginalization were reported as barriers to participation and retention in such studies. Monetary incentive, the thought of a better life, protection from police interventions and trust between health workers and PWID were addressed as motivators of engagement in cohort studies among PWID.

CONCLUSIONS

Strategies to enhance data security and reduce stigma associated with injecting drug use along with involving peer workers in research, providing pre and post-test counselling and education and addressing the needs of more marginalized groups potentially through integrated healthcare programs and housing support are among few approaches that may help address barriers and strengthen the motivators for successful cohort studies among this population.

The hepatitis C virus in Iran: health policy, historical, ethical issues and future challenges

Background

Hepatitis C infection (HCV) can have a harmful effect on the health of people and can impose relevant healthcare costs. The World Health Organization has identified the elimination of Hepatitis C by 2030 as an important goal for all countries. This study aimed to identify the HCV-related policies in Iran.

Methods

A qualitative approach was used for this study. Data was collected through a comprehensive search of documents and interviews with different stakeholders related to the HCV program. Data was analyzed and validated using content analysis based on the policy triangle framework.

Results

Our findings highlighted that certain social and cultural issues related to stigma can impact on awareness-raising processes. It is also necessary to consider HCV directly in the context of government policies. All relevant stakeholders should be included. Continued talks and interactions need to be made between them for the active participation of all actors.

Conclusion

The findings of this study can provide useful information for improving, supporting and developing policy processes. Healthcare providers should address all aspects of the disease by 2030 in order to achieve the goal of HCV elimination. Evidence-based planning, support for up-to-date policies and resource mobilization are needed to achieve this ambitious goal.

Hepatitis C virus-related policy-making in Iran: a stakeholder and social network analysis

Background

Hepatitis C virus (HCV) infection is a major public health challenge worldwide. Implementing policies to cope with this challenge requires commitment from all stakeholders at various levels, and all necessary resources should be mobilised. Support for various HCV-related stakeholders can reduce the challenges and obstacles that can be encountered during the programme implementation. The present study aims to identify all stakeholders involved with HCV-related policy-making in Iran at different steps (policy development, implementation and evaluation) and to characterise them in terms of interest, position, power and influence, in order to provide valuable information for appropriate decision-making and design. The present study can also serve as a case study for healthcare systems in other countries.

Method

An approach based on social network analysis was utilised. Data collected included relevant document searches and in-depth interviews to a sample of 18 key informants.

Results

Various stakeholders were found to be involved with HCV-related policies in Iran. The extent of their participation and support in policy-making varied. Specifically, international agencies had a high interest for HCV-related policy-making, whereas media and members of the private sector were characterised by a medium interest and governmental and non-governmental bodies by a highly variable interest, ranging from low to high, depending on the specific organism. Moreover, media and members of the private sector, non-governmental institutions and international agencies were rated low in terms of position, whereas governmental actors were rated low to high. Media were rated medium in terms of power, whereas international agencies and members of the private sector were respectively rated low to medium and low. Non-governmental actors were rated low, whilst governmental bodies were rated low to high. Finally, media, members of the private sector and international agencies were rated medium in terms of influence, whereas non-governmental and governmental actors were respectively rated low to medium and low to high.

Conclusion

Policy-making involves trust, negotiation and integration of the different views of all stakeholders. Social network analysis was critical for identifying stakeholders and showing that, in Iran, involvement in HCV-related policy-making is generally low. This information is of practical implication for policy- and decision-makers regarding the adoption of more favourable and effective strategies.