Title: NIHR Global Health Research Group on developing strategies for hepatitis C in Ethiopia (DESTINE)
Funder: Department of Health and Social Care

Abstract: Aims:Clinicians and the Ethiopian Government urgently seek the development of a Hepatitis C Virus (HCV) strategy for Ethiopia. They have identified the need for implementation and scale-up of testing and treatment, and development of effective preventive strategies. This collaboration of Universities of Dundee and Bristol, Ethiopian Medical schools and the Ethiopian Public Health Institute (EPHI) on behalf of the Ethiopian government will generate epidemiological, modelling and pathways of care data for an Ethiopian context that will inform strategic planning for HCV and enhance associated research skill sets within four major Medical schools. These aims will be achieved in 3 Work Packages (WP). WP1 will establish the prevalence and impact of HCV infection and parameters which determine disease progression. WP2 will model the ongoing HCV epidemic in Ethiopia and the health consequences for those infected; it will estimate the impact on HRQoL utility data for different modelled HCV related disease stages and of different testing and treatment strategies, evaluating piloted interventions from WP 3. This will inform strategic health decision-making in Ethiopia. WP 3 will co-develop with stakeholders, pathways of care to improve the diagnosis and access to treatment of HCV, test the feasibility and pilot these pathways._x000D_ Background:HCV is transmitted by blood transfusion, reuse of needles and by vertical or sexual transmission. Over 20-30 years HCV can lead to cirrhosis, liver cancer and end-stage liver disease if left untreated. There is no effective vaccination, but there are direct acting anti-viral therapies, with sustained virological response rates in excess of 95%. This has led to the World Health Organisation’s target of global HCV elimination by 2030. Approximately 3 million people currently live with HCV in Ethiopia. These estimates are based on poor data, making forward planning impossible._x000D_ Design and methods:In WP1 systematic reviews and a sero-behavioural nested case control study using stored sera from an earlier HBV and HIV stratified population surveys will be used. In WP2 a Markov model of HCV screening, disease progression and treatment will be used to estimate costs and future health benefits of each screening and treatment strategy. The EQ-5D-5L tool will be used to generate HRQoL utility data for different modelled HCV related disease stages and of different testing and treatment strategies. WP3 will use focus groups and semi-structure interviews based on the COM-B Model of behaviour, as well as Delphi techniques to generate care pathways. These will be tested in feasibility studies and pilot trials._x000D_ Community Engagement and Involvement:In the co-production of the interventions for improved diagnosis and access to treatment, all levels of the health care system will be consulted and involved via focus groups and meetings. Users of health care services will be surveyed for attitudes to provisions of services, stigma, regional, ethnic issues around services._x000D_ Dissemination:The most important recipients of this work are people with HCV, clinicians and the Ethiopian government. The clinical community are linked to this project by the direct involvement of the main medical schools and key opinion leaders. EPHI as a government body and member of the consortium provides a direct link to policy makers. Dissemination will be via conventional publications and presentations at meetings, as well as extensive use of social media.

Lay abstract: Aims: Clinicians and the Ethiopian Government are discussing the development of a Hepatitis C Virus (HCV) strategy for Ethiopia. They have identified the need for implementation and scale-up of testing and treatment, as well as the development of effective preventive strategies. This collaboration of Universities of Dundee and Bristol, world leaders in HCV research, Ethiopian Medical schools and the Ethiopian Public Health Institute (EPHI) on behalf of the Ethiopian government will generate epidemiological, modelling and pathways of care data for an Ethiopian context that will inform strategic planning for HCV and enhance associated research skill sets within four major Medical schools. These aims will be achieved in 3 Work Packages (WP). WP1 will establish the prevalence and impact of HCV infection and parameters which determine disease progression. WP2 will model the ongoing HCV epidemic in Ethiopia and the health consequences for those infected; it will estimate the impact and cost-effectiveness of different testing and treatment strategies, evaluating piloted interventions from WP 3 and different treatment eligibilities, e.g. treating all diagnosed infections or only those with advancing disease and monitor others. This will inform strategic health decision-making in Ethiopia. WP 3 will co-develop with stakeholders, pathways of care to improve the diagnosis and access to treatment of HCV, test the feasibility and pilot these pathways._x000D_ Background: HCV is transmitted by blood transfusion, reuse of needles and by vertical or sexual transmission. Over 20-30 years HCV can lead to cirrhosis, liver cancer and end-stage liver disease if left untreated. HCV is also associated with lymphoma, a common cancer in Ethiopia. An estimated 71 million people are living with chronic HCV infection worldwide. There is no effective vaccination, but there is highly effective treatment that can cure the infection in most people. This has led to the World Health Organisation’s target of global HCV elimination by 2030. Approximately 3 million people currently live with HCV in Ethiopia, a figure predicted to increase by 2030. These estimates are based on poor data, making forward planning impossible._x000D_ Design and methods: Include focus groups, feasibility trials, pilot studies and sero-behavioural nested case control study using stored sera from an earlier HBV stratified population survey. Mathematical modelling will be used to simulate the transmission dynamics of HCV in Ethiopia and to determine what screening and treatment strategies could eliminate HCV. Economic evaluation methods will determine the most cost-effective strategies._x000D_ Community Engagement and Involvement: In the co-production of the interventions for improved diagnosis and access to treatment, all levels of the health care system will be consulted and involved via focus groups and meetings. Users of health care services will be surveyed for attitudes to provisions of services, stigma, regional, ethnic issues around services._x000D_ Dissemination: The most important recipients of this work are people with HCV, clinicians and the Ethiopian government. The clinical community are linked to this project by the direct involvement of the main medical schools and key opinion leaders. EPHI as a government body and member of the consortium provides a direct link to policy makers. Dissemination will be via conventional publications and presentations at meetings, as well as extensive use of social media.

Research activity codes: 2.1 BIOLOGICAL AND ENDOGENOUS FACTORS;2.4 SURVEILLANCE AND DISTRIBUTION;8.1 ORGANISATION AND DELIVERY OF SERVICES;8.2 HEALTH AND WELFARE ECONOMICS
Health categories: INFECTION