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
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.
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
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
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
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.