A Montefiore Doctor Takes on the Hepatitis C Epidemic in East Africa

Hepatitis C virus (HCV) is a global pandemic, with an estimated 71 million individuals infected worldwide. This staggering statistic is ironic in light of the availability of direct-acting antiviral (DAA) therapies with high cure rates and few side effects.

“The availability of DAA therapy is still relatively new in the international landscape and, thus far, high costs have prohibited widespread dissemination,” explained Matthew Akiyama, MD, MSc, a clinician-investigator and assistant professor of Medicine in the divisions of General Internal Medicine and Infectious Diseases at Montefiore-Einstein. Dr. Akiyama, a recognized expert on the treatment and prevention of the Hep C virus, said that similar delays in treatment availability were observed with antiretroviral therapy for HIV in low and middle-income countries. “We’ve already learned these lessons, yet similar delays are being observed for HCV. Rapid scale-up of DAA therapy is urgently needed to prevent the propagation of ongoing HCV epidemics in these settings," he said, noting the assessment is in accordance with the World Health Organization (WHO)’s recommendations for the elimination of viral hepatitis.

Hepatitis C—a liver disease caused by the hepatitis C virus—is spread by blood to blood contact, and most people are unaware they have it. The disease disproportionately affects hard to reach populations, such as people who inject drugs and individuals with criminal justice-involvement. Left untreated, hepatitis C causes cirrhosis and liver failure, resulting in liver transplant, liver cancer or death.

Matthew Akiyama, MD

Matthew J. Akiyama, M.D.

A Lack of Access in Sub-Saharan Africa

The WHO has outlined global HCV elimination targets to be enacted by 2030, but a lack of access to treatment and necessary infrastructure means few nations are on target to achieve this goal. People who inject drugs (PWID) are central to HCV elimination efforts. In Sub-Saharan Africa, many PWID lack access to addiction treatment and prevention services, such as needle and syringe exchanges, and face stigma and persecution. This is alarming since PWID are the population with the highest HCV prevalence as well as ongoing potential risk factors for HCV and HIV transmission. “Injection drug use has been an underappreciated risk factor for HCV and HIV in much of sub-Saharan Africa,” Dr. Akiyama said. “The marginalization of PWID has resulted in low levels of treatment and prevention services for HCV and other blood-borne infections in many African countries."

On the Ground in Kenya

In 2017, with a grant from the Einstein Global Health Center, Dr. Akiyama traveled to Kenya to better understand HCV-related knowledge, attitudes, and behaviors among PWID. He also provided HCV treatment support for emerging HCV providers in Nairobi and the Coastal region of Kenya.

In collaboration with researchers from Yale and Kenya’s National AIDS & STI Control Programme, Dr. Akiyama conducted a study on the prevalence of HCV mono-infection and HIV/HCV co-infection, estimated HCV incidence, genotypes, and risk behaviors among PWID in Nairobi, Coastal, and Western Kenya. Researchers enrolled 2188 PWID in these areas who were screened for the presence of an HCV antibody (anti-HCV). Those who were anti-HCV positive were confirmed with HCV RNA testing and those with detectable HCV RNA were genotyped. Researchers examined correlates of HCV and HIV/HCV co-infection and estimated HCV incidence among PWID with less than five years injecting.

The findings of the study, recently published in the Lancet Infectious Diseases journal, showed a relatively low HCV prevalence and regional variability among PWID in Kenya with the highest rates and greater risk of HCV in the Coastal region. Correlates in that region included lifetime incarceration, more years injecting, more injections in the past month, and receptive cooker sharing. The HCV prevalence among HIV+ participants was also highest in the Coastal region.

“The higher HCV prevalence in the Coastal region may be a result of increased international tourism in the 1980s,” said Dr. Akiyama, noting the study is among the first to outline the prevalence of HCV among PWID in a sub-Saharan African country. “The relatively low HCV prevalence is an opportunity to intervene on an epidemic that’s not as established as it is among PWID in higher income countries.”

These conclusions, he added, may be used to implement focused strategies to reduce HCV transmission, such as expansion of needle syringe programs, scaling up opioid agonist therapy, and treatment as prevention in regions affected by PWID and HCV.

Meanwhile, on the ground in Nairobi and the coastal city of Mombasa, Dr. Akiyama provided training on HCV and treatment support to clinical officers and healthcare workers who were rolling out Hepatitis C medications in methadone maintenance therapy programs and syringe exchange centers.

Targeting New York’s Silent Epidemic

In 2018, Dr. Akiyama was selected by Governor Andrew Cuomo to serve as a member of New York State’s Hepatitis C Elimination Task Force to advise on how to end the “silent” epidemic that effects an estimated 200,000 New Yorkers.

The state’s proposed elimination plan to stop the spread of the virus by increasing access to medications that can cure hepatitis C and expanding programs to connect New Yorkers with prevention, screening and treatment services is expected to be released soon.

Dr. Akiyama was recently was awarded K99/R00 from the National Institute on Drug Abuse to develop and test an innovative strategy to improve linkage to and retention in HCV treatment among individuals recently released from jail. He is the recipient of additional institutional and NIH funding including an NIDDK P30 pilot grant focused on HCV Transmission Networks Among People Who Inject Drugs. Most recently, Dr. Akiyama was appointed Vice Chair of the International Network of Hepatitis inSubstance Users (INHSU) Prisons special interest group. Given the intersection of the criminal justice system and viral hepatitis, its goal is to bring together people with an interest in the prison sector, where the criminalization of individuals with substance use disorders has resulted in disproportionate prevalence of HCV.