A small-scale 'Development Impact Bond' for hepatitis C diagnosis and treatment financing in Cameroon: the way to elimination?

# Background Many governments in low- and middle-income countries (LMICs) have difficulties paying healthcare costs upfront leading to high out-of-pocket payments for patients. A Development Impact Bond (DIB) is an innovative financing mechanism in which pr ivate investors provide pre-payment of development program expenses. At the same time, public agencies or donors repay the investor's investment with a reasonable interest rate if the program succeeds in delivering independently measurable results that are contractually agreed upon. This study assessed quantitatively and qualitatively the feasibility of a DIB for hepatitis C Virus (HCV) diagnosis and treatment in Cameroon. # Methods A revolving fund of up to €230,000 was made available by the investor. The outcome payor reimbursed the investor only in case of good performance, defined as cured patients (HCV-RNA negative). HCV carriers who were identified were referred for treatment and tested for cure 12 weeks after completion of treatment, the outcome being validated by an independent assessor. The evaluation was guided by the six-agents model, involving interviews with relevant stakeholders (N= 22). # Results In total, 253 (98%) patients completed treatment, of which 244 (96%) are cured at week 24. We estimated that the average per-patient *outcome payment* for HCV diagnosis and treatment is €1,542, and the *average costs per treated patient* is €1,858. The investor was fully repaid, including the agreed interest and bonus. Themes or findings from the interviews confirmed the feasibility of a DIB in a low-resource setting. # Conclusions This study demonstrates that a DIB can be a suitable financing mechanism for HCV services, supporting the path towards elimination. When governments in LMICs do not have sufficient resources to fund such elimination programs upfront, such public-private partnerships can offer a solution

Prevalence of HIV infection among people with disabilities: a population-based observational study in Yaoundé, Cameroon (HandiVIH).

International audienceBACKGROUND: In resource-limited settings, people with disabilities have been left behind in the response to HIV. In the HandiVIH study, we estimate and compare HIV prevalence and associated risk factors between people with and without disabilities. METHODS: In this cross-sectional, population-based, observational study, we used two-phase random sampling to recruit adults with disabilities and a control group matched for age, sex, and residential location from households of the general population. We used the Washington Group Short Set of Questions on Disability to identify people with disabilities. We administered an HIV test and a life-course history interview to participants. The primary outcome was the prevalence of HIV among participants with and without disabilities. FINDINGS: Between Oct 2, 2014, and Nov 30, 2015, we recruited 807 people with disabilities and 807 participants without disabilities from Yaounde, Cameroon. 28 of 716 people in the control population had a positive HIV test result (crude prevalence 3.9%, 95% CI 2.9-5.3) compared with 50 of 739 people with disabilities (6.8%, 5.0-8.6; conditional odds ratio [OR] 1.7; p=0.04). Women with disabilities were more often involved in paid sexual relationships than were women without disabilities (2.5% vs 0.5%, p=0.05). People with disabilities were also at increased risk of sexual violence than were women without disabilities (11.0% vs 7.5%, OR 1.5; p=0.01). Sexual violence and sex work were strongly associated with increased risk of HIV infection among participants with disabilities but not among controls (OR 3.0, 95% CI 1.6-5.6 for sexual violence and 12.3, 4.4-34.6 for sex work). Analyses were done in men and women. INTERPRETATION: The higher prevalence of HIV infection in people with disabilities than people without disabilities reflects a higher exposure to HIV infection as well as the presence of disability-associated HIV infection. The susceptibility of people with disabilities to HIV infection seems to be shaped by social and environmental factors. Research is needed to inform firm recommendations on how to protect this vulnerable population

Achieving a high cure rate with direct-acting antivirals for chronic Hepatitis C virus infection in Cameroon: a multi-clinic demonstration project

Objectives: Highly effective direct-acting antivirals (DAAs) for Hepatitis C treatment are largely inaccessible in sub-Saharan Africa. Data on treatment feasibility and outcomes in clinical settings are limited. We assessed the feasibility of achieving a high (≥90%) cure rate with DAAs in six gastroenterology clinics in Cameroon. Methods: Patients with chronic Hepatitis C virus (HCV) infection were treated for 12 or 24 weeks with ledipasvir/sofosbuvir, ledipasvir/sofosbuvir/ribavirin or sofosbuvir/ribavirin, depending on the stage of liver disease and HCV genotype. The cure rate was defined as the proportion of patients with a sustained virological response 12 weeks after treatment completion (SVR12) among all treatment completers. Results: We identified 190 HCV RNA positive patients between September-2017 and August-2018, 161 (84.7%) of whom started treatment. 105 (65.2%) were female, median age was 61.3 years [IQR = 55.9–66.9] and 11 (6.8%) were HIV-positive. Median plasma HCV RNA was 6.0 log10IU/mL [IQR = 5.6–6.4]. HCV genotypes identified were 1 (34.8%), 2 (13.7%), 4 (50.9%), 1 and 4 (0.6%); 46 (28.6%) strains of 160 single-genotype infections were non-subtypeable. Of 158 treatment completers, 152 (96.2%, 95%CI = 91.9–98.6%) achieved SVR12. Six patients did not achieve SVR12: five carried HCV with NS5A resistance mutations and one with NS5B resistance mutations. Three patients died before and two after treatment completion. The most common adverse events were asthenia (12.0%), headache (11.4%) and dizziness (18.9%). Conclusion: High cure rates of Hepatitis C with DAAs are achievable in clinical settings of Cameroon. However, the accessibility and provision of HCV screening, diagnosis, treatment, monitoring and care should be addressed for large-scale implementation