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Abstract

Hepatitis C virus (HCV) affects 58 million people globally and resulted in 290,000 deaths in 2019. While global targets aim to eliminate HCV by 2030, there remains limited knowledge regarding the accessibility and impact of HCV treatment, particularly in resource-limited settings. This dissertation assessed access to HCV testing and treatment in Rwanda and investigated inequities in global access to HCV medicines. I conducted a retrospective cohort study and hierarchical logistic regression to assess factors associated with HCV positivity, treatment dropout, and treatment failure among people who received HCV services during the 2017-19 mass campaign. In addition, I used qualitative methods to investigate patients' perspectives on accessing HCV care during the campaign. Lastly, I used data from 54 countries to describe sales of HCV medicines and conducted an Interrupted Time Series (ITS) analysis to assess the effect of COVID-19 on sales using Autoregressive Integrated Moving Average Model (ARIMA). Among people who attended the campaign, the prevalence of HCV was 2.9%, and 52% of those who tested positive initiated treatment. Sustained Virological Response (SVR) was achieved in 88% of individuals who initiated treatment and returned for assessment. Age, socioeconomic status, and comorbidities were associated with higher HCV positivity and dropout rates. Treatment failure was associated with advanced stage of HCV, and a prior history of HCV. My qualitative study found that patients experienced unavailability of second-line treatment and delays in testing results and treatment initiation. Lastly, globally I found that high-income countries had much higher sales of Direct Acting Antivirals (DAAs) and higher use of newer generations of DAAs. The COVID-19 pandemic led to a decrease of DAA sales of 85% of the countries I studied. This dissertation suggests that future HCV treatment interventions in Rwanda should focus on older individuals and people with comorbidities. In addition, improvements should be sought in the follow-up and timeliness of screening and treatment. Internationally, future policy should prioritize improving access to DAAs in countries with limited resources through pricing policies and licensing agreements. Lastly, elimination strategies may need to be revised given current inequities in access to DAAs and the impact of the COVID-19 pandemic.