Much of the focus of

Much of the focus of expert and public attention has been on HIV treatment, including test and treat (ie, treatment as prevention) strategies. This is understandable. Treatment for HIV has become extraordinarily effective, costs have dropped substantially during the past two decades, and the potential for antiretroviral therapy to reduce SCR7 viral load and transmission was shown in the groundbreaking HPTN 052 trial in 2011. Against this background, the publication of these important and positive findings on the benefits and economic attractiveness of Avahan serves as a welcome reminder that so-called prevention as prevention can be extremely cost-effective.
Hepatitis C virus (HCV) is a parenterally transmitted pathogen that has infected about 185 million people worldwide and is a major cause of cirrhosis and hepatocellular carcinoma. The recent advent of direct-acting antivirals has revolutionised the treatment of hepatitis C. Direct-acting antivirals achieve a permanent cure in over 90% of cases and have little or no side-effects. Treatment schedules are simple and short, with little or no monitoring needed. Thus, direct-acting antivirals will soon make obsolete present regimens containing interferon alfa and ribavirin, which have frustrated patients and health-care providers alike for years with their meagre effectiveness and poor safety profiles. In resource-rich countries, HCV prevalence is low: most new infections occur among people who inject drugs, whereas older infections were established iatrogenically—ie, via blood transfusions and invasive medical procedures. This route has been virtually eliminated by the introduction of standard safety procedures and an improved awareness of blood-borne pathogens. Unfortunately, unsafe injections continue to occur in developing areas, in which up to 75% of injections are still done with insufficiently sterilised equipment. Unsafe injections have been estimated to transmit 8–16 million hepatitis B virus, 2·3–4·7 million HCV, and 80 000–160 000 HIV infections every year. In Egypt, HCV prevalence is about 15% among adults and incidence is about 150 000 new cases per year. These high rates are due to the mass campaign of intravenous anti-schistosomiasis treatment in the 1960s–80s. From this original pool of infected individuals, HCV spread to large swathes of the population because of various unsafe invasive procedures—a problem that still persists. In , Romulus Breban and colleagues use mathematical modelling to estimate the effect of combined preventive and therapeutic interventions on the self-sustained spread of HCV in Egypt. Findings are expressed as R—the basic reproduction number—which corresponds to the number of new infections that an index case generates in an uninfected population. If everybody accessed health-care facilities for injections and invasive medical procedures according to the average rates derived from field data, the R would be 1 or lower and HCV transmission would not be self-sustained. The R of the spread of HCV without treatment was 3·54 (95% CI 1·28–6·18). The investigators conclude that a small core group of patients who receive frequent health-care interventions maintain the spread of HCV via a higher than mean rate of unsafe injections, infecting, as a result, several people who access the same facilities.
Many global health technologies, including medical devices and interventions, have been developed specifically for low-resource settings, and aim to be of low cost, easy to use, and culturally appropriate. Although their design, development, and clinical validation are often well funded, these devices commonly fail to reach scale of production and implementation in their intended markets. Some international organisations have emphasised the ability of global health technologies to support universal health coverage. However, the extremely difficult so-called last mile translation (eg, the final phase when the product is finally delivered to patients and providers) for existing, highly effective medical devices has to first be addressed to improve health-care in low-resource settings.