Cost of eliminating viral hepatitis needs to take into account social as well as medical burden of disease

Securing commitments from national governments to treat viral hepatitis, scale up prevention activities and aim for elimination of hepatitis B and C by 2030 will require a broad coalition of forces – and a sophisticated approach to proving the value of investing in elimination of viral hepatitis – delegates at last month’s International Liver Congress heard.

At the Transforming HCV Care Together symposium held ahead of the International Liver Congress, delegates heard how governments could be convinced to act, and what sorts of tools are available to help in advocacy and planning.

Charles Gore, President of the World Hepatitis Alliance described the global policy framework that can be used by advocates to pressure national governments into developing national plans for viral hepatitis that commit to providing treatment and prevention measures.

A World Health Assembly resolution in 2014 called on national governments to “develop and implement coordinated multisectoral national strategies,” and called on the World Health Organization to develop a strategy for the elimination of viral hepatitis as a public health problem. This led to a health sector strategy that is due to be adopted by UN member governments, and the development of regional plans by WHO.

Another major step forward has been the acknowledgment of viral hepatitis as a global public health problem in the Sustainable Development Goals (SDGs) adopted by the United Nations in 2015. The SDGs commit member states to `combat` viral hepatitis, to reduce by one third premature mortality due to non-communicable diseases (liver cancer) and to strengthen the prevention and treatment of substance abuse.

Charles Gore pointed out to delegates that the SDGs language on reducing non-communicable disease mortality and strengthening substance use prevention and treatment provide important opportunities to make the case for viral hepatitis prevention and treatment, to reduce the burden of liver cancer and to support viral hepatitis prevention through harm reduction and through substance use treatment.

“No disease has ever been eliminated just by clinical work – they are eliminated by planning, by strategies and by people putting money behind them,” said Rafael Bengoa of Deusto University Business School, Madrid. “If you want to cure, control and eliminate, be ambitious,” he went on.

“You need to be looking across seven or eight areas to come up with a comprehensive approach, otherwise you are just silo planning,” said Rafael Bengoa. Deusto Business School has launched HCV Hub as a resource to assist in national planning. It provides examples of situational analyses, national action plans, evidence-based interventions and case studies to help policy makers develop national programmes.

Coming up with arguments to convince governments and other stakeholders to invest in a comprehensive viral hepatitis plan requires a comprehensive approach, speakers agreed.

“One of the biggest mistakes over the years has been to concentrate only on doctors, patients and the pharmaceutical industry,” said Achim Kautz of Deutsche Lieberhilfe.

In Germany advocates have set out to persuade employers, retirement funds, the social welfare fund, insurance funds and municipal governments of the financial burden imposed by viral hepatitis and the benefits of investing in viral hepatitis prevention and treatment. Assembling a broad array of support has been critical in persuading government to act, said Kautz.

A think tank of national and international experts developed an economic model for projecting the costs of viral hepatitis, which was validated by German experts. The model calculated the downstream costs of managing serious liver disease, including cirrhosis, liver cancer and liver transplants, according to different rates of diagnosis, treatment and new infections, and also took into account indirect costs such as pensions, sickness pay and other costs to employers and the social insurance system.

The process of engaging a wide range of stakeholders and costing the benefits beyond the health budget led to preliminary discussions with the Ministry of Health regarding a national strategy, and very quickly, to the development and publication of a national strategy for Germany in April 2016.

“Rather than saying we want A, B and C, we can say that our recommendation will cost X million euros but it will save Y million euros,” Achim Kautz said.

The modelling exercise concluded that in Germany 80% of healthcare expenditure on viral hepatitis is devoted to treating 20% of patients – those with cirrhosis, liver cancer or undergoing transplantation. Averting this expenditure through wider treatment would result in a short-term increase in costs, followed by accumulating savings during the decade beginning in 2020, when health budgets are likely to be under greatest pressure from an ageing population in Europe.

Although costs would rise modestly in the period up to 2019, expanded diagnosis and treatment aiming at elimination of hepatitis C would begin to result in savings from 2020 onwards – 255 million euros between 2025 and 2029 for employers and the Ministry of Labour and Social Affairs alone.

But models of hepatitis C-related health care costs which focus only on the costs of end-stage liver disease may fail to capture substantial economic and social costs generated by extrahepatic disease caused by hepatitis C, Professor Patrice Cacoub of Hôpital La Pitié-Salpêtrière, Paris, told the meeting. Chronic hepatitis C infection has been shown to double the risk of non-liver-related mortality over a follow-up period of 18 years. Hepatitis C increases the risk of chronic kidney disease, cardiovascular disease and cancers, and recent research has shown that people with hepatitis C have an increased risk of developing lymphoma, a cancer of the lymphatic system. Depression and fatigue are common in people with hepatitis C, although the causal mechanisms and the burden of these conditions is still poorly defined.

The Transforming HCV Care Together symposium was co-organised by the European Liver Patients Association, World Hepatitis Alliance, World Federation of Science Journalists, Deusto Business School and infohep.org. The event was sponsored by AbbVie.