Georgia is making strong progress towards eliminating hepatitis C but will need triple the number of people starting treatment if it is to reach its national elimination target of a 90% reduction in prevalence by 2020, presentations at last month's International Liver Congress showed.
Georgia is a small country with a very high burden of hepatitis C: around 5% of the population had chronic hepatitis C in 2015, or 150,000 people out of a population of 3.7 million.
Prevalence of hepatitis C is highest among men aged 30-59 and people who inject drugs. Approximately two-thirds of people who inject drugs in Georgia have antibodies to hepatitis C, although a 2015 national seroprevalence survey indicated that only one-third of infections were associated with injecting drug use.
Hepatitis C prevalence is also high in people with HIV (34%), in people diagnosed with tuberculosis (21%) and people diagnosed with sexually transmitted infections (11%).
For a lower middle-income country like Georgia, eliminating hepatitis C would have been impossible without a major reduction in the cost of treatment. In April 2015 Gilead Sciences agreed to provide sofosbuvir and sofosbuvir/ledipasvir (Harvoni) free of charge, as part of a national elimination programme that aims to reduce the prevalence of chronic hepatitis C virus (HCV) by 90% by 2020. Georgia’s government plans to spend approximately $39 million between 2018 and 2020 on HCV elimination.
The national programme also aims to reduce HCV incidence among people who inject drugs by intensifying outreach and HCV screening, and provision of needle and syringe programmes and opioid substitution therapy. Prime Minister Giorgi Kvirikashvili appealed to Georgia’s parliament in 2017 for drug law reform so as to reduce the criminalisation of drug users.
Between April 2015 and March 2018, approximately 1.5 million people were tested for HCV. A total of 48,764 people were diagnosed with hepatitis C, approximately one-third of the estimated population living with chronic HCV infection. Of these people, 93% started direct-acting antiviral treatment, 29,620 have been evaluated for sustained virologic response after treatment and 29,090 (98.3%) have been cured of hepatitis C.
The predominant genotypes in Georgia are genotypes 1, 2 and 3. There has been no substantial difference in the rates of cure according to hepatitis C genotype, or by fibrosis stage, although people with genotype 3 infection and advanced fibrosis who received sofosbuvir/ribavirin prior to March 2016 had a lower cure rate than those who received sofosbuvir/ledipasvir.
To achieve the target of a 90% reduction in prevalence by 2020, or even by 2025, Georgia’s HCV treatment programme will have to increase the rate at which people start treatment. Modelling by Josephine Walker of the University of Bristol – a programme partner – shows that the current rate of treatment initiation (1000 a month by the end of 2017) is inadequate. The programme will need to triple the rate of treatment initiation during 2018 to achieve a 90% reduction in prevalence by 2020.