WHO progress report on access to treatment

A new report from the World Health Organization (WHO) released in March shows that the annual number of people receiving treatment to cure hepatitis C increased from around 1 million in 2015 to 1.5 million in 2016.

However, global access to hepatitis C treatment remains uneven, with a small number of countries accounting for the bulk of the increase. Egypt and Pakistan accounted for about half of all people starting direct-acting antiviral (DAA) treatment to cure hepatitis C in 2016. There has also been encouraging progress in countries as diverse as Australia, Brazil, China, France, Georgia, Mongolia, Morocco, Rwanda and Spain.

WHO’s report, titled Progress report on access to hepatitis C treatment: focus on overcoming barriers in low- and middle-income countries, reviews the progress made in expanding access to life-saving treatment for hepatitis C infection in 23 low- and middle-income countries. It also provides information from innovator and generic medicine manufacturers and multiple partner organisations working in the field of viral hepatitis.

In a joint letter releasing the report, Dr Gottfried Hirnschall, WHO Director of HIV and Hepatitis, and Dr Suzanne Hill, WHO Director of Essential Medicines and Health Products, underlined the importance of government leadership in scaling up hepatitis C treatment. "A great number of countries need to seize the opportunity to procure the more affordable generic DAAs, which have become available through voluntary licensing or local production," they wrote.

Their joint message also called on global leaders and partners to take urgent action. "We need to join forces to unblock the price barriers in upper-middle- and high-income countries, which are home to 38% of all people with chronic hepatitis C infection. We also need to rapidly scale up access to hepatitis testing, as most people with hepatitis C remain unaware of their infection, let alone the need and chance to be cured."

According to the report, the overall number of people initiating DAA treatment has reached 3 million. However, this progress also points to a long road ahead: it is estimated that 71 million people worldwide have hepatitis C infection – and all need treatment.

Hepatitis B: five countries account for more than half of all HBV infections

Ninety per cent of people with chronic hepatitis B virus (HBV) are undiagnosed, according to research published in The Lancet Gastroenterology & Hepatology. The study also showed that just 5% of eligible patients are receiving HBV therapy. These proportions are well below those needed to achieve the World Health Organization (WHO) target of eliminating HBV as a health threat by 2030.

“Successive governments in high-prevalence regions have accepted the doctrine of vaccination, but have overlooked the larger picture of screening, diagnosis, and treatment to prevent progression,” comment the authors of an editorial accompanying the study. “The incidence of new chronic HBV infections will increase in unvaccinated adults unless large increases in screening and linkage to care are implemented.”

In 2016, WHO set the target of eliminating chronic HBV as a public health threat by 2030. Although there is no cure for HBV, there is a highly effective vaccine and the infection can be controlled by treatment with antiviral drugs.

Elimination of HBV by 2030 will require:

  • 90% coverage of three-dose infant vaccination by 2020
  • Timely birth-dose vaccination in 50% of infants by 2020, reaching 90% by 2030
  • Chronic HBV prevalence in children of 1% by 2020 and 0.1% by 2030
  • Diagnosis of 90% of people infected with HBV
  • Antiviral treatment of 80% of diagnosed people eligible for therapy.

To enable monitoring of progress towards these targets, a team of investigators estimated national, regional and global prevalence of HBV, as well as rates of diagnosis, vaccination and treatment. Data were obtained from published studies, government reports and interviews with national experts.

On the basis of these data, the investigators calculated that 364 million individuals – 5% of the world population – had chronic HBV infection. But after taking into account epidemiology, demographic changes, vaccination coverage, treatment and diagnosis, the researchers revised their prevalence estimate down to 4% of the world population.

Prevalence was highest in East Asia and sub-Saharan Africa, reaching 12% in the Central African Republic, compared to less than 1% in the UK. Just 21 countries accounted for 80% of all cases of chronic HBV in 2016. Moreover, 57% of these infections were in five countries: China, India, Nigeria, Indonesia and the Philippines.

Global diagnosis rates were poor. Even though an accurate test has been available since the 1970s, only 10% of people with the infection had been diagnosed in 2016. Diagnosis was not just a problem for poor countries: two-thirds of those with chronic HBV in the US and 80% in the UK were unaware of their infection status.

Only a small fraction of eligible people – 5% – were receiving anti-HBV drugs. Treatment coverage was even poor in Western Europe: just 3% in Belgium, 5% in Ireland, Norway and Portugal and 25% in the UK.

Globally, less that 1% of expectant mothers with a high HBV viral load received antiviral prophylaxis to prevent mother-to-child transmission.

Prevention of mother-to-child transmission of hepatitis B

Mothers who took tenofovir disoproxil fumarate (Viread) during pregnancy did not have a significantly lower risk of transmitting hepatitis B virus (HBV) to their infants compared with those who used standard preventive therapy, according to research presented at the 25th Conference on Retroviruses and Opportunistic Infections (CROI 2018) held in Boston, USA, earlier this month.

Rates of HBV transmission were very low overall, with no infants in the tenofovir group and three in the standard prophylaxis groups having confirmed HBV infection at 6 months of age, reported Gonzague Jourdain of the Institut de Recherche Pour le Développement in Chiang Mai, Thailand.

The iTAP study was a randomised clinical trial to evaluate whether tenofovir – the standard of care for treating chronic hepatitis B – could further reduce the risk of perinatal transmission when added to the usual preventive measures. Antiviral treatment could potentially lower the risk both by reducing the mother's HBV viral load and acting as pre-exposure prophylaxis for the infant.

The authors noted that the HBV transmission rate in the placebo arm was low, as prior studies have seen HBV transmission rates of 7% or higher among infants born to mothers with high HBV DNA levels, despite using hepatitis B immune globulin (HBIG) and HBV vaccine prophylaxis. Addition of tenofovir, therefore, could potentially be beneficial for pregnant women with high HBV viral load. Tenofovir may also reduce the risk if the first infant vaccine dose is delayed after birth or if the mother undergoes amniocentesis or Caesarean delivery, they suggested. This study did not test whether tenofovir works as well as – or perhaps better than – HBIG when combined with HBV vaccination.

Hepatitis C elimination in prisoners

Hepatitis C virus (HCV) infection can be rapidly eliminated in prison populations with the use of direct-acting antivirals (DAAs), results of an Australian study published in Clinical Infectious Diseases suggests.

The research involved prisoners incarcerated at the Lotus Glen Correctional Centre, Queensland. In the 22 months following the introduction of DAAs, the proportion of people with chronic HCV infection – or HCV viraemia – fell from 12% at baseline to 1%  at the end of the study. However, a substantial proportion of DAA-treated people were lost to follow-up and a small number of people were re-infected after cure.

“Micro-elimination of HCV is close to being realised in a large Australian prison, 22 months following unrestricted access to DAA therapy,” comment the investigators. “DAA therapy was highly acceptable among this population.”

“The close relationship between injecting drug use, incarceration, and prevalence of blood-borne viruses makes correctional centres a crucial setting for enhanced DAA access and broad prevention strategies,” conclude the investigators. “Population-level HCV elimination success will require effective HCV treatment and prevention programmes among both PWID [people who inject drugs] and people who are incarcerated.”

Eliminating hepatitis C in England

The All-Party Parliamentary Group (APPG) on Liver Health has issued a report setting out proposed actions that could lead to the elimination of hepatitis C in England. The APPG on Liver Health is a cross-party group of parliamentarians with an interest in health issues rather than a formal parliamentary committee, but its recommendations will be used to lobby ministers and public health officials for innovative approaches to hepatitis C elimination in England. A similar exercise for Scotland has been co-ordinated by The Hepatitis C Trust.

Key recommendations of the report include:

  • A high-profile, Government-backed awareness campaign should be considered, and awareness messaging should be targeted through novel channels at those who may not consider themselves to be ‘at risk’.
  • Industry to be incentivised via a long-term strategic funding agreement to invest in national awareness-raising campaigns.
  • Provision of needle and syringe programmes and opioid substitution therapy should be protected or increased to prevent hepatitis C transmission.
  • Incentives to treat those most likely to transmit hepatitis C should become a standard element of service funding.
  • Provision of hepatitis C testing should be expanded across a wide range of settings.
  • Referral pathways after diagnosis should be simplified to eliminate the need for additional tests and appointments, with the eventual aim of initiating treatment on the same day as a positive diagnosis.
  • An increased target of at least 20,000 new treatment initiations per year should be adopted nationally to achieve the commitment to eliminate hepatitis C by 2025 expressed by NHS England.
  • Treatment must be made available in community settings, and be flexible and accessible to all patients.
  • Treatment should also be made available to those who are reinfected in line with a ‘treatment as prevention’ approach.

Successful HCV therapy reduces the risk of diabetes

Successful hepatitis C virus (HCV) therapy reduces the risk of developing type 2 diabetes by approximately a fifth, according to results of a large US study published in the Journal of Viral Hepatitis.

Investigators from the US compared incidence of type 2 diabetes according to HCV treatment outcomes in patients enrolled in the Chronic Hepatitis Cohort Study. This is a geographically and racially diverse cohort involving patients in four large US health systems.

People who attained a sustained virological response (SVR) were 21% less likely to develop diabetes than people who did not respond to treatment. In people who did not attain an SVR to HCV therapy, other risk factors for the development of type 2 diabetes were race, high body mass index (BMI) and baseline cirrhosis.

Next month: News from The International Liver Congress

Next month, infohep will be providing news coverage from The International Liver Congress 2018, organised by the European Association for the Study of the Liver (EASL). The conference is taking place in Paris, France from 11-15 April.

We will be publishing news online and the April infohep bulletin will be dedicated to news from the conference.

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