NHS England announced this week that it aims to eliminate
hepatitis C by 2025 – if it can negotiate 'best value for money' deals with the
pharmaceutical industry in a new round of tendering for direct-acting
antivirals due to take place in February.
NHS England already operates a 'no cure, no fee' deal with
The money saved has allowed more people to be treated, including
re-treatment of people with advanced or decompensated cirrhosis who were not
cured by a previous course of direct-acting antiviral treatment.
Approximately 160,000 people are estimated to have hepatitis
C in England. To achieve elimination by 2025 NHS England will need to increase
the number of people treated each year. The World Health Organization defines
elimination of hepatitis C as a 65% reduction in HCV-related deaths and a 90%
reduction in new infections by 2030, with 80% of eligible people treated by
- decompensated cirrhosis
The later stage of
cirrhosis, during which the liver cannot perform some vital functions and
complications occur. See also ‘cirrhosis’ and ‘compensated cirrhosis’.
Achieving this target by 2025 implies either that more money
will be made available, which is highly unlikely, or that NHS England is looking
for a very substantial cut in the price of direct-acting antivirals.
Health England says that approximately half of all people with hepatitis C may
have been diagnosed in England and Wales, but according to Charles
Gore, chief executive of the Hepatitis C Trust, “We have at least 100,000
people to find.” According to estimates released by the Polaris Observatory at
the World Hepatitis Summit in November 2017, at least 10,000 people will need
to be treated each year to achieve elimination by 2030. This number would need
to rise to at least 16,000-17,000 a year to achieve elimination in 2025. But
the Polaris Observatory warns that unless rates of diagnosis improve the number of
people treated could fall to 5000 a year by 2020.
NHS England plans to increase the number of people treated
for hepatitis C to 13,000 in the year beginning April 2018, Professor
Graham Foster announced earlier this month. A review of Operational
Delivery Networks for hepatitis C treatment in England, published
by the Hepatitis C Coalition in December 2017, indicated growing concern among
healthcare professionals about how to identify new people in need of
NHS England says that it wants to collaborate with the
pharmaceutical industry to identify more people living with hepatitis C in need
of treatment. If the treatment budget is not elastic, this implies that what
NHS England hopes to secure is an agreement similar to the one obtained by the
Australian government in 2016.
The Australian deal committed the government to spend AUS$1
billion on direct-acting antivirals up to 2020, specified a heavily discounted price
per treatment course, and placed a maximum cap on expenditure each year but no
cap on the number of people who could be treated. The expenditure cap
effectively allows free treatment for each additional patient once the annual
budget is spent. As a result of the high enrolment on treatment, the deal has
resulted in a cost
per treatment of around £3100 to £3700 (5400 to 6500 euros) in 2016 in Australia,
compared to a cost between £15,000 and £20,000 per treatment course in the
Calculations of the cost of production of generic versions
of direct-acting antivirals presented
at recent international scientific meetings show that a 12-week course of
treatment with sofosbuvir/ledipasvir can be manufactured for $79, suggesting
the scope for reductions in the cost of branded products.
The Australian deal incentivises new diagnoses and new
treatment starts. A
recent inquiry conducted in Scotland, led by the Hepatitis C Trust, shows
that numerous parts of the health system will need to be encouraged to improve
hepatitis C diagnosis, including substance misuse services, prison, general
practitioners, pharmacies and accident and emergency departments.