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Public-sector hepatitis C treatment programmes expanding in lower- and middle-income countries

Keith Alcorn
08 January 2021
Image: lovelypeace/

Public-sector hepatitis C treatment programmes have cured tens of thousands of people in lower- and lower-middle-income countries with the aid of low-cost direct-acting antivirals and diagnostics, a simplified approach to treatment and large-scale screening for hepatitis C, researchers report in BMJ Global Health.

The treatment programmes, established with the support of the Clinton Health Access Initiative between 2014 and 2017, had screened over 2.2 million people in seven countries by the end of 2019, of whom 120,522 people began direct-acting antiviral treatment after confirmation of chronic hepatitis C infection. Over 90% of those tested after completing treatment have been cured of hepatitis C.

A public health approach to hepatitis C treatment, which depends on simplified algorithms for diagnosing and treating hepatitis C and low-cost diagnostics and medication, is modelled on large-scale programmes for the treatment of HIV, tuberculosis and malaria. HIV treatment began to be provided in lower-income countries from 2003, after demonstration projects proved that a public health approach to the delivery of antiretroviral treatment was feasible and effective in some of the world’s poorest countries.

As in the early days of HIV treatment expansion in resource-limited settings, advocates for hepatitis C treatment have been challenged by high drug costs and lack of finance for hepatitis C treatment in countries with a high burden of hepatitis C.

Using its expertise in medicines and diagnostics procurement, price negotiation, planning and monitoring, Clinton Health Access Initiative worked with partners in Cambodia, India, Indonesia, Myanmar, Nigeria, Rwanda and Vietnam to develop public-sector testing and treatment programmes. Technical assistance was funded by the UK Department for International Development.

In most cases, treatment was already being offered, often focused on people co-infected with HIV and hepatitis C. Since 2017, treatment has expanded in all countries. Examples include:

  • India: A demonstration programme in Punjab from 2016 provided a model for a national programme that aims to treat 300,000 people over three years.
  • Indonesia: Hepatitis C treatment programme expanded from seven to 15 provinces since 2017. A national hepatitis C elimination programme has been launched in prisons, to be expanded throughout the country.
  • Rwanda: High prevalence of hepatitis C (4%); Rwanda built on the success of its HIV treatment programme, beginning hepatitis C screening in people with HIV before expanding to national screening of 1.5 million by 2019 and a national commitment to eliminate hepatitis C by 2023.

Treatment access has been greatly aided by reductions in the costs of diagnostics and treatment. Rapid antibody test prices had fallen to around $1 per test by 2019 while viral load test prices have fallen from around $100 in 2014 to less than $15 a test. Generic versions of direct-acting antivirals cost $39 for a 12-week treatment course in India and $60 in Rwanda. The total commodity cost of curing hepatitis C in Rwanda is now less than $80 per person, compared to $923 in Vietnam and $781 in Indonesia.

Clinton Health Access Initiative has worked with regulatory authorities to streamline regulatory and importation processes for new medicines and tests, as well as supporting price negotiations with manufacturers.

The researchers say that as new manufacturers of low-cost diagnostics and commodities enter the growing market, prices will fall, making public sector hepatitis C treatment a more affordable proposition in many countries.

Procurement costs are likely to be lower where a single national programme can negotiate with manufacturers, as in India and Rwanda.

Loss to follow-up at each stage in the cascade of care from screening to post-treatment testing has proved challenging in all countries. Charges for diagnostic tests, especially confirmatory viral load after diagnosis and after treatment, have been obstacles in some countries, as have stigma and marginalisation, for example among people who inject drugs.

Monitoring and evaluation have also proved challenging, especially where electronic record systems are underdeveloped.

But the biggest challenge remains the lack of global donor finance for hepatitis C treatment, say the researchers. “Advocacy at the global level is needed to continue building support for national hepatitis C virus programmes in [lower- and middle-income countries] in order to achieve elimination,” the authors conclude.


Boeke CE et al. Initial success from a public health approach to hepatitis C testing, treatment and cure in seven countries: the road to elimination. BMJ Global Health, 5: e003767, 2020.