WHO hepatitis C elimination targets are achievable, model shows – if 51 million treated by 2030

Keith Alcorn
Published:
29 January 2019
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Expanding hepatitis C screening to diagnose 90% of people by 2030, providing treatment to everyone with hepatitis C, scaling up harm reduction and improving blood and medical safety would avert over 15 million new hepatitis C virus (HCV) infections by 2030 and reduce deaths caused by HCV by 61% compared to 2015, a modelling study carried out by Imperial College, London shows.

The study is published this week in The Lancet.

In 2016, all 194 member-states of the World Health Organization (WHO) committed to eliminating viral hepatitis as a public health threat. These targets include reducing mortality by 65% and reducing new infections by 80% by 2030, compared with 2015 rates.

Glossary

direct-acting antiviral (DAA)

A drug which prevents hepatitis C from reproducing by blocking certain steps in its lifecycle.

The modelling exercise was designed to test if these targets are achievable by 2030 and what would be required to achieve the reductions in incidence and mortality.

The model

The model developed by researchers at Imperial College London incorporates information on HCV prevalence and mortality in 190 countries. It also incorporates information on demographics, current treatment and prevention coverage, and the number of people who inject drugs.

Six scenarios were tested:

  • No use of direct-acting antiviral (DAA) treatment, treatment rates fixed at 2015 or 2016 levels
  • Continuing levels of treatment and prevention at 2015 levels

Addition of four interventions to the status quo in sequence:

  • Expansion of blood safety and infection control sufficient to reduce the risk of infection by 80% by 2020
  • Expansion of harm reduction to 40% of people who inject drugs (PWID), sufficient to reduce the risk of infection by 75% in PWID by 2020
  • Offer of DAAs at diagnosis for all
  • Expansion of outreach screening so that 90% of people with HCV are diagnosed by 2030.

Results

The model estimated that 69 million people were living with HCV in 2015, 512,000 died as a result of HCV and the infection rate was 277 per million people.

Between 2016 and 2030, 22% of all new infections will occur in PWID, the model found.

If treatment and prevention continue at 2015 levels, the number of people living with HCV will be almost unchanged in 2050 (58 million). Incidence would decrease slightly by 2060 and then begin to increase again, as would deaths due to HCV.

Improving blood safety and infection control would reduce new infections by 58% in 2030 compared to the status quo.

Adding expanded access to needle and syringe programmes and opioid substitution for 40% of people who inject drugs to improved blood safety would reduce new infections by a further 7%.

In total, these two prevention interventions would avert 14.1 million new infections by 2030. They will have less impact on mortality up to 2030 as the interval between infection and liver disease is so long.

If, on top of these measures, DAAs were made available to everyone at the time of diagnosis, 640,000 deaths from liver cancer or cirrhosis would be averted by 2030. The expansion of treatment would have no effect on incidence, the model found.

Both incidence and mortality would be reduced if outreach screening was expanded to diagnose 90% of people with HCV by 2030. Mortality would be reduced by 61% and an additional 950,000 new infections would be averted by 2030.

But to achieve this outcome, 51.8 million people would need to be started on DAA treatment by 2030. After 2030, the number of people in need of treatment would fall dramatically, so that only 12 million people would need treatment between 2030 and 2050.

The impact of various interventions would differ from one country to another according to local conditions. Blood safety interventions would have an especially large impact in Egypt and Pakistan, whereas harm reduction measures would have the greatest impact in the United States and Australia.

Infections and deaths averted are concentrated in a small number of countries, in particular China, India, Pakistan, and Egypt, which are the countries that contribute most to projected new infections by 2030.

The WHO target for reducing mortality would be narrowly missed in 2030 if the comprehensive package of all interventions was implemented but would be achieved by 2032. The WHO target for reducing new infections would be achieved by 2030. But the authors caution that if the effectiveness of harm reduction interventions in preventing HCV transmission is reduced, due to the way in which services are delivered or to high reinfection rates, the incidence target might not be met until 2052.

“Even on the global scale where incidence is dominated by non-PWID transmission, reducing incidence among PWID plays a key part in determining whether elimination targets are met.”

The study authors say that the benefits of DAAs will only be realised with an enormous increase in screening so that 90% of people with HCV are diagnosed by 2030.

The interventions are not costed in the modelling study, but in an accompanying comment article Stephan Wiktor, of the University of Washington says “WHO estimated that implementing its strategy would cost US$11·9 billion for the period 2016–21. Identifying these resources will be particularly difficult at a time of reduced investment in global health and a shift in focus toward universal health coverage rather than disease-specific programmes.”

Reference

Heffernan A et al. Scaling up prevention and treatment toward the elimination of hepatitis C: a global mathematical model. Lancet, advance online publication, 28 January 2019.

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