Most countries will struggle to eliminate hepatitis C by
2030 due to lack of investment and political will, missing an
internationally agreed target set by the World Health Organization, The
International Liver Congress in Vienna heard earlier this month.
“Despite the progress we’ve seen, we’re clearly not going to
make it,” said Gottfried Hirnschall, Director of HIV and Hepatitis at the World
Health Organization (WHO), speaking at a symposium on elimination of viral hepatitis organised by WHO.
The World Health Assembly agreed ambitious targets for
elimination of viral hepatitis in 2016. Countries pledged to scale up
prevention, diagnosis and treatment so that deaths caused by viral hepatitis
would be cut by 65% and new infections cut by 90%
Although 124 countries now have national plans for viral
hepatitis elimination, 42% of plans have no domestic funding, Mark Bulterys,
head of WHO’s hepatitis team told the symposium.
Furthermore, although 5 million people had been treated with
direct-acting antivirals (DAAs) by the end of 2017, most of these treatments occurred
in ten 'champion countries' which have scaled up treatment quickly, including
Egypt, Brazil and Australia.
Even in higher-income countries, hepatitis C elimination may
only be achieved by a handful of countries by 2030, the Center for Disease Analysis
estimates. Nine countries – Australia, France, Iceland, Italy, Japan, South
Korea, Spain, Switzerland and the United Kingdom – will achieve elimination by
2030 at current rates of diagnosis and treatment.
Elimination may not occur before 2050 in Canada, the United
States and smaller European countries, the modelling exercise found. Two-thirds
of higher-income countries are seriously off-track, the Center for Disease
Despite dramatic reductions in the prices of generic
versions of DAAs to less than $100 per cure, some lower-income
countries are still paying substantially higher prices although they are
eligible for low-price drugs under voluntary licensing agreements. Sixty-two per cent of people with hepatitis C live in countries covered by these agreements, which
allow generic versions of DAAs manufactured under voluntary licence from the
originator company to be imported from countries such as India or Egypt.
WHO has calculated how much it
will cost to eliminate hepatitis C by 2030. Its model, developed by Dr Melikha
Toy of Stanford University, estimates that it will cost $58.8 billion to
achieve elimination of viral hepatitis by 2030, slightly higher than the estimate
presented by Professor Margaret Hellard of the Burnet Institute, Melbourne,
on the opening day of the conference.
But Dr Toy said that the cost of elimination could be
considerably lower if drug prices fall rapidly, if countries use voluntary
licensing arrangements to obtain low-cost drugs, and if the cost of diagnostics
falls, especially hepatitis B DNA testing. A large part of the cost of
elimination will be the cost of HBV DNA monitoring, and much of the cost of
elimination will be concentrated in the Western Pacific region and Africa due
to the high burden of hepatitis B in those regions, she said.
The cost of elimination would add 1.5% to
the total budget for universal health coverage proposed by WHO in 2017. The budget set out how much it would cost to
achieve the Sustainable Development Goals for health by 2030 through universal
health coverage in 67 lower- and middle-income countries. Hepatitis diagnosis
and treatment was not included in that costing.
“If you look at data, and ask, 'what is hepatitis achieving
in the context of universal health coverage', it’s just about getting off the
ground,” Dr Gottfried Hirnschall told infohep in an interview.
“We hear about Egypt, Mongolia, Georgia, China, Brazil, but
there are many other countries that are not moving yet. There are whole
continents that are falling behind, Africa when it comes to hepatitis B, and for
hepatitis C some of the larger high burden countries are not moving
sufficiently – Russia for example, and China still has a long way to go despite
some positive momentum that has been building up.”
“A movement has been created, the momentum has been sparked,
the feasibility has been demonstrated in some countries but too many others are
still looking across the fence and finding easy excuses for not doing it.”
To maintain a positive trajectory and accelerate it, advocacy
will still be needed. We must not give the impression that HIV is almost done,
and we must encourage countries to factor those services into a broader health
financing approach, and we see that in some countries, such as Thailand.
“In hepatitis, we have to demystify that management is
highly complex and can only be done by hepatologists – we are here at a
hepatology conference and we need to convince them, 'it’s not just your job, it
can be done by any general practitioner' and in some low-income settings it
could be simplified further, which is what we’ve seen in HIV.”