Hepatitis elimination by 2030 in doubt as countries fail to scale up diagnosis and treatment

24 Apr 2019 Keith Alcorn
Originally published on www.infohep.org

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 Analysis reported.

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.”