Crunching the numbers for viral hepatitis

Abstract

According to WHO estimates, 9·4 million people were treated for hepatitis C virus (HCV) infection between 2015 and 2019, a substantial increase from the 1 million who had been treated by the end of 2015. Since 2016, treatment coverage has increased by 550%; concurrently, there has been a 75% decrease in treatment price, according to a recent report from the Clinton Health Access Initiative (CHAI). This shift in treatment cost and uptake is a step in the right direction if WHO 2030 global elimination targets for viral hepatitis are to be met. But while the increase in numbers of patients treated worldwide is undoubtedly an improvement on previous years, there are still notable disparities that threaten the likelihood of meeting the targets within the next decade. WHO estimates suggest that 58 million people worldwide have chronic HCV infection and that 75% of people with HCV live in low-income and middle-income countries (LMICs). Although there have been increases in the number of people diagnosed worldwide, some regions still have high proportions of undiagnosed cases: in Africa, it is estimated that as many as 95% of people with HCV were undiagnosed by the end of 2019. Between LMICs, efforts towards elimination in some countries—eg, Egypt and Pakistan—have outpaced those in others, and global statistics do not provide an accurate picture of progress at the country level. In the past few years alone, the diagnostic and therapeutic landscape for HCV has evolved substantially. The introduction of next-generation direct-acting antivirals (DAAs) has galvanised efforts to meet elimination targets and the growing number of generic DAAs available have provided stiff competition for branded regimens. Cost-effective diagnostic tests have also provided an opportunity for LMICs to increase diagnosis rates. The CHAI report outlines the remaining barriers to scale-up in LMICs. According to the report, treatment costs for HCV have declined as the generic market for DAAs has expanded; an increase in production of DAAs and competition between suppliers within countries such as India has not only improved the security of drug supply in these countries, but has also driven costs down. However, in other countries, access to generic DAAs and tests is more logistically complex and expensive. These findings echo those from a 2020 WHO report, which also drew attention to fragmented, inequitable access to HCV testing and treatment in LMICs. And it is not just HCV elimination efforts that are affected by this lack of access. Although substantial progress has been made towards the WHO elimination targets for hepatitis B virus (HBV), systematic testing for the virus in LMICs—which are disproportionately affected—is still uncommon. There are also parallels in the lack of equitable access to treatment in these countries. Tenofovir disoproxil fumarate (TDF) is approved for both HIV and HBV at the same dosage. However, while the cost of TDF for HIV treatment has been brought down to US$28·80 per year, the cost of a course of TDF for HBV can be much higher and varies widely between LMICs: in Cambodia, a 1-year course of TDF cost $336 in 2020, but in Rwanda the cost was $36. Why are there such discrepancies in pricing for the same drug? Greater transparency and clarity are needed. Ultimately, the elimination of viral hepatitis will only be possible if populations who are most at risk are included in efforts to diagnose and treat disease; lessons learned from the scale up of HCV programmes could also be adopted to improve HBV screening, as shown in India and Rwanda, where the infrastructure used to test and treat HCV has been expanded to include HBV. But improved testing and diagnosis are only two elements in large-scale efforts to eliminate hepatitis. Dedicated funding, political will, simplified treatment guidelines, and national strategic plans are just as crucial to consider if barriers are to be surmounted, and many of these have already been incorporated into successfully scaled-up elimination programmes. Multipronged strategies that incorporate these concepts help bolster the cascade of care, with the ultimate goal of expanding access to treatment to anyone who needs it. And although using the same approach to scale-up in every LMIC might not be feasible, ensuring reasonable treatment prices for all is not only a good start, but also an equitable one. This online publication has been corrected. The corrected version first appeared at thelancet.com on October 12, 2021 This online publication has been corrected. The corrected version first appeared at thelancet.com on October 12, 2021 Correction to Lancet Gastroenterol Hepatol 2021; 6: 875The Lancet Gastroenterology & Hepatology. Crunching the numbers for viral hepatitis. Lancet Gastroenterol Hepatol 2021; 6: 875—The first two sentences of this Editorial have been corrected to read “According to WHO estimates, 9·4 million people were treated for hepatitis C virus (HCV) infection between 2015 and 2019, a substantial increase from the 1 million who had been treated by the end of 2015. Since 2016, treatment coverage has increased by 550%; concurrently, there has been a 75% decrease in treatment price, according to a recent report from the Clinton Health Access Initiative (CHAI).” This correction has been made online as of Oct 12, 2021. Full-Text PDF