Viral hepatitis: setting sights on the right target

Abstract

Viral hepatitis is gaining greater attention as the scale of the disease burden has become impossible to ignore. This recognition was reaffirmed earlier this year by the World Health Assembly's resolution on viral hepatitis, which outlined that these infections were responsible for 1·4 million deaths each year. Meaning they are major causes of infection attributable deaths, such as HIV (1·6 million deaths), tuberculosis (1·3 million), and malaria (600 000). More worrying still, it was acknowledged that most people infected with hepatitis B or C virus were unaware that they were infected. A key element of this resolution was a commitment to assess the feasibility of eliminating hepatitis B and C with a view to potentially setting targets. Elimination of these infections will be an enormous task, but that this is now being contemplated is some indication of the advances made so far. However, a major obstacle on the path towards elimination will be ensuring that treatments are accessible to people in low-income and middle-income countries and that prevention and treatment measures reach marginalised groups. In the context of hepatitis C, people who inject drugs must be placed at the centre of prevention and treatment planning since they are disproportionately affected by this infection. This month in The Lancet Infectious Diseases Sunil Solomon and colleagues assess the burden of hepatitis C in people who inject drugs in India. They highlight that so far this population, which is at the intersection of groups (ie, injection drug users and from a low-income country) that should be proactively targeted for prevention and treatment, are not a health priority in India. In an accompanying Comment Avina Sarna and Samiran Panda express a lack of surprise in what they describe as the neglect of hepatitis C. A major problem identified in the research was that only 5% of seropositive people who inject drugs were aware of their serostatus. Awareness of serostatus is a pillar of hepatitis C prevention and treatment. Also this month, Rajender Reddy and colleagues report their non-inferiority phase 3 trial comparing simeprevir versus telaprevir for the treatment of hepatitis C virus infection in patients who have previously not responded to treatment. They found that simeprevir was non-inferior, and they postulated that simeprevir might improve compliance since it is taken as a single capsule rather than the six tablets of telaprevir. Good adherence to antivirals will be key to any plans to eliminate viral hepatitis. In a Comment accompanying this trial, Geoffrey Dusheiko points out that the important finding is that simeprevir has a better safety profile than telaprevir. Also he suggests that the real advantage of this drug is that it can be used in combination with other direct-acting antiviral drugs in interferon-free regimens. In one sense short-duration interferon-free regimens will bring the goal of viral hepatitis elimination much closer, but they will also introduce new complications. These new drugs have been coming to market with very high prices, clearly aimed at high-income countries. The danger here is that this pricing ignores low-income and middle-income countries where the bulk of the disease burden is present. Dusheiko emphasises that it is inadvisable to operate a two-tier system where patients in low-income and middle-income countries receive current interferon-based regimens and patients in rich countries are given the new interferon-free regimens. Efforts need to be made to harmonise access to these more effective drugs. The cost of these drugs does not only hinder access in poorer countries. In the recent Lancet Commission on liver health in the UK, the authors point out that, even if renegotiated, the cost of these drugs would mean that their availability would need to be restricted. Not a strategy conducive to the elimination of viral hepatitis. Particularly since this will add to the logistical and financial costs by creating a need to identify and prioritise patient groups. Despite the logic of targeting people who inject drugs, it is easy to imagine that these people will not initially be among the prioritised groups who receive these expensive medicines. To contribute to the debate and help drive progress, The Lancet Infectious Diseases will be hosting a meeting on viral hepatitis in Shanghai, China, on April 10–12, 2015. If elimination of viral hepatitis is to become a reality, bold steps will need to be taken. One lesson from tackling HIV is that marginalised groups only become an important focus of policy after other groups are reached. To effectively deal with viral hepatitis goals from the outset must primarily target marginalised people and low-income and middle-income countries. For more on cost of hepatitis C drugs see Newsdesk Lancet Infect Dis 2014; 14: 452–53 For more on cost of hepatitis C drugs see Newsdesk Lancet Infect Dis 2014; 14: 452–53 For more on the Viral Hepatitis summit see http://www.viralhepsummit.com/ For more on the Viral Hepatitis summit see http://www.viralhepsummit.com/ Controlling hepatitis C with simeprevirChronic hepatitis C poses a major global health burden and threat worldwide. The threat from hepatitis C stems from the prevalence and incidence of the infection, the anticipated rise in the incidence of long-term complications of chronic hepatitis C, including cirrhosis, portal hypertension, and hepatocellular carcinoma, and the low treatment rates in many countries.1 These outcomes have led to increased mortality rates that will continue to rise during the next two decades unless appropriate interventions are introduced. Full-Text PDF HCV in people who inject drugs: a neglected epidemicDespite the serious health implications of hepatitis C virus (HCV), especially in the context of concurrent HIV infection, its prevention and management has not been a national health priority in India. With the advent of highly efficacious direct acting antiviral drugs for HCV that can be administered orally once daily,1 and activism around the reduction of treatment costs, HCV treatment might be added to the national health mission plan, which is especially important for people who inject drugs, the population most affected by HCV. Full-Text PDF Simeprevir versus telaprevir with peginterferon and ribavirin in previous null or partial responders with chronic hepatitis C virus genotype 1 infection (ATTAIN): a randomised, double-blind, non-inferiority phase 3 trialSimeprevir once a day with peginterferon alfa-2a and ribavirin was well tolerated in HCV genotype 1-infected previous non-responders and was non-inferior to telaprevir, thus providing an alternative treatment in areas of the world where all-oral HCV regimens are not available or accessible. Full-Text PDF Burden of hepatitis C virus disease and access to hepatitis C virus services in people who inject drugs in India: a cross-sectional studyThe high burden of HCV and HIV/HCV co-infection coupled with low-access to HCV services emphasises an urgent need to include resource-limited settings in the global HCV agenda. Although new treatments will become available worldwide in the near future, programmes to improve awareness and reduce disease progression and transmission need to be scaled up without further delay. Failure to do so could result in patterns of rising mortality, undermining advances in survival attributed to widespread HIV treatment. Full-Text PDF