HCV Elimination Is Possible, First Estimates Suggest

Marcia Frellick

January 30, 2019

Reaching most of the World Health Organization's (WHO) targets to eliminate hepatitis C virus (HCV) infections worldwide can be accomplished by 2030, according to the first study to estimate the progress. But study authors and other experts say the level of improvements required to meet those goals is daunting.

If several key strategies are successfully implemented, countries could collectively meet the WHO target of reducing new infections by 80% by 2030, compared with 2015.  But even with successful implementation, the target of reducing HCV mortality by 65% would take until 2032, according to the paper, published online January 28 in The Lancet.

"Even though it narrowly falls short of the WHO targets for 2030, the impact our estimates suggest would be a tremendous stride forwards," write lead author Alastair Heffernan, PhD, Imperial College London in the United Kingdom, and colleagues.

Putting in place a comprehensive package of prevention, screening, and treatment could, by 2030, avert 15.1 million new infections and 1.5 million deaths from cirrhosis and liver cancer worldwide, the authors' models show.

Currently, 71 million people globally are chronically infected with HCV, according to the 2017 WHO Global Hepatitis Report.

In evaluating the power of several interventions to help reach the goals, the study authors used a transmission model with data from 190 countries that considered demographics; prevalence of people who inject drugs (PWID); current reach of treatment and prevention programs; natural history of HCV and its prevalence; and percentages of deaths caused by HCV.

What Would Need to Change

Heffernan and colleagues then used the model to project what it would take to reach the targets, set by WHO in 2017, and to identify major obstacles.

Goals include improving blood safety and infection control, extending harm reduction services for PWID, expanding testing, and increasing treatment with direct-acting antivirals (DAAs), which have cure rates above 90%.

The authors say that meeting targets could happen only with intensive improvements and strong political will, particularly in four countries — China, India, Pakistan, and Egypt — which would otherwise contribute most of the new infections by 2030.

"Achieving such reductions requires a massive screening programme and demands a rapid increase in new treatment courses in the short term — namely, 51.8 million courses of direct-acting antivirals by 2030," the authors write.

The goals require boosting the diagnosis rate to 90% by 2030; so far Malta is the only the country with a rate that high, the authors point out.

"The treatment of only those already in care will not translate into substantial reductions in HCV deaths or incidence," they add.  

Integral to reaching the WHO targets, the authors note, is increasing access to harm reduction strategies (such as opioid substitution therapy and needle and syringe programs) to 40%. However, the authors report that only 1% of people who inject drugs live in countries with harm reduction coverage rates that high.

The projections also depend on the effectiveness of harm reduction measures.

"If the effectiveness of those programmes is lower than has been estimated in some settings," the authors write, "then elimination becomes a much more remote prospect, with elimination not being reached until after 2050, even with high coverage of other interventions." The effect of harm reduction programs on PWID has not been studied much outside of North America and Europe, the authors acknowledge.

Another obstacle lies in blood safety and infection control, as only 39% of countries have hemovigilance systems, the authors write.

Political Will, Investments Critical

Stefan Wiktor, MD, acting professor of global health at University of Washington Schools of Medicine and Public Health in Seattle, said in an accompanying commentary that Heffernan's results are encouraging in that they conclude WHO goals can be achieved, but he noted the authors also point out how difficult the path will be.

"The required expansion of hepatitis services will require political will and substantial new investments from national budgets and global funding sources," Wiktor writes.

The study authors didn't address how much HCV elimination would cost globally, but a previous WHO report projects the strategies would cost the United States alone $11.9 billion between 2016 and 2021.

"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," Wiktor writes.

Wiktor said the main limitation of the study is that the calculations rely on factors based on models themselves or, in some cases, expert opinions rather than measured values.

Still, there are signs that some countries are making great advances. According to the study authors, Egypt, using innovative strategies, treated 700,000 people with DAAs in 2016. Australia also negotiated a deal for volume-based pricing for the expensive DAAs so uptake, rather than rationing, is encouraged.

The authors note that innovations such as point-of-care viral load finger-stick tests are also expected to become more widely available.

The study was funded by the Wellcome Trust . Coauthors report advisory or educational roles with AbbVie, Gilead, and Merck Sharp & Dohme; personal fees from WHO for work related to this topic; and fees from the Bill & Melinda Gates Foundation, Anansi Health, and Avenir Health for unrelated work.

Wiktor has disclosed no relevant financial relationships.

The Lancet. Published online January 28, 2019. Full text, Editorial

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