HEPATITIS C ELIMINATION; WHAT ARE THE BARRIERS?

In a prior post earlier in the year I wrote on this topic. A closer look at the current global situation suggests that whilst the cost of Hepatitis C (HCV) treatment may appear to be a major barrier there are many nations in the world that have managed to overcome that. In this piece I would look at the some of hurdles on the road to global elimination of HCV and how some countries are doing despite these challenges. Below is a World Health Organization graph representing global access to HCV diagnosis and treatment.

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Source: WHO Report -Progress Report on Access to Hepatitis C Treatment; March 2018

Cost of treatment of HCV on account of the high cost of medications has always been a major problem. In the United States where drug costs are most expensive the Veterans Health Administration popularly known as the VA has managed to negotiate a deal with the drug company GILEAD, to pay $12,500 for a months supply of Harvoni one of it Hepatitis C combination regimens. This deal is not such a great bargain when compared to what GILEAD has provided to countries like Georgia, Egypt and many other low income countries, but has allowed the VA to make treatment available to all veterans. At this point the VA is working to get its hard to reach populations into care. Most veterans who get regular care from the VA and are willing to get treatment have been treated and cured.

Australia’s public health system has also negotiated a deal with various pharmaceutical companies. This agreement involved an upfront commitment of $1 billion over 5 years for Hepatitis C drugs. This involved a risk sharing agreement with pharmaceutical companies which allows these companies to pay monies back to the Australian government as rebate if their drug costs exceeds their annual limits. The details of this agreement and the structures used in the rebates were described as convoluted in an Australian government document. These agreements along with a public health drive using primary care and other non-physician providers to address hepatitis C is yielding good fruits. Australia is currently one of the 12 countries on track to achieve WHO targets of 65% reduction in mortality from hepatitis C and 90% reduction in new Hepatitis C Infections by 2030.

In Egypt the drive to elimination is using a combination of interventions. Pharmaceutical companies in Egypt have utilized an agreements with GILEAD to produce locally generics versions of its popular and widely used NS 5B Hepatitis C Polymerase inhibitor Sofosbuvir. GILEAD also provides Harvoni to Egypt at a cost close to $900 for a months supply. This as well as other agreements has allowed Egypt to drive the total cost of treatment to $84 per patient. This is less than 1% of the cost paid by US patients. This as well as encouraging local pharmaceutical businesses to develop generic medications locally. In Egypt out of pocket costs of treatment for individuals with hepatitis C in the public sector has been driven to less than $5. About 70 % of those treated in Egypt use the public sector with about 30% paying for medications either through several forms of private insurance and out of pocket. The most common regimen used in Egypt is a combination of Daclastavir a NS5A inhibitor developed by Bristol Myers & Squibb, Sofosbuvir, GILEAD’s widely used NS5B HCV RNA Polymerase inhibitor and Ribavirin an old HCV drug initially developed by Bausch Health Companies Inc 1970 then ICN (International Chemical & Nuclear Corporation) for the treatment of RSV (Respiratory Syncytial Virus). The used of discounted brand name drugs and locally produced generics as well as a nationwide public health campaign has placed Egypt as an unlikely leader in the global elimination of HCV. Egypt is currently well ahead of countries like the US in its targets towards elimination.

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By end of year 2017 only 12 countries were on track towards WHO Elimination targets. Source: Polaris Observatory – http://www.cdafound.or/polaris

In the United States many believe that poor access to specialty care could be a barrier to elimination. This is however a barrier that Australia and the VA overcame using non-specialist including non-physician providers to provide care based on clear protocols and guidance  documents. Currently there are studies underway to help develop well validated simplified standardized protocols that would make treatment easy for non-specialist as well as provide care in resource constrained settings. The VA in the US and  the Australia health system have already used systems level interventions to prove that HCV care can effectively be provided by well trained non-specialists.

Globally hepatitis C is a disease of marginalized patients with poor healthcare access, iv drug users, men who have sex with men and prison populations. In the United States prevalence rates in prisons could be as high as 10%. This is similar to other countries with prevalence of 38% in Central Asia, 35% in Australia, 18.7% in Ghana and 22.8% in Italy.  In the US, prison health systems, usually run by private companies have used various restrictions to reduce treatment among prison populations. Thus even though most public health professionals believe treatment in prisons would be technically very effective cost makes treatment in prisons mostly impossible except in a few instances.  Florida has a policy that allows treatment of patients with F-2 disease (mild liver scarring). California has awarded $106 million for the treatment of inmates with HCV. Intravenous drug users (IDUs) are the most affected by HCV, however many still refuse to offer treatment to them.

Reinfection, whilst definitely a problems has been shown to vary by patient characteristics. Most concerns about reinfection are directed at IVDUs however data suggest that MSM also have the high reinfection rates which may be similar if not higher than IVDUs. Reinfection can be mostly addressed by expansion of various harm reduction interventions such as needle exchange programs, supervised injections centers and condom use.

Overall though all viral hepatitis are highly  stigmatized diseases that most societies rather than address prefer to blame those affected. It is therefore not surprising that even in countries with resources that can be effectively harnessed towards elimination there are only small dents in the current disease burden.

One thing that we can all learn from the current California fire is this;  “Fires do not discriminate between trees and the grass, when the fire starts it burns everything in its path”.

By Dr. Leonard Sowah, an internal medicine physician in Baltimore, Maryland

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