Only a handful of countries are on course to achieve the World Health Organization (WHO) target of eliminating hepatitis C virus (HCV) as a major public health concern by 2030, according to a study published in the Journal of Virus Eradication. Investigators estimated progress towards elimination by examining 2016 data on rates of cure after therapy with direct-acting antivirals (DAAs), HCV-related deaths and new HCV infections. An overall reduction in prevalence of 0.71% was observed in the 91 countries included in the study, and global prevalence fell by just 0.4%.
“Some countries are treating a high percentage of patients, with significant reductions in HCV epidemic size,” comment the authors. “By contrast other countries have very low rates of treatment, and new HCV infections are driving the HCV epidemics.”
Cure rates considerably outpaced the rate of new infections in North America and North Africa/Middle East. But the opposite was true in sub-Saharan Africa and Central and Eastern Europe.
More needs to be done to expand access to affordable HCV therapy, improve HCV detection and prevention and to strengthen health systems to deliver treatment, suggest the authors.
In 2016, WHO set the target of treating 80% of people with HCV by 2030 to reduce the rate of new infections by 90% in that year. If achieved, this would eliminate HCV as a major public health concern.
This is potentially achievable as treatment with DAAs can cure at least 90% of people. It has already been shown that increasing treatment rates can lead to lower infection rates. The Netherlands provided unrestricted access to DAAs for all people newly infected with HCV in 2015, leading to a 51% fall in new infections among men who have sex with men, the first reduction in HCV infections seen in this population for over a decade.
To estimate global progress towards the attainment of the WHO 2030 target, investigators examined 2016 data to assess net cure, taking into account the number of new infections, number of cures and number of HCV-related deaths.
An annual net cure rate of 7% would be needed to meet the WHO target of eliminating HCV as a major public health concern by 2030.
Of 210 countries globally, 91 had sufficient reporting data to be included in the analysis.
A total of 57.3 million people were estimated to be living with HCV in the 91 countries included in the study, representing 81% of the global HCV burden. However, only eight countries in sub-Saharan Africa were included in the study.
Regionally, the proportion of people with HCV who received DAA therapy in 2016 ranged from 8% in North America, North Africa/Middle East to just 0.1% in sub-Saharan Africa. Individual country estimates ranged from 50% in Iceland to 0.0015% in Kenya.
For countries with over 1000 people living with HCV, Australia had the highest percentage of treated people (16%). Ten countries had a treatment rate of over 7%, of which eight had a disease burden of over 1000 HCV patients. Four of these countries were in Western Europe. There were 44 countries with a treatment rate below 1%, including all eight countries from sub-Saharan Africa.
Net cure rates varied considerably by country and region. In Australia, there were 29,160 cures, 830 HCV-related deaths and 5900 new infections, meaning there were 24,090 net cures, a 12% reduction in the total epidemic size. Net cure rates ranged from 35% in Iceland to 5.6% in Russia.
Regionally, net cure rates ranged from 7% in North America to 4.3% in Central and Eastern Europe.
Ten countries had five times more people cured than new infections. In contrast, 23 countries had five times fewer people cured than new infections. This latter group included all eight countries in sub-Saharan Africa where there were 34 times more new infections than cures. Worldwide, 54 of the 91 countries had more new infections than cures.
In the 91 countries analysed, the size of the HCV epidemic decreased in 2016 by 0.7%. When the 109 other countries with suboptimal data collection were included, the global reduction in the size of the HCV epidemic was just 0.4%. “This is despite the $56 billion that has been spent on HCV DAAs since their launch,” write the authors.
The overall net cure rate for the countries included in the analysis was 0.78%, with a global net cure rate of 0.48%.
The investigators believe their findings have a number of important policy implications:
- Current treatment rates are not high enough. More therefore needs to be done to make DAAs more affordable.
- Further resources need to be devoted to HCV diagnosis and prevention.
- Investment is needed in health service capacity in low- and middle-income countries so they can cope with the intensive healthcare monitoring needed during DAA therapy.
“The inflated prices of DAAs pose a barrier to treatment in many countries,” conclude the authors.
Hill AM et al. The road to elimination of hepatitis C: analysis of cures versus new infections in 91 countries. Journal of Viral Eradication, 3: 117-23, 2017.