Eliminating Viral Hepatitis: the Research–Policy Nexus

On 28 July, more than 150 countries will be marking World Hepatitis Day (...) to communicate the sense of urgency felt by those of us who are addressing viral hepatitis

On 28 July, more than 150 countries will be marking World Hepatitis Day with a range of high-profile events. It is a time to communicate the sense of urgency felt by those of us who are addressing viral hepatitis as researchers, service providers, patients, advocates, policy-makers and public health officials. It is also a time to take stock of recent progress and ongoing challenges.

Just over a year ago, the World Health Organization (WHO) introduced its first-ever Global Health Sector Strategy on Viral Hepatitis. The context for the strategy is notable. World Health Assembly resolutions on viral hepatitis in 2010 and 2014 charged WHO with developing a comprehensive response to this group of diseases after so many years of insufficient attention.

Regional distribution of viral hepatitis deaths

 Source: Global Health Sector Strategy on Viral Hepatitis. Stanaway and Cooke (personal communication)

In 2016, a Global Burden of Disease analysis determined that more people die each year from viral hepatitis than from HIV, malaria or tuberculosis. Almost half of these deaths (48%) are caused by the hepatitis C virus (HCV).

More people die each year from viral hepatitis than from HIV, malaria or tuberculosis

Prior to the introduction of direct-acting antiviral (DAA) drugs in 2013, there were low cure rates for people taking interferon-based HCV treatment regimens. Furthermore, notoriously unpleasant side-effects deterred many people with chronic HCV diagnoses from trying this treatment. Other people at high risk for HCV did not even bother getting tested, reasoning that a diagnosis would not be helpful since they were unwilling to take interferon. 

The new DAA regimens cure more than 90% of chronic HCV cases, with most patients taking a 12-week course of drugs that have few side-effects. Without the DAAs, it is questionable whether WHO would have introduced a strategy with the goal of eliminating viral hepatitis as a major public health threat by 2030.

The new DAA regimens cure more than 90% of chronic HCV cases, with most patients taking a 12-week course of drugs that have few side-effects

The strategy puts forth a number of quantitative targets in support of this goal, encompassing hepatitis B virus along with HCV. The HCV targets include diagnosing 90% of chronic HCV infections by 2030 and achieving a 65% reduction in HCV mortality by 2030. The strategy calls for increasing HCV treatment coverage to 80% among those who are eligible for treatment.

WHO's campaign posters for the World Hepatitis Day, 28 July 2017

Only 7% of the 71 million people with chronic HCV in 2015 received treatment

The ambitious nature of these targets becomes clear when one considers the quantitative baseline: WHO’s latest published estimates indicate that only 7% of the 71 million people with chronic HCV in 2015 received treatment. A huge component of the problem was underdiagnosis: an estimated 80% of people with chronic HCV did not know they had it.

Like most major public health challenges, eliminating HCV is a policy challenge as well

What these numbers tell us is that eliminating HCV is a public health challenge as much as it was a biomedical challenge before the advent of DAAs. Medications with high cure rates are useless sitting on shelves. And like most major public health challenges, eliminating HCV is a policy challenge as well.

This is why the first-ever Catalan hepatitis elimination summit presents such an important opportunity. The Barcelona Institute for Global Health (ISGlobal) is co-convening the September 2017 event with the Department of Health of the Government of Catalonia. The summit will be coupled with expert working group meetings focusing on two issues: HCV testing, particularly for key populations, and access to HCV treatment.

Not everyone may realise the extent to which Spain is at the forefront of addressing the policy infrastructure that is needed to drive progress against HCV. The WHO global strategy calls on countries to implement evidence-based national hepatitis plans and strategies, which can be seen as the bedrock of all viral hepatitis elimination efforts. But most countries have been slow to take this essential step; Spain stands apart for already having an HCV strategy in place since 2015.

Furthermore, only weeks ago, the Spanish government updated its HCV strategy to eliminate treatment restrictions. Now, all chronic HCV patients who are medically eligible can initiate treatment. Again, this sets Spain apart from the vast majority of countries, including a number of other European countries whose governments have imposed treatment restrictions on the basis of disease stage and illicit drug use.

The ultimate lesson is that translating research into practice requires directly addressing the policy dimensions of public health

The ultimate lesson is that translating research into practice requires directly addressing the policy dimensions of public health.

By establishing a forum to explore what this should mean in terms of specific policies and practices in Catalonia, the upcoming elimination summit will provide an exciting learning experience for stakeholders across Spain and worldwide.

Selected further reading

• Many European countries ‘flying blind’ in their efforts to eliminate viral hepatitis. Nature Reviews Gastro Hep, July 2017.
• Micro-elimination – a path to global elimination of hepatitis C. Journal of Hepatology, July 2017.
• Late presentation of chronic viral hepatitis for medical care: a consensus definition. BMC Med. 2017 May 3;15(1):92.
• Restrictions on access to direct-acting antivirals for people who inject drugs: The European Hep-CORE study and the role of patient groups in monitoring national HCV responses. Int J Drug Policy, 2017 Jul 6.
• Research priorities to achieve universal access to hepatitis C prevention, management and direct-acting antiviral treatment among people who inject drugs. Int J Drug Policy, 2017 July
• Associations between national viral hepatitis policies/programmes and country-level socioeconomic factors: a sub-analysis of data from the 2013 WHO viral hepatitis policy report. BMC Public Health, 2017.
• Road to Elimination: Barriers and Best Practices in Hepatitis C Management. Overview of the status of HCV care in Europe and Australia.
• One year into the WHO viral hepatitis strategy: are we all doing our part? Blog post by Jeffrey V. Lazarus and Kelly Safreed-Harmon. Nature Microbiology. July 2017.