MANILA — The second World Hepatitis Summit opens November 1 in Sao Paolo, Brazil, to take stock of countries’ progress in developing national plans for hepatitis elimination.
The number of countries with such plans has increased fivefold over the past half decade, from 17 to 82 to date. About one-third of these countries have started to allocate resources toward their agendas. Dr. Gottfried Hirnschall, director of the HIV/AIDS Department and the Global Hepatitis Program at the World Health Organization, sees that as encouraging progress, though more remains to be done.
“There is still the issue of funding the response, and it is very clear that governments will have to largely shoulder the financial burden,” Hirnschall told Devex ahead of the summit.
He urged countries to build hepatitis control into broader health policies, for example by building data systems to understand the disease burden in their country and plan a tailored response. “The push for universal health coverage under new leadership of WHO is very visible. We want hepatitis to be realized in that context,” he said.
The WHO has no plans to promote a large-scale, vertical hepatitis program. But the international community will continue to help countries scale up their responses and address gaps in the prevention, diagnosis and treatment of viral hepatitis.
In contrast to the progress being made on many diseases globally, hepatitis-related deaths continue to climb. Devex looks at the case of Asia to understand why.
Devex spoke with Hirnschall and Marc Bulterys, team leader of the Global Hepatitis Program at the WHO in Geneva, about the gaps, outstanding challenges, and ongoing work toward elimination. Here’s what you can expect from the three-day meeting.
1. Countries will reaffirm their support for the fight
Countries have been negotiating for the past few weeks on a declaration that, Hirnschall said, essentially reaffirms their commitment to the global hepatitis agenda. It will detail the current status of the epidemic and existing challenges. The document will also restate the time-bound targets in the global hepatitis strategy and call on governments to commit to action. Brazil is leading the process, and the declaration is expected to be released at the summit’s opening session.
2. The WHO will release new data on country-level plans
The WHO recently conducted a survey of countries’ preparedness to respond to hepatitis, and the agency will be releasing preliminary data during the summit. The survey offers details on countries with national plans for hepatitis response, such as the contents of the plan, whether the government has allocated funding, and which stakeholders are involved in implementation. The full results will be released either by the end of the year or early next year.
The survey could provide the hepatitis community with vital information about progress in individual countries, allowing for tailored assistance. It could also build momentum for efforts to gather country-level data to help in the hepatitis response. Countries still need to work on their surveillance systems and build hepatitis indicators, Hirnschall said.
“We have released an M&E [monitoring and evaluation] framework on which indicators countries should be looking at and measuring. We have developed normative guidance on how this best can be done. And we’re working with countries to build up their data systems,” he said.
3. Infection control remains incomplete
The WHO has observed a scaling up of hepatitis B vaccination in some countries, but immunization is often not comprehensive. For example, many countries don’t consistently offer birth-dose vaccination, which should be given to babies within 24 hours after birth as a means to stop transmission.
Addressing hepatitis C infections among injecting drug users remains another challenge. One-fourth of new infections occur among injecting drug users, Hirnschall said. The U.S., for example, has seen a tripling of new cases of hepatitis C over the past five years, tied to opioid usage by injection, according to Bulterys.
4. More cases need to be diagnosed earlier
Another key component in addressing hepatitis is early diagnosis, which facilitates early treatment. Yet, according to Hirnschall, “only about 1 in 10 of people who have chronic hepatitis B infection know their status, and only 20 percent of people [or 1 in 5] with chronic hepatitis C infection know their status.”
“We have a lot to do to improve on diagnostic tools that are available,” he told Devex. “We’re working with Unitaid on that to make cheap and affordable diagnostic tools, but also make them available and build them into health services.”
New technologies could help. The WHO has prequalified three point-of-care diagnostic tools that would provide bedside diagnosis for hepatitis C. One of them is the SD BIOLINE HCV from South Korea, which can be used by minimally trained health care workers.
Once diagnosed, patients can be introduced to treatment. Tenofovir, for example, an antiviral drug for HIV infection, can also be used on patients with hepatitis B.
5. Weighing cheap medicines versus quality assurance
Affordable medicines are a point of contention in many health issues, and hepatitis is no exception. Hirnschall said there have been encouraging successes in price reductions when it comes to some medicines for hepatitis, as well as the introduction of generic competitors. Today, there are drugs for hepatitis C treatments under $100 that can be found in Pakistan and Bangladesh.
In Egypt, a three-month treatment period that used to cost $900 can now be availed for only $150, Bulterys said.
These cheaper options are currently only being used domestically, however, as they have not yet been prequalified by the WHO for quality assurance. “It is very inexpensive to produce, but we want to make sure there is quality control,” Bulterys said.
The WHO has a database, called the Global Price Reporting Mechanism, which contains information on medicine costs in different countries. The database was originally developed for HIV drugs, but the WHO is now building it up to include hepatitis drugs.
6. The global hepatitis price tag
Due to limited data and the lack of systems in place, advocates often struggle to estimate how much it would cost to address the global hepatitis problem. Hirnschall said they’ve now done costings on the global hepatitis strategy in 2016, and the amount needed to implement the five key interventions in the strategy would be $11.9 billion. That amount assumes high-income countries will finance their own response.
Low- and middle-income countries will require annual investments of up to $4.1 billion by 2021. Cost projections extending to 2030 estimate that those investments will peak at $5.2 billion in 2026 but decline to $3.5 billion in 2030.
“As we are in late 2017, prices could change and even be lower,” he said. But he added: “What’s more important is for countries to understand not only what is the cost, but also at what point will they be able to make the case to say, ‘Wow, this is a cost-effective and possibly cost-saving intervention to scale up.’”
The WHO has released an online tool that Hirnschall said countries can use to help make an investment case for hepatitis.
7. The WHO may issue new treatment regimen recommendations
The WHO is in the process of reviewing its hepatitis C guidelines and may include new treatment regimens that have come onto the market with the potential to simplify treatment. Again, however, cost is an issue.
“Some of the regimens and drugs are not that cheap yet,” Hirnschall said. “With price reductions, even though we’ve had some encouraging developments, this is not universally true … and not yet true for newer regimens developed by some of the manufacturers.”
8. The issue of equity and access
About 3 million people were able to access a new generation of hepatitis C drugs in 2016, and 2.8 million have been introduced to treatment for hepatitis B.
But gaps remain. Over 70 million people are living with hepatitis C infection globally, according to the WHO, and only 20 percent of them know their health condition. Not all those who know their status are able to gain access to, or afford, treatment.
“We are encouraged and optimistic to see that momentum has started to build up, that a hepatitis movement, if you wish, has started to shape up,” Hirnschall said. “But, obviously, getting the services to the people who need them, there [is] still a very long way to go.”
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