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• W2912671403 abstract "The introduction of direct-acting antiviral agents in 2013 revolutionised the treatment of hepatitis C virus (HCV) infection.1Manns MP Buti M Gane E et al.Hepatitis C virus infection.Nat Rev Dis Primers. 2017; 3: 17006Crossref PubMed Scopus (275) Google Scholar With duration of therapy as short as 8 weeks, few side-effects, the fact that more than 90% of patients can be cured, and more affordable drug prices following the introduction of generics, treatment has become a realistic option for many people living with HCV infection. In 2016, approximately 1·5 million people received HCV treatment.2WHOProgress report on access to hepatitis C treatment Focus on overcoming barriers in low- and middle-income countries. World Health Organization, Geneva2018Google Scholar These treatment-related developments along with an improved understanding of the substantial global morbidity and mortality attributable to viral hepatitis led to increased advocacy for more action to address hepatitis.3Stanaway JD Flaxman AD Naghavi M et al.The global burden of viral hepatitis from 1990 to 2013: findings from the Global Burden of Disease Study 2013.Lancet. 2016; 388: 1081-1088Summary Full Text Full Text PDF PubMed Scopus (908) Google Scholar Most notably, in 2016, the 194 member states of WHO adopted the first-ever global hepatitis strategy, which framed its targets in the context of elimination, defined as a combined 90% reduction in hepatitis B and HCV incidence—comprising a 95% reduction in hepatitis B incidence and an 80% reduction in HCV incidence—and 65% reduction in mortality by 2030.4WHOWHO global health sector strategy on viral hepatitis. World Health Organization, Geneva2016Google Scholar The strategy is now being adapted into national hepatitis elimination plans and some countries are on track to reach the targets.5Hill AM Nath S Simmons B The road to elimination of hepatitis C: analysis of cures versus new infections in 91 countries.J Virus Erad. 2017; 3: 117-123Crossref PubMed Google Scholar However, questions remain on whether these goals are attainable on a global scale and what it will take to achieve them. Alastair Heffernan and colleagues in The Lancet help to address these questions.6Heffernan A Cooke GS Nayagam S Thursz M Hallett TB Scaling up prevention and treatment towards the elimination of hepatitis C: a global mathematical model.Lancet. 2019; (published online Jan 28.)http://dx.doi.org/10.1016/S0140-6736(18)32277-3Summary Full Text Full Text PDF PubMed Scopus (161) Google Scholar The authors developed a mathematical model that projects the impact on HCV-related incidence and mortality of four additive intervention scenarios: (1) implementation of comprehensive blood safety and infection control measures; (2) expansion of harm reduction services (opioid substitution therapy and needle and syringe programmes) for people who inject drugs (PWID); (3) provision of treatment for all people currently diagnosed with HCV infection, regardless of disease stage; and (4) expansion of HCV testing such that 90% of all people with HCV infection are diagnosed and offered treatment by 2030. To do this, the authors developed a model that uses sophisticated statistical methods and relies on country-specific estimates of HCV prevalence and rates of HCV testing and treatment as of 2015. The model also accounts for HCV reinfection risk and the prevention effect of HCV treatment. The authors conclude that elimination of HCV as defined in the WHO strategy is possible, albeit by 2032, and would prevent 15·1 million (95% credible interval 13·8–16·1) HCV infections and 1·5 million (1·4–1·6) deaths by 2030. However, elimination is only achievable by the combined interventions (scenario 4), which would prevent 80% of infections in the non-PWID population, provide harm reduction services to 40% of all PWID, and expand HCV diagnosis and treatment to 90% of the infected population. Progress would vary geographically, and regions with a high proportion of HCV incidence among PWID would not reach the incidence elimination target until after 2050. Finally, just four countries (China, Egypt, India, and Pakistan) have an outsized influence on reaching these targets because of their large populations of people with HCV infection. If these countries fail to implement all four interventions, the WHO incidence elimination target will not be reached globally until nearly 2050. The principal limitation of the analysis by Heffernan and colleagues relates to the uncertainty of the data inputs to their model. These are not measured values but rather are based, themselves, on models or, in some cases, on expert opinion.7Polaris Observatory HCVGlobal prevalence and genotype distribution of hepatitis C virus infection in 2015: a modelling study.Lancet Gastroenterol Hepatol. 2017; 2: 161-176Summary Full Text Full Text PDF PubMed Scopus (1420) Google Scholar Furthermore, for countries with no available data, estimates were borrowed from neighbouring countries. Uncertainty in these estimates would influence the dates by which the targets would be met but should have less effect on the estimated impact of the different interventions because these rely primarily on the efficacy of the interventions rather than on country-specific information. The concept of eliminating hepatitis is gaining traction with the adoption of the WHO strategy, mention of “combating hepatitis” in the Sustainable Development Goals, and expansion of hepatitis services in some countries.8UNTransforming our world: the 2030 Agenda for Sustainable Development. United Nations General Assembly, New York, NY2015Google Scholar Thus, it is encouraging that the analysis by Heffernan and colleagues shows that this concept is achievable. However, their analysis also indicates that the road to elimination will be difficult. The required expansion of hepatitis services will require political will and substantial new investments from national budgets and global funding sources. The authors do not address the cost of elimination, but WHO estimated that implementing its strategy would cost US$11·9 billion for the period 2016–21.4WHOWHO global health sector strategy on viral hepatitis. World Health Organization, Geneva2016Google Scholar 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. I declare no competing interests. Scaling up prevention and treatment towards the elimination of hepatitis C: a global mathematical modelFurther improvements in blood safety and infection control, expansion or creation of PWID harm reduction services, and extensive screening for HCV with concomitant treatment for all are necessary to reduce the burden of HCV. These findings should inform the ongoing global action to eliminate the HCV epidemic. Full-Text PDF Open Access" @default.
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• W2912671403 title "How feasible is the global elimination of HCV infection?" @default.
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