In the first few years of this century, the country of Georgia, in the Caucasus region between Europe and Asia, was plagued by civil war, economic instability and a number of severe aftershocks—including a surge of hepatitis C infections. Today, its hepatitis C elimination programme, the first of its kind in Europe, is becoming an example of an effective approach to beating back the epidemic at the country level.
Georgia has the third highest hepatitis C infection rates in the world. But in working with Gilead Sciences, the producer of the drug sofosbuvir, through an innovative public-private partnership, the government has provided new treatment to 40,000 people, curing 84 percent of them. As part of this programme, which included improvements in monitoring, surveillance and screening, the country was able to gain a better understanding of the prevalence of the disease. Previous estimates were based on data captured 15 years ago.
Georgia, however, is an exception. Although we have new hepatitis C treatments that can be up to 100% effective for a 12-week course, they simply are not getting to those who need them. Why? Well for starters, more than 70% of estimated 71 million suffering with hepatitis C live in low- and middle-income countries where access to testing, let alone treatment, is limited. Hepatitis C also is a disease of poverty; the easiest ways to become infected involve sharing needles while injecting drugs or being treated with outdated medical equipment—often found in locations with underfunded health systems. Intravenous drug users do not often have consistent access to medical services—even for a three-month stretch—and underfunded health systems do not often provide consistent care.
The initial, extremely high price of new drugs has been a major barrier to access, but there are some bright spots on the horizon. Egypt, with the world’s highest hepatitis C burden, is supplying locally-produced hepatitis C drugs to its patients, and has achieved impressive coverage rates. Gilead Sciences signed licensing agreements with 11 Indian manufacturers to locally produce sofosbuvir for developing countries, and 10 generic companies are working through the Medicines Patent Pool to develop low-cost versions of Bristol-Myers Squibb’s daclatasvir, which works best when paired with sofosbuvir. One hundred and twelve countries stand to benefit from the MPP deal, one of them Indonesia. The government just approved the treatment for its 1.3 million hepatitis C patients and expects to rollout these affordable curative regimens in early 2018.
As a result of generic competition, prices are dropping. At the end of October, Médecins Sans Frontières announced it had secured a price of $120.00 for a three-month course of sofosbuvir-daclatasivr, a dramatic cut from a $147,000 price point for the medicines in 2013.
Of course, treatment gains only go so far. Without proper systems in place to prevent and detect the disease, we cannot hope to eliminate hepatitis C in this generation. Countries are making good progress in keeping blood supply safe and improving injection safety. Hepatitis C diagnostics costs such as laboratory based tests for HCV antibodies are relatively low, but they require trained personnel and modern equipment. An estimated 57 million people are unknowingly living with the disease. Reaching them must be part of an international effort to stop hepatitis C in its tracks.
The picture of hepatitis C today looks similar to that of HIV/AIDS at the end of the last century, with some remarkable differences. HIV and hepatitis C affect marginalized populations, and both are challenging to pinpoint, with silent infections that can lie dormant for decades. In both HIV and hepatitis C, new better regimens revolutionized the field—from HAART for HIV in the mid-1990s to hepatitis C direct-acting antivirals of today. However, it took between five and 10 years before new HIV drugs reached low and middle-income countries as quality-assured generics. In contrast, countries like Egypt, Pakistan and India are already benefiting from low-cost options of new hepatitis C technologies.
While there is no cure for HIV, which remains a chronic illness, we have at our disposal effective remedies for hepatitis C if we can deliver them to all patients in need. Unlike HIV treatment which requires a life-time commitment, the battle against hepatitis C can be won over the course of a season. Community involvement and commitments from national governments to eliminate the disease through coordinated prevent, screen, treat and monitor programmes are the way forward. If countries like Georgia are any proof, this is doable.