In the JournalsPerspective

Researchers say barriers to HCV eradication must be addressed

WHO launched its global health strategy this year with the goal of eliminating hepatitis C virus infection as a public threat by 2030. While the prevention and control of infection is feasible, many barriers exist for the complete eradication of the infection, including access to treatment and implementation of the strategy among global partners, according to a report published in Clinical Microbiology and Infection.

“One of the core elements of a global control program against hepatitis C will be the new direct-acting antiviral (DAA) drugs,” researcher Giuseppe Ippolito, MD, scientific director at the National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS in Rome, said in a press release. “These are extremely effective, with short-duration oral treatment courses achieving cure rates in excess of 90%.”

HCV control more feasible than eradication

Ippolito and colleagues gathered research from PubMed, Scopus, WHO, other outlets and experts to configure a personal interpretation of the various health strategies for controlling the HCV epidemic at a global level since DAA treatment became available. They found that preventing infection is more feasible than complete eradication and noted that transmission of the infection can be greatly reduced via effective primary prevention interventions including blood safety, provision of harm reduction services and enhanced infection control.

“Transmission of HCV through the transfusions still occurs because of poor or absent screening. … ensuring the availability of safe blood and blood products is a vital public health measure for every national government,” the researchers wrote.

Implementing proper prevention interventions also will play a key role in preventing infection. According to Ippolito and colleagues, consistent safety practices, such as safe injection measures, proper training of staff and effective waste management of sharps will help reduce transmission among patients and health care workers.

In addition to prevention, the use of DAA therapy is vital for global HCV control. The researchers wrote that high safety and efficacy rates of the DAAs from the ASTRAL clinical trials (97% to 100% virus clearance in ASTRAL-1 and ASTRAL-2) is crucial because it involves all HCV genotypes. However, a barrier to treatment, they said, are the costs of diagnostics and the drugs. Previous research and strategies for tackling pricing include treating patients with advanced liver disease first to prevent further diseases and targeting populations at greatest risk for infection (people who inject drugs, men who have sex with men, etc.).

“With effective global scale-up of the new DAA treatment alongside evidence-based interventions for primary prevention, control of HCV is a feasible goal,” the researchers wrote.

Keys to eradication

The researchers said three epidemiological conditions are essential to eradicate HCV: productive interventions to interrupt transmission, accurate diagnostic tests to identify carriers, and that humans are essential for the life-cycle of the agent. While these factors are important, the DAA treatments satisfy most of these requirements, but other requirements also must be accounted for, according to the researchers. For example, stakeholders must believe infection is a relevant health issue, the elimination/eradication program or strategy must be economically convenient, and it must be supported by institutions.

The researchers listed several barriers to the complete eradication of HCV:

  • Inadequate surveillance data are available.
  • Coverage of prevention programs is limited.
  • Few people know their hepatitis status and have access to therapies.
  • Medicine and diagnostics are unaffordable for many people.
  • A public health approach to the infection is lacking.
  • Leadership and commitment to eradication is uneven.

“Complete eradication of HCV although desirable is not yet in reach. Key barriers to elimination especially in [low to middle income countries] that will need to be addressed include current low implementation of primary prevention measures, poor definition of local HCV epidemiology and relatively weak diagnostics capability,” Ippolito and colleagues wrote.

“Effective implementation of the global hepatitis strategy will depend on effective collaboration with partners, including multilateral and bilateral donor and development agencies, funds and foundations and civil society,” they said. – by Melinda Stevens

Disclosure: The researchers report no relevant financial disclosures.

WHO launched its global health strategy this year with the goal of eliminating hepatitis C virus infection as a public threat by 2030. While the prevention and control of infection is feasible, many barriers exist for the complete eradication of the infection, including access to treatment and implementation of the strategy among global partners, according to a report published in Clinical Microbiology and Infection.

“One of the core elements of a global control program against hepatitis C will be the new direct-acting antiviral (DAA) drugs,” researcher Giuseppe Ippolito, MD, scientific director at the National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS in Rome, said in a press release. “These are extremely effective, with short-duration oral treatment courses achieving cure rates in excess of 90%.”

HCV control more feasible than eradication

Ippolito and colleagues gathered research from PubMed, Scopus, WHO, other outlets and experts to configure a personal interpretation of the various health strategies for controlling the HCV epidemic at a global level since DAA treatment became available. They found that preventing infection is more feasible than complete eradication and noted that transmission of the infection can be greatly reduced via effective primary prevention interventions including blood safety, provision of harm reduction services and enhanced infection control.

“Transmission of HCV through the transfusions still occurs because of poor or absent screening. … ensuring the availability of safe blood and blood products is a vital public health measure for every national government,” the researchers wrote.

Implementing proper prevention interventions also will play a key role in preventing infection. According to Ippolito and colleagues, consistent safety practices, such as safe injection measures, proper training of staff and effective waste management of sharps will help reduce transmission among patients and health care workers.

In addition to prevention, the use of DAA therapy is vital for global HCV control. The researchers wrote that high safety and efficacy rates of the DAAs from the ASTRAL clinical trials (97% to 100% virus clearance in ASTRAL-1 and ASTRAL-2) is crucial because it involves all HCV genotypes. However, a barrier to treatment, they said, are the costs of diagnostics and the drugs. Previous research and strategies for tackling pricing include treating patients with advanced liver disease first to prevent further diseases and targeting populations at greatest risk for infection (people who inject drugs, men who have sex with men, etc.).

“With effective global scale-up of the new DAA treatment alongside evidence-based interventions for primary prevention, control of HCV is a feasible goal,” the researchers wrote.

Keys to eradication

The researchers said three epidemiological conditions are essential to eradicate HCV: productive interventions to interrupt transmission, accurate diagnostic tests to identify carriers, and that humans are essential for the life-cycle of the agent. While these factors are important, the DAA treatments satisfy most of these requirements, but other requirements also must be accounted for, according to the researchers. For example, stakeholders must believe infection is a relevant health issue, the elimination/eradication program or strategy must be economically convenient, and it must be supported by institutions.

The researchers listed several barriers to the complete eradication of HCV:

  • Inadequate surveillance data are available.
  • Coverage of prevention programs is limited.
  • Few people know their hepatitis status and have access to therapies.
  • Medicine and diagnostics are unaffordable for many people.
  • A public health approach to the infection is lacking.
  • Leadership and commitment to eradication is uneven.

“Complete eradication of HCV although desirable is not yet in reach. Key barriers to elimination especially in [low to middle income countries] that will need to be addressed include current low implementation of primary prevention measures, poor definition of local HCV epidemiology and relatively weak diagnostics capability,” Ippolito and colleagues wrote.

“Effective implementation of the global hepatitis strategy will depend on effective collaboration with partners, including multilateral and bilateral donor and development agencies, funds and foundations and civil society,” they said. – by Melinda Stevens

Disclosure: The researchers report no relevant financial disclosures.

    Perspective

    Joop E. Arends

    Joop E. Arends

    The study by Lanini and colleagues is a very comprehensive and clear overview of the global epidemiology of HCV together with a personal interpretation of intervention strategies for achieving global control of HCV infection. The scale-up to worldwide availability and affordability of the new DAAs is very important but will not be enough to eradicate HCV. A very important quote from the paper deserves attention: “HCV transmission can be dramatically reduced through effective primary prevention interventions, including ensuring blood safety, enhancing infection control and provision of adequate harm reduction services.” The contradiction is that these control measures are most difficult to implement due to their high budget impact because the low- and middle-income countries suffer the highest HCV prevalence.


    Joop E. Arends, MD, PhD
    Chairman of the ESCMID Study Group for Viral Hepatitis, Infectious Disease physician, internal medicine and infectious diseases department, University Medical Centre Utrecht

    Disclosure: Arends reports no relevant financial disclosures.