Elimination of Hepatitis C: Challenges and Micro-Elimination Approach

Begüm Öztürk,

University of Istanbul, Faculty of Medicine (Istanbul, Turkey)

Hepatitis C Virus is a major cause of cirrhosis, hepatocellular carcinoma and mortality worldwide.  At least 71 million people have HCV viremia globally. (1) 50% of the global HCV burden carried in countries: China, Pakistan, India, Egypt, Russia and US. (2)

Despite the burden of the HCV, direct-acting antiviral (DAA) drugs provide a simple, well-tolerated and higly effective treatment and cure rates are approaching 100% in adherent patients. The World Health Organization has called for elimination of HCV and for the reductions in HCV-associated mortality by 65% and in the rate of new infections by 90% by 2030.  The strategy laid out national targets that include diagnosing 90% of people living with hepatitis C, treating 80% of people with hepatitis C who are eligible for treatment and reducing new infections by 90%. (3)

To achieve this goal, health care providers must deal with these challanges:

-Under-diagnosis: Unawareness. Previously baby-boomers were the majority of the cases of HCV. The increase in new HCV infection among young adults requires a shift in screening strategies, especially in those with risk factors such as intravenous drug users and HIV positive patients.

-Under-treatment: The first approved DAA, sofosbuvir had a cost of 1000 USD per pill and subsequent combinations had cost higher; making the standard 12 weeks of treatment of ledipasvir-sofosbuvir 94500 USD. This partly reduced by DAA manufacturers, but still an issue for those who do not have insurance. (4)

A micro-elimination approach can be particularly useful for to achieve national elimination through initiatives that eliminate Hepatitis C for defined segments of the population, such as within settings, geographic areas, sub-populations and  age groups. (5)

There are four criteria for a micro-elimination approach:

-There must be a plan as to how resources and services will be tailored to overcome known barriers to achieve micro-elimination goals.

-The plan should include realistic annual targets including the treatment and diagnosis levels required to achieve elimination targets.

-The plan should be developed and implemented through a multi-stakeholder process that includes government officials, health service providers and civil society representatives, including people with lived experience.

-Progress and outcomes should be monitored and publicly reported using pre-defined indicators.

Microelimination can address the gap in the number of under-diagnosed people who have HCV and don’t know by scaling up screening and diagnosis efforts. Further, scaling up treatment access has the primary beneift of curing a person of Hepatitis C and it is also suggessted to have a prevention benefit: wide-scale treatment and cure means there are fewer people with Hepatitis C, therefore fewer oppurtunites for onward transmission of the virus and a decrease in the number of new infections, also called Treatment as Prevention.

This approach along with DAA accessibility is important for the achieving WHO Goal for reducing infections by 90% in 2030.

1) Polaris Observatory HCV Collaborators. Lancet Gastroenterol Hepatol. 2017 Mar; 2(3):161-176.

2)The road to elimination of hepatitis C: analysis of cures versus new infections in 91 countries. Hill AM, Nath S, Simmons BJ Virus Erad. 2017 Jul 1; 3(3):117-123.

3)World Health Organization. Global Health Sector Strategy on Viral Hepatitis, 2016–2021. 2016 Jun

4)Terrault NA. Hepatitis C elimination: challenges with under-diagnosis and under-treatment. F1000Res. 2019;8:F1000 Faculty Rev-54. Published 2019 Jan 14.

5)Lazarus JV, Wiktor S, Colombo M et al. Micro-elimination – a path to global elimination of hepatitis C. Journal of Hepatology. 2017 Oct;67(4):655-66.

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.