29 January 2024
With abstracts and scholarships for INHSU 2024 taking place in Greece this October now open, we look back at key sessions on hepatitis C from last year’s conference in Geneva.
Despite Direct direct-acting antivirals having a well-documented cure rate of 95%, access to testing and treatment continues to be sub-par across the globe. From funding issues and treatment restrictions to stigma and discrimination stopping people from seeking treatment, the research presented in Geneva shows just how much work there is still to do to make HCV treatment equitable.
Peer-facilitated telemedicine hepatitis C treatment for rural people who use drugs: results from a randomised controlled trial
In the US, less than 10 per cent of people who use drugs receive HCV treatment, primarily due to limitations in the healthcare system capacity, especially in rural areas. Andrew Seaman from the Oregon Health & Science University in the US discussed a promising study focusing on rural Oregon.
The research compared peer-assisted telehealth with enhanced standard care provided by local healthcare providers. The results clearly demonstrate the power of the model, with 85 per cent initiating treatment (66 per cent achieving cure) in the peer-assisted telehealth group, as opposed to just 13 per cent in the standard care group (with only 12 per cent achieving cure).
Key takeaways include:
- Peer-assisted TeleHCV substantially increased HCV treatment initiation and cure among rural people who use drugs
- The model de-centres medical providers and uplifts trusted voices with lived experience
- This model could be replicated in rural and lower resource settings by expanding HCV treatment access directly to people who use drugs via peers and telemedicine
- Peer-assisted TeleHCV may offer a critical new tool to inform HCV elimination strategies with dispersed populations
Hepatitis C: elimination progress, testing innovations, advanced liver disease management
We welcomed Dr. Jordan Feld, University Health Network, Dr. Olufunmilayo Lesi, WHO, Professor Mark Sonderup, UCT, Rachel Halford, The Hepatitis C Trust, and Peter Vickerman, University of Bristol who discussed the latest advancements in HCV elimination progress.
Sonderup presented data on the global burden of liver disease, with prevalence of HBV currently at 258 million globally, HCV at 58 million and Metabolic dysfunction-associated fatty liver disease (MAFLD) at 1.4 billion. Alcohol-associated liver disease was also discussed as one of ‘the Big Four’ when it comes to liver disease.
Despite these figures, there is progress being made, particularly within HCV. Jordan Feld discussed the game-changing potential of new HCV testing technology, including point-of-care antibody testing and point-of-care RNA testing. Although successful case studies of these technologies can be found in countries such as Australia and the UK, they’re yet to be approved everywhere despite their potential to streamline and speed up testing, getting more people to treatment.
Feld also explored self-testing as another promising technological development, with HCV oral fluid tests proving successful in Egypt, China, Vietnam, Georgia and Kenya. In Pakistan, a study showed high uptake but concerns over false positives. But, as Feld said, “Don’t let perfect get in the way of very, very good.” Dried Blood Spot testing was also highlighted as a powerful option, especially for rural or remote settings.
Lesi, from WHO, spoke of the importance of being able to accurately monitor progress and measure success, especially in light of the 2030 elimination goals. She presented the updated 2023 version of the country elimination validation guidance, which establishes for the first time a global criterion for Path to Elimination (PTE) for hepatitis B and C.
The guidance looks at both incidence and mortality and describes a step-wise progression through the prevention, diagnosis and treatment coverage from bronze to silver to gold tiers. The PTE offers guidance for in-country monitoring as well as a way to track global progress. Egypt was the first country to reach gold status as revealed last year.
Global availability and restrictions to direct-acting antiviral therapies for hepatitis c infection
Jason Grebely, INHSU president and professor at the Kirby Institute, UNSW, in Australia presented a new study which he co-authored with Dr. Alison Marshall. The study demonstrates that access to curative Direct-Acting Antivirals (DAAs) remains restricted in many countries, despite the cost of the drugs decreasing.
Grebely reported how data on the availability and subsidising of DAA drugs in 160 countries indicated that despite DAAs being registered in most low- and middle-income countries (LMICs) (87%), only half of those countries subsidised these drugs to make them affordable to those people who needed them. That includes countries like Nigeria (#7 burden globally) and Ethiopia (#13 globally). 50 million of the 57 million people globally living with HCV live in LMICs.
Other key takeaways included:
- Data gaps, notably in HCV RNA testing and HIV/HCV treatment, were observed in numerous countries
- The uptake of HIV and HCV testing and treatment was highly variable and often suboptimal in countries with available data
- Significantly increased investments and efforts at both national and international levels are essential for generating high-quality data on HIV and HCV care coverage for people who inject drugs
- Targeted strategies and interventions are imperative to enhance the connection between individuals who inject drugs and crucial clinical care for HIV and HCV
Leveraging funding opportunities to improve the health of people who use drugs
“This is an example of one desperately inadequately funded area of health, meeting another desperately inadequately funded area of health.”
These words from Naomi Burke-Shyne, Executive Director, Harm Reduction International, summarise the shocking lack of funding for harm reduction and hepatitis C globally, with 750x more being spent on punitive drug control.
In fact, in July of this year, The Lancet highlighted a funding gap, indicating that 6 billion dollars are required to meet the HCV elimination targets, yet, current funding only covers 10% of this amount.
Despite the clear need for more funding, the session also highlighted success stories where current funding is making a real on-the-ground impact, such as Egypt, which is dramatically scaling up harm reduction services, including OAT, and Ukraine, whose agility and innovation during wartime is astounding — with funding moving towards opening 50 mobile clinics, extra Naloxone supplies and digital initiatives like AI, chatbots and telehealth.
Funding panel takeaways include:
- Market shaping is crucial for affordable HCV testing and treatment commodities, drawing from successful models in other countries
- Appropriately priced HCV testing and treatment can redirect funds towards vital harm reduction services
- Similar market-shaping efforts should be extended to harm-reduction commodities
- Transformational advocacy is imperative to lower costs in both HCV treatment and harm reduction
- The future of harm reduction services in low- and middle-income countries (LMIC) is likely to involve integration into broader healthcare services. For example, moving away from standalone clinics for opioid agonist therapy (OAT)
- A call to provide harm reduction services at even lower thresholds for enhanced efficiency was emphasised