E-DRUG: BMJ on access to hepatitis treatment
[Although written with the perspective of the UK, this has relevance to
other countries. Many low- and middle-income countries have access to
hepatitis C treatments at lower costs than in high income countries, but
issues of affordability and reaching affected patients remain. Copied as
Fair Use. DB]
Slashed cost of hepatitis C drugs spurs drive to eliminate the disease
BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k1679 (Published 16 April
2018) Cite this as: BMJ 2018;361:k1679
Access to hepatitis C virus testing and treatment should be expanded now
that effective, curative drugs are so affordable, the World Health
Organization said on 13 April. The advice comes two years after the
agency made a global commitment to eliminate all types of viral
hepatitis by 2030.1
Until recently, such a promise felt like pie in the sky. Eye watering launch
prices of drugs such as sofosbuvir of around $90 000 (�63 000;
�73 000) per patient in the US and almost �35 000 in England meant
that even rich countries were restricting access to direct acting antiviral
combinations when they launched, some five years ago.
In the UK, NHS England took action in 2015 to ensure that only the
sickest patients had access to the drugs, although they were recommended
by the National Institute for Health and Care Excellence.2 But in
January this year the agency promised that England would be the 'first
in the world' to eliminate hepatitis C by 2025, beating WHO's deadline
by “at least five years.”3
The change of policy seems to have come after NHS England secured deals
with manufacturers, reducing the cost of a course of treatment to about
£5000 a patient, says Charles Gore, chief executive of the UK advocacy
group the Hepatitis C Trust.
Worldwide, everyone over 12 should now receive treatment regardless of
the disease's severity, say imminent WHO guidelines announced on 13
April at the International Liver Congress in Paris, France.4 Prevention,
testing, and treating should be embedded in countries' broader service
delivery, they say.
Gottfried Hirnschall, director of WHO's HIV and AIDS Department and the
Global Hepatitis Programme, told The BMJ, 'We need an aggressive
stepping-up of the pace. The treatment is simple, can be given in
primary care, and is curative.'
Oral, fixed dose combinations of direct acting antiviral drugs taken
once a day for 8-12 weeks can cure six common genetic variants of the
hepatitis C virus, making expensive genotyping redundant. Elimination
rates exceed 90%, and the life saving treatment is now cost saving
because of the substantial reduction in liver cirrhosis or cancer, as
well as diseases such as depression and diabetes.
Last month the UK All Party Parliamentary Group on Liver Health outlined
'a vision for a national elimination strategy,' recommending how the
government should fund prevention, case finding, testing, and treatment.5
Gore said, “The NHS was worried about initial prices, but it’s
completely turned around, and now they’re worried about finding people
to treat.” The bloodborne infection carries a stigma because it is often
transmitted by sharing needles when injecting drugs, which was probably
more common before dangers such as HIV transmission were known about.
At least 80.000 symptomless people in England do not know that they have
the infection, he explained, and 50,000 others have tested positive but
have been lost to follow-up.
'We need to make it easy for anonymous testing, in pharmacies, for
example. And we need a public awareness campaign,' said Gore. Another
challenge, he added, is getting different healthcare commissioners to
prioritise the issue in drug services, community nursing, and prison care.
Hirnschall said that 'champion countries' such as Egypt and Pakistan,
which have some of the heaviest burdens of hepatitis C virus infection,
show what can be achieved with government action. Currently, they
account for half of the total number of people receiving treatment.
In other countries, such as Malaysia and India, compulsory and voluntary
licensing has led to generic production and lower treatment costs.
Unpublished interim trial results presented at the Paris conference
showed that generic drugs costing just $300 have shown over 95%
effectiveness in Malaysia and Thailand.6
'A cure for hepatitis C cure has sparked momentum. Patients are
demanding it. Now politicians need to step up,' said Hirnschall, calling
for a response similar to that seen with HIV: political leadership,
international solidarity, and considerable funding, as well as civil
'The alternative is more costly and will cost more lives,' he said. 'We
-� Viral hepatitis of all types kills 1.3 million people a year worldwide -
more than HIV, malaria, or tuberculosis.
-� Last year 1.7 million people became infected with hepatitis C, and 1.5
million were cured.
-� Only three million of the 71 million people infected with hepatitis C virus
in 2017 had access to direct acting antiviral drugs, and only 20% of people
know their status.
World Health Organization. Global health sector strategy on viral hepatitis,
2016-2021. June 2016.
Gornall J, Hoey A, Ozieranski P. A pill too hard to swallow: how the NHS is
limiting access to high priced drugs. BMJ2016;354:i4117.
NHS England. NHS England sets out plans to be first in the world to eliminate
hepatitis C. 29 Jan 2018.
World Health Organization. Hepatitis C: simplified curative treatments can
drive global scale-up. 13 April 2018.
All-Party Parliamentary Group on Liver Health. Inquiry report: eliminating
hepatitis C in England. March 2018.
Drugs for Neglected Diseases Initiative. New affordable hepatitis C combination
treatment shows 97% cure rate. 12 April 2018.