From 2016 to 2017 worldwide HCV prevalence dropped meekly from 69.6 million to 68.3 million, a decline of only 2%, far too little to reach the goal of wiping out HCV infection by 2030 . University of Liverpool and Imperial College London researchers figured that 6 to 7 million people with HCV must be diagnosed and treated each year to begin to contain the worldwide HCV epidemic.
Direct-acting antivirals (DAAs) can cure more than 90% of HCV infections, a potency that inspires hopes of shutting down the global HCV epidemic. World Health Organization (WHO) officers set a goal of diagnosing 90% of people with HCV worldwide by 2030 and treating 80% of infected people.
The Liverpool/London team used 2016 country-level rates of HCV diagnosis and treatment to see if the world is "on the road to elimination of HCV." From the Polaris Observatory 2016 (http://www.polarisobservatory.org/), they gathered national data on new HCV infections, percentage diagnosed, numbers treated and cured (assuming a 90% sustained virologic response rate), and HCV-related and non-HCV related deaths in the HCV population. With these data, the researchers aimed to chart the change in HCV prevalence from 2016 to 2017, years with widening availability of DAAs.
HCV diagnosis rates in 2016 substantially lagged the WHO 2030 target of 90%: 44% in high-income countries, 17% in upper middle-income countries, 15% in lower middle-income countries, and 9% in low-income countries. The researchers identified only 10 countries in which more than 5 people were cured for each new HCV infection detected in 2016: Qatar, Iceland, Israel, Portugal, Canada, Spain, Japan, Australia, USA, and Egypt. In contrast, 23 countries had more than 5 new HCV infections for every 1 patient cured in 2016.
Among 7 global regions, five have a net drop in HCV prevalence from 2016 to 2017: Asia/Pacific, Central/South America, North Africa/Middle East, North America, and Western Europe. Two regions have a net increase in HCV prevalence from 2016 to 2017: Central/Eastern Europe and Sub-Saharan Africa. The investigators calculated a global HCV prevalence of 69,563,426 in 2006 and 68,257,207 in 2017, a decline of 1,306,219 or 1.9%. From 2016 to 2017, HCV prevalence fell substantially in Australia (-13%), Japan (-13%), Egypt (-11%), Spain (-9%), and the United States (-9%), while rising 4% in Russia and 1% in India.
Even countries doing well in diagnosing and treating HCV may have problems ending their epidemics because of diagnostic burnout--the stage where no more newly diagnosed people are available for treatment. The Liverpool/London team projected that Spain could reach diagnostic burnout in 2022, Brazil in 2025, and Portugal in 2026.
The researchers cautioned that this kind of analysis has a few limitations: (1) Estimated HCV incidence (new infections) and prevalence are changing. (2) Current diagnosis and treatment rates may change. (3) Many people may be diagnosed with HCV but unable to access or afford DAAs.
The Liverpool/London investigators concluded that the 2% dip in HCV prevalence from 2016 to 2017 is too small to achieve HCV elimination by 2030. They believe 6 to 7 million people need to be diagnosed with HCV and treated each year to have a meaningful impact on the epidemic. Harm reduction programs should be intensified, they urged, to lower HCV infection rates.
The researchers observed that sofosbuvir/daclatasvir can now be produced for under $50 for a 12-week course. At that price they figured it would cost $3.5 billion to treat all 70 million people with HCV across the world. Global sales of HCV DAAs from the first quarter of 2014 to the second quarter of 2017 totaled $66 billion, or an average $1.6 billion per month. Thus if all 70 million people with HCV got treated with a $50 course, the cost would be equivalent to about 10 weeks of current commercial DAA sales.
1. Hill AS, Nath S, Simmons B. The road to elimination of hepatitis C: analysis of SVR versus new HCV infections in 91 countries. 16th European AIDS Conference. October 25-27, 2017. Milan. Abstract PS16/5.