New ‘treat all’ hepatitis C guidelines learn from the HIV experience
In their first treatment update since 2016, the World Health Organization (WHO) adopts a ‘treat all’ approach for hepatitis C, guided by the success of the HIV treatment experience.
A new era for hepatitis C
Every person living with chronic hepatitis C (HCV) should start treatment, no matter the disease stage, according to new advice from the World Health Organization (WHO) in updated HCV treatment guidelines released last month.
The guidance is set to usher in a new era for the 71 million people infected with HCV worldwide – much like ‘treat all’ did for HIV – fast-tracking access to new and effective direct-acting antiviral drugs (DAAs) that can cure up to 90% of cases of chronic HCV.
Global targets call for the elimination of HCV by 2030, but in 2015 just 20% of people living with chronic HCV worldwide were aware of their status and 7.4% were on treatment. Left unchecked, HCV can lead to liver cirrhosis, cancer and premature death. In 2015 there were 399,000 unnecessary HCV-related deaths.
The new guidelines call for all adults and adolescents to access DAAs, which have been transformational for the HCV response. These drugs act quickly – viral suppression occurs in a matter of weeks and they are much less toxic than older treatments. Prior to 2014, treating HCV involved using interferon-based regimens which had low cure rates, a prolonged treatment duration (6–12 months), an inconvenient administration route (via injection), significant side-effects and high costs.
But DAAs are safe and effective with high rates of sustained viral response. The ‘Treat All’ approach will simplify treatment regimens and has the potential to prevent more liver-related morbidities such as cancer and cirrhosis, as well as other wider HCV-related morbidities such as diabetes, depression and chronic renal disease.
Their extremely high cost previously put DAAs out of reach to even those living in high-income countries. But this is changing, and the reality of DAAs being widely accessible is slowly being realised. More countries are taking advantage of licensing to procure drugs, and more DAAs are coming to market, including pan-genotypic ones that combat all strains of HCV, eliminating the need for expensive genotype testing to choose which drug is suitable.
Learning from the ‘treat all’ HIV experience
When ‘treat all’ for HIV, or ‘Test-and-treat’ as it is also known, was rolled out in 2015 by the WHO, their guidance was driven by the increased clinical and public health benefits for people living with HIV. But many were concerned about operationalising such a policy and the feasibility of implementation in low- and middle-income countries where they were struggling to get antiretroviral treatment to those even at an advanced stage of the disease.
But getting the guidelines down is often the first step in galvanising political will and funding towards these challenges.
In the case of HIV, ‘treat all’ has allowed for more people to realise the health benefits of early treatment for HIV, while also rendering themselves untransmittable to others through viral load suppression. Without the guidelines in place – would countries have been so successful in bringing antiretroviral treatment access to scale? This is arguably one of public health’s biggest success stories.
In high HIV-burden low- and middle-income countries, the decentralisation of HIV treatment services was vital for increased uptake of testing and treatment services, and reducing loss to follow up. In contrast, testing and treatment of HCV has until recently generally relied on specialist-led centralised care models in hospital settings. From the health system point of view, ‘treat all’ make protocols for healthcare workers much simpler, there is no need for additional testing to decide when the person should start treatment, and with which drugs. People don’t have to go away and then come back – meaning they are actioned straight away.
Like HIV, it is hoped that the policy will be more cost-effective in the long run, by averting new infections and keeping people healthier and out of hospital with fewer morbidities.
Not forgetting people who inject drugs…
There is, however, one population that many worry could be left behind by the guidelines – people who inject drugs. It is also the one population where ‘treat all’ may not be cost-effective, nor will it decrease HCV incidence if it does not come hand-in-hand with increased access to prevention and harm reduction services.
Globally, injecting drug use may account for 23% of new HCV infections and 8% of current HCV infections are among people who inject drugs. This group suffers from stigma, discrimination, high rates of infection, criminalisation, vulnerabilities, and general difficulties in accessing services.
They need focused interventions, and vitally, increased support and access to harm reduction services. But in many places where injecting drug use is prevalent, the political will is not, and these countries will continue to be challenged by epidemics of HIV and HCV.
What is clear is that we are a long way off HCV elimination targets. These guidelines are just the first step, countries now need to take the lead to drive down new infections.
“Eliminating hepatitis will require ongoing innovation, better medicines, and improved health services,” said Dr Gottfried Hirnschall, WHO Director for HIV and Hepatitis. “Our new recommendations should pave the way for everybody with hepatitis C to access testing and curative treatment now.”
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