AUSTRALIA is unlikely to hit the World Health Organization’s (WHO) 2030 target for the elimination of hepatitis C as a public health threat unless the identification and testing of people exposed to the virus is increased by 50%, according to the authors of research published online today by the Medical Journal of Australia.
In 2015, the first WHO viral hepatitis strategy set specific targets: that the incidence of hepatitis C virus infections be reduced by 80% and hepatitis C-related mortality by 65%. A major strategy for achieving those targets was to increase access to highly effective direct-acting antiviral (DAA) treatments.
Researchers from the Burnet Institute and St Vincent’s Hospital, Melbourne, set out to assess progress in Australia toward the 2030 WHO hepatitis C elimination targets 2 years after the introduction of DAAs.
They analysed quarterly data on government-subsidised hepatitis C RNA testing and hepatitis C treatment between January 2013 and June 2018. Changes in testing and treatment levels associated with DAA availability were assessed, and the impact by 2030 of different levels of testing and treatment were estimated. They wanted to measure hepatitis C prevalence among people who inject drugs; annual hepatitis C incidence relative to 2015 levels; and projections for the hepatitis C care cascade in 2030.
“Australia is one of only a few countries that have had unrestricted access to DAAs for several years,” wrote the authors, led by Dr Nick Scott, from the Burnet Institute.
“In 2016, the Australian government provided about $1.2 billion to fund DAA treatments over 5 years, so that every Australian with hepatitis C could receive treatment with low out-of-pocket cost to the patient ($39.50 per month or $6.40 per month for concession holders, and no out-of-pocket costs for Indigenous Australian patients).
“DAAs were made available without restrictions according to disease stage or risk behaviour, and re-infected people were allowed to re-commence treatment. In addition, broad access to treatment was ensured by policies that increased therapeutic capacity, including treatment of patients without significant liver disease by non-specialist general practitioners in primary care.”
Scott and colleagues found that the mean annual number of treatments initiated for people with hepatitis C increased from 6747 during 2013–2015 (before the introduction of DAAs) to 28 022 during 2016–18; the mean annual number of diagnostic RNA tests increased from 17 385 to 23 819.
“If current trends in testing and treatment continue (ie, 2018 testing numbers are maintained but treatment numbers decline by 50%), it is projected that by 2030 only 72% of infected people would be treated (by 2025 all people diagnosed with hepatitis C would be treated),” they wrote.
“The incidence of hepatitis C in 2030 would be 59% lower than in 2015, well short of the WHO target of an 80% reduction.”
The authors wrote that their findings suggested that most treatments were prescribed to people who had been diagnosed for some time.
“If treatment is predominantly of people who have been diagnosed some time ago, some people with newly acquired infections may be missed,” Scott and colleagues wrote.
“In Australia, people with newly acquired infections are likely to be people who inject drugs, as sharing injecting equipment is the major route for HCV transmission, and low treatment uptake in this group would have consequences for overall viral transmission.
“While data from the Australian Needle Syringe Program Survey indicate that the prevalence of recent hepatitis C treatment (during the past 12 months) among people who inject drugs has increased from less than 3% before DAAs to 36% in 2017, our findings suggest that a subgroup of people who inject drugs with newly acquired infections is being missed.
“Our modelling suggests that hepatitis C RNA testing in Australia would need to increase by at least 50% for the WHO elimination targets to be achieved,” they concluded.
“To eliminate hepatitis C as a public health threat in Australia by 2030, hepatitis C elimination programs should maintain treatment uptake by focusing on increasing testing and linkage to care.”
- Cate Swannell
- Medical Journal of Australia