It seems to be the ultimate irony that a cure has been found to treat Hepatitis C ( HCV) and we can't afford it. That the world's 180 million people infected with HCV now have access to daily tablets with tolerable side effects and could be free of the virus in up to 12 weeks is remarkable.
However, the estimated cost of achieving this at today's prices would be $US 15.1 Trillion, close to the US GDP of $US 16.7 Trillion. Add to this dilemma the nature of HCV transmission and high rates of re-infection in some settings, and the subsequent recurring costs, and this makes the task of eliminating - let alone eradicating - HCV seem unachievable. It also lends support for the need to implement other strategies which reduce transmission of infection and for the obvious need to develop a vaccine.
Professor Greg Dore from St Vincent's Hospital and the University of NSW, in Sydney Australia, provided an eloquent account of the priorities and strategies he proposes for tackling treatment as prevention. (The prevalence of chronic HCV in Australia is 280,000.)
He proposes a strategy which provides for:
- Programs to increase testing/screening (in Australia this has already been well covered with 85-95% of cases detected).
- Programs which enhance harm reduction for people who inject drugs (PWID) through needle syringe programs (NSP) and opiate substitution therapy (OST).
- Prioritised treatment so that "the transmitters", those most likely to transmit HCV - particularly the under 25yr old PWID who are more likely to share needles more often - prisoners, MSM (and pregnant women) are treated early.
- Increase treatment rates in those with more advanced liver disease who have a more imminent risk of severe morbidity and mortality.
Professor Dore modelled a scenario where 8% per year of PWID in Melbourne are treated. Using this projection he predicted elimination of HCV in Melbourne by 2027. His proposal that a rapid scale-up of treatment be implemented in the PWID group, so that high transmitters are treated contemporaneously and removed as sources of reinfection for each other, seems to provide a possible solution to this problem.
Currently there are no interferon-free HCV treatment regimes subsidised in Australia. Hopefully this will change in the near future with clinicians, stakeholders, patients, government and Pharmas negotiating prices that are more affordable, as have some of the developing countries who have used their huge economies of scale to negotiate relatively low cost supplies of HCV antiviral drugs.
We all look forward to a world free of the suffering and stigmatisation associated with HCV infection.