Lessons from an earlier battle
Viral hepatitis B and C affect as many as 500 million people globally. Of those, about 340 million are from the Asia-Pacific region - 10 times the number of people living with HIV worldwide.
Yet despite this devastating reach and the knowledge of the impact of these types of hepatitis for many decades, the global response to the disease lags far behind that of HIV. In the 30 years since the first reported Aids cases in 1981, advocacy and activism have been very successful in bringing about significant progress in prevention, control and treatment of HIV/Aids.
Leaders from the global hepatitis community recognise there are lessons to be learned from the Aids experience, and discussed this at a meeting in Taipei last month organised by the Coalition to Eradicate Viral Hepatitis in Asia-Pacific (Cevhap) and held at the 22nd Conference for the Asian Pacific Association for the Study of the Liver.
HIV expert, Professor David Thomas, director of the division of infectious diseases at the Johns Hopkins University School of Medicine in Baltimore, Maryland, delivered the keynote speech at the meeting, highlighting the following five lessons for the hepatitis community.
1. Treatment saves lives
In 1996, an effective combination of antiretroviral therapy (ART) drugs that delays the onset of Aids became available to those living with HIV in developed countries, cutting death rates of people with HIV/Aids in these countries by 84 per cent. But it wasn't until 2001, when the price of the drugs per patient fell from US$15,000 a year to US$295 - thanks to an Indian generic drug maker that sparked a price war - that developing countries had access to them.
The most widely used drug combination now costs US$64 per year. Between 2003 and 2010, figures from the World Health Organisation showed a 16-fold increase in the number of people receiving ART, with an estimated 6.6 million people in low- and middle-income countries at the end of 2010.
'With viral hepatitis, we have proved in principle that treatment saves lives as well. The question is: can we push those treatments into a broad enough proportion of the population to actually have efficacy, as has occurred with HIV?' says Thomas.
'We certainly need to improve the safety and efficacy of the treatments that we have right now. For hepatitis C, that means getting rid of Interferon - a cure which costs about US$90,000 - and replacing it with a cheaper, simpler pill that you take once a day for 12 to 24 weeks. For hepatitis B, it means extending the treatments that we have now to the people who need them.'
2. Improved treatment efficacy means improved urgency
In 2010, 119 countries reported a total of 95 million HIV tests that year alone, up from 67 million tests in 100 countries in 2009. Expanded testing and detection of infection was driven by developments in treatment efficacy, says Thomas.
'In the beginning, when many were dying from HIV, some people said, 'Look, don't bother testing people because you're just going to ruin their lives when they find out they have HIV; let them live in peace until they die.' But when treatments were effective and could save lives, everything changed.
'Once ART was discovered, in the United States, we changed our recommendations so that everyone from age 13 to 64 was to have an HIV test. Throughout Sub-Saharan Africa there was a paradigm shift: instead of occasionally offering testing, testing was actually the expectation - you had to opt out of it.'
With hepatitis C, advances in treatment have been made and celebrated, with drugs offering up to a 70 per cent cure. But Thomas says only a small fraction of the estimated 170 million individuals with chronic hepatitis C infection know they are infected; far fewer ever start treatment. In the US, from 2002 to 2007, only about 663,000 of the four to five million people with chronic hepatitis C were treated.
'When we take this kind of perspective, we haven't done anything yet. There's no reason to stop just because we can cure an individual when the population is not benefitting. We certainly need different models for hepatitis control, to expand testing and treatment access, and we need programmes to make care more affordable.'
3. You reap what you sow
'There's a dose-response relationship between the amount of effort and funding, and the outcome. Prior to 2002, there'd been approximately 65 million persons infected with HIV worldwide, and 25 million deaths and 14 million orphans because of its devastating effects. The treatments were effective, but they weren't working where most of the infections were.
'So the Global Fund devoted some money to treatment, and the US put in US$15 billion over five years to fight HIV, malaria and TB. About half of it went into HIV testing and treatment. In the following years, there was a 16-fold increase in ART use in Africa. So we've taken an effective treatment, put resources behind it, pushed it into an area where it's needed, and it has reduced mortality.
'Hepatitis C has surpassed HIV in deaths in the US, but the resources put into it are hardly anything compared to what's put into HIV. So it's not surprising that we haven't had the same impact, because what you reap is what you sow, and we're not sowing in chronic hepatitis.'
4. There's more to disease than just the virus
'With HIV, even after viral suppression was achieved, an HIV infected person still has a diminished lifespan because there's more to it than just the virus. In Denmark, for example, HIV infected persons taking ART still have lower life expectancies than the general population. In the same way, we'll cure hepatitis C, but still have to worry about liver cancer and some of the end organ effects. It's true for hepatitis B as well, and persons with cirrhosis.'
5. Prevention is better than treatment
Thomas cites the success of Taiwan's universal hepatitis B vaccination programme for newborns started in 1984, which reduced infection rates in children aged below 15 from 9.8 per cent in 1984 to 0.7 per cent in 1999.
'This lesson needs to be taken to HIV in this instance. In recognising the potential value of the hepatitis B vaccine, Taiwan was essentially able to reduce incidence of liver cancer even in children, by a campaign that was extraordinarily effective at the population level. I think this is one of the most spectacular achievements that I know of, right up there with the saving of millions of lives with ART use in Sub-Saharan Africa.'