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The cost of eliminating hepatitis C in Pakistan
Effects and cost of different strategies to eliminate hepatitis C virus transmission in Pakistan: a
modelling analysis
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Open AccessPublished:March, 2020
https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30003-6/fulltext?dgcid=raven_jbs_etoc_email
Summary
Background
The WHO elimination strategy for hepatitis C virus advocates scaling up screening and treatment to reduce global hepatitis C incidence by 80% by 2030, but little is known about how this reduction could be achieved and the costs of doing so. We aimed to evaluate the effects and cost of different strategies to scale up screening and treatment of hepatitis C in Pakistan and determine what is required to meet WHO elimination targets for incidence.
Methods
We adapted a previous model of hepatitis C virus transmission, treatment, and disease progression for Pakistan, calibrating using available data to incorporate a detailed cascade of care for hepatitis C with cost data on diagnostics and hepatitis C treatment. We modelled the effect on various outcomes and costs of alternative scenarios for scaling up screening and hepatitis C treatment in 2018-30. We calibrated the model to country-level demographic data for 1960-2015 (including population growth) and to hepatitis C seroprevalence data from a national survey in 2007-08, surveys among people who inject drugs (PWID), and hepatitis C seroprevalence trends among blood donors. The cascade of care in our model begins with diagnosis of hepatitis C infection through antibody screening and RNA confirmation. Diagnosed individuals are then referred to care and started on treatment, which can result in a sustained virological response (effective cure). We report the median and 95% uncertainty interval (UI) from 1151 modelled runs.
Findings
One-time screening of 90% of the 2018 population by 2030, with 80% referral to treatment, was projected to lead to 13⋅8 million (95% UI 13⋅4-14⋅1) individuals being screened and 350 000 (315 000-385 000) treatments started annually, decreasing hepatitis C incidence by 26⋅5% (22⋅5-30⋅7) over 2018-30. Prioritised screening of high prevalence groups (PWID and adults aged ≥30 years) and rescreening (annually for PWID, otherwise every 10 years) are likely to increase the number screened and treated by 46⋅8% and decrease incidence by 50⋅8% (95% UI 46⋅1-55⋅0). Decreasing hepatitis C incidence by 80% is estimated to require a doubling of the primary screening rate, increasing referral to 90%, rescreening the general population every 5 years, and re-engaging those lost to follow-up every 5 years. This approach could cost US$8⋅1 billion, reducing to $3⋅9 billion with lowest costs for diagnostic tests and drugs, including health-care savings, and implementing a simplified treatment algorithm.
Interpretation
Pakistan will need to invest about 9⋅0% of its yearly health expenditure to enable sufficient scale up in screening and treatment to achieve the WHO hepatitis C elimination target of an 80% reduction in incidence by 2030.
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The cost of eliminating hepatitis C in Pakistan
Open AccessPublished:March, 2020
https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30036-X/fulltext?dgcid=raven_jbs_etoc_email
In 2016, the World Health Assembly pledged to eliminate hepatitis C virus, a major public health threat, by 2030.1
To achieve this ambitious goal, 90% of all patients with hepatitis C must be diagnosed in a timely fashion and about 80% of all eligible patients must be treated with direct-acting antivirals. Pakistan has the second-largest burden of hepatitis C globally, with a nationwide prevalence of 4⋅8%.2
Despite the availability of generic direct-acting antivirals in Pakistan and an accompanying reduced cost of treatment, the prevalence of hepatitis C remains persistent, with no evidence of decline.3
One of the reasons for this persistence is the absence of a comprehensive, population-wide screening programme that can identify the missing millions of people who require treatment.
To set diagnosis and treatment targets for hepatitis C elimination in Pakistan, Aaron G Lim and colleagues4present in The Lancet Global Health projections from a revamped deterministic model of the spread and control of hepatitis C. The new, dynamic model incorporates important new parameters, such as the cascade of care and local cost data. The study compared four possible strategies to the status quo. Modelling showed that if the status quo was to be maintained, hepatitis C prevalence and incidence would remain unchanged, whereas a comprehensive, one-time screening programme for 90% of the 2018-30 population (14 million per annum) with an 80% referral rate to treatment (350 000 patients) would decrease incidence by 26⋅5%. The numbers, while astounding, are not new. The same group previously suggested that large-scale screening coupled with the treatment of 880 000 patients per annum was needed to attain WHO's 2030 target.5
Alternative modelling by Chhatwal and colleagues6 suggests that the number needing screening might be even higher at 25 million per annum to diagnose 900 000 cases and treat 700 000 patients per year.
The novel message of the study by Lim and colleagues is that by prioritising the aforementioned comprehensive screening to higher prevalence groups (people who inject drugs and adults aged ≥30 years), increasing the rates of referral (with minimal loss to follow-up), and introducing rescreening for high-risk groups (which in turn would increase the total number screened per annum), WHO's targets for decreasing the incidence of new hepatitis C infections by 80% can be met. However, even the most aggressive strategy cannot tackle the lofty goal of a decrease in hepatitis C-related mortality by 65% by 2030.
Although the findings are illuminating, the numbers needed to screen and treat might be far larger in reality; the model does not consider that the most at-risk groups in the country are paradoxically those receiving treatment in medical centres. Indeed, unsafe therapeutic injections and nosocomial transmission are bigger risk factors for hepatitis C transmission than intravenous drug use.7, 8
An example of this trend was the 2019 outbreak of HIV amongst children in Larkana, Pakistan that was traced back to negligent practices at the health-care centres.9
This example also challenges the underlying assumption that the largest at-risk group consists of adults older than 30 years.
Lim and colleagues also did financial modelling in their analysis and show that it would cost the national exchequer about US$8 billion. The best-cost scenario, incorporating a discount from the use of future cheaper direct-acting antivirals and diagnostics alongside savings from implementing a simplified treatment pathway, would still require an investment of 9% of Pakistan's health expenditure for the 2017-18 fiscal year. However, as the authors acknowledge, this projected figure ignores the additional costs associated with the establishment of the appropriate infrastructure, training, and transport facilities. In a resource-limited setting, the allocation of the projected figures coupled with overheads appears highly challenging.
Perhaps some of this cost may be offset by a public information campaign that discourages high-risk behaviour. The impact of such a strategy is not addressed by this model and might best be captured by agent-based modelling. Such modelling could help researchers and policy makers to understand the network effects that must be leveraged to facilitate the participation of targeted high-risk groups, alongside the broader public, in the prevention, diagnosis, and treatment of hepatitis C.
In Pakistan, the control of hepatitis has so far remained a low political priority, with poor implementation of health-related policies and government-sponsored treatment programmes by the devolved provincial health ministries. There is an urgent need for a central decision body to set guidelines and recommendations that can simplify the treatment pathway and, with the education and recruitment of non-specialists, facilitate the mass screening and treatment effort proposed by Lim and colleagues. Inspiration for such a paradigm shift could be drawn from the hugely successful hepatitis C control programme in Egypt.10
Such a body must also be empowered to federally negotiate discounted procurements for the programme in an accountable and transparent manner.
Despite the barriers to an effective strategy, there are grounds for optimism. The establishment of the National Blood Transfusion Authority in Pakistan has been a major development that addresses one of the biggest sources of infection in the country: contaminated blood units. Injection safety, another major concern for transmission, is also being addressed with the introduction of auto-disable syringes. Together with the newly announced Prime Minister's hepatitis C control programme, all of these steps serve as important groundwork for the challenging work ahead.
We declare no competing interests.
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