CROI 2020 Abstract eBook
sequelae surveillance is needed to describe baseline mortality trends so that we can better predict the impact of testing and treatment. MODELING AND EXAMPLES OF HCV ELIMINATION: POSSIBILITIES, ACHIEVEMENTS, AND NEXT STEPS Natasha Martin , University of California San Diego, San Diego, CA, USA The WHO viral hepatitis elimination strategy set ambitious targets for reducing HCV incidence and mortality by 2030. Modeling indicated these targets could be achieved at global, national, and local levels through scaling-up interventions to prevent and treat HCV. However, differences in transmission risks and historical or on-going epidemiology highlight the need for setting-specific strategies, and local data to understand these differences. Indeed, a recent modeling study indicated unsafe injecting practices among people who inject drugs will contribute to ~43% of incident HCV infections globally from 2018-2030, but varying considerably by country. In Pakistan, where transmission is highly disseminated the contribution is low, whereas in the U.S. the contribution is high due to the ongoing opioid crisis thus requiring combination harm reduction and treatment strategies. Where are we now? Several countries are implementing ambitious national elimination strategies, with interim evaluations occurring. In Egypt, from 2014 to 2018, >2.5 million people were treated, yet an even greater number were undiagnosed. In 2018, Egypt initiated the world’s largest HCV screening program, aiming to screen the entire population (101 million); 50 million were screened in the first 6 months. In Georgia, >54,000 people were treated between 2015 and February 2019 and a recent interim dynamic modeling analysis predicted the country was on track to achieve both WHO targets by 2030. In Australia, unrestricted access to direct-acting antivirals since 2016 led to widespread treatment uptake, with modeling indicating the country is on track for elimination. What is still needed? Despite progress in a few countries, the vast majority are not on track to achieve elimination. Political commitment and funding for harm reduction interventions, which additionally prevent HIV and overdose, are urgently needed. Interventions to increase diagnoses will be required as the diagnosed and untreated pool dwindles. Strategies to reduce cost are still required and will be setting-specific. For example, in Pakistan, modeling indicates elimination requires a national screening program, which could require annual expenditure of 9% of the health budget even with a simplified treatment algorithm and low DAA costs. Integration strategies could reduce costs. Robust local data systems will enable modeling to inform efficient elimination strategies and evaluation of elimination progress across the next decade. VERTICAL HEPATITIS C TRANSMISSION: DÉJÀ VU ALL OVER AGAIN? Ali Judd , University College London, London, UK Vertical transmission of HIV and hepatitis B virus (HBV) is preventable, and risk is reduced through routine antenatal screening coupled with treatment during pregnancy for all women with HIV and those with high HBV viral loads. This approach is a “double dividend” for HIV, as it provides the opportunity for pregnant women to receive treatment for their own health, while at the same time preventing vertical transmission. The number of new HIV infections in children is declining, but the global incidence of chronic hepatitis B is still largely driven by vertical and early childhood infections, and challenges remain in implementing HIV and HBV prevention and treatment strategies in pregnant women and infants in some high burden countries.
There are important differences between vertical transmission of HCV, and HIV and HBV, most notably that HCV is not associated with high infant mortality (unlike HIV), there is no vaccine (unlike HBV), and HCV is curable (unlike HIV and HBV). Efforts are being made to scale up HCV treatment worldwide, and there are ambitious HCV elimination goals. However, pregnant and breastfeeding women and their infants have been left behind in the HCV elimination agenda, as no direct acting antivirals are licensed for use in these groups. This is partly due to uncertainty regarding optimal test and treat strategies, with a weak evidence base, and many countries know little about the epidemiology of HCV in pregnant women due to the scarcity of universal antenatal HCV screening. In this talk the evidence for the effect of HCV on pregnancy and neonatal outcomes, risk of vertical transmission, potential interventions to prevent transmission, safety profiles of DAAs, screening and linkage to care for mothers and HCV diagnosis and treatment for children, will be reviewed. Key gaps in knowledge and areas for future research will be identified. There is a need to improve our understanding of the potential benefits associated with routine HCV screening and treatment in these vulnerable populations, to ensure that the double dividend approach of treatment and prevention is used in the most effective way. Fast-forwarding to the future, if we are serious about HCV elimination then we cannot neglect the potential opportunities of universal antenatal screening to treat mothers and prevent vertical transmission. We need to learn from our experience with HIV and HBV and accelerate our response. Otherwise, will it be déjà vu all over again? Despite the effective diagnostic & therapeutic tools available to eliminate hepatitis C, WHO reported that only 5M people with HCV, out of 71 million infected, had received treatment by the end of 2017. Of these, 2.5M people were treated in Egypt, 1.8M in high-income countries, and a tiny fraction (0.7M) in the rest of the world. In Egypt, a 2018 campaign aimed to screen 53M people and treat 2.2M HCV patients. This is facilitated by locally produced DAAs priced below 1% of the US price, following government rejection of DAA patents. After agreements signed between DAA patent holders and generic manufacturers, DAA prices decreased spectacularly by over 99%, from $120,000 in 2013 to $20 for 12 weeks of the same curative treatment. However, most low- and middle-income countries eligible for the lowest generic DAA prices end up paying $ 750-1,000, which does not support test and treat strategies. High and middle-income countries excluded from licensing agreements used different strategies to decrease DAA prices and implement elimination programs. In Brazil, the threat of patent rejection and local DAA production initiatives supported government pricing negotiations, resulting in the lowest prices offered by originator companies. The Malaysian government opted to grant a compulsory license to import affordable generic sofosbuvir at $237 per course, compared to $11,200 with sofosbuvir. Australia paved the way with “Netflix” type agreements aimed at reduced prices based on volumes to support test and treat programs. As demonstrated by countries on track for HCV elimination, the main challenges are detecting the 80% of people unaware of their status and providing universal access to DAAs, essential to halt HCV transmission. Simplification of HCV models of care and DAA affordability are key determinants for countries to launch elimination programs. Isabelle Andrieux-Meyer , Drugs for Neglected Diseases Initiative, Geneva, Switzerland
164 HEPATITIS C TREATMENT ON A SHOESTRING
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