Sunday, October 8, 2017

Pathways to the elimination of hepatitis C: prioritising access for all

In Case You Missed It

Journal - Expert Review of Clinical Pharmacology

Pathways to the elimination of hepatitis C: prioritising access for all
Alisa E. Pedrana, Rachel Sacks-Davis, Joseph S. Doyle & Margaret E. Hellard

Received 09 Aug 2017, Accepted 20 Sep 2017, Accepted author version posted online: 25 Sep 2017, Published online: 28 Sep 2017       

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While momentum for hepatitis C elimination grows, debate continues about the most cost-effective pathway for achieving it. Much of this debate has focused on the prohibitive initial costs of direct-acting antivirals (DAAs) [1,2], which have resulted in treatment prioritization and rationing in many countries [3,4]. While some countries have successfully negotiated reduced DAA prices [5], price remains a significant barrier to scaling up access to treatments, disproportionately affecting low-middle income countries (LMICs) with high prevalence [2,4]. Modeling suggests that if treatment can be scaled to need, hepatitis C prevalence and incidence can be reduced in line with elimination targets. However, recent empirical data [2,4,6] have identified barriers to elimination, including restrictive prescribing patterns, healthcare system limitations, and inadequate national testing programs, preventing adequate treatment scale-up.

As the costs of DAAs decrease [7], other hepatitis C treatment-associated costs, and health systems limitations which have largely been overlooked until now, will become increasingly important considerations for elimination planning. In particular, effective strategies are required to increase access to testing as the necessary entry point to treatment. Routine screening and monitoring is also required to prevent endstage liver disease, reduce the risk of reinfections and prevent new infections. To achieve disease elimination for hepatitis C by 2030 we must prioritize access for all affected people, alongside delivering more integrated and flexible models of care that increase opportunities for testing and treatment across low, middle, and high-prevalence settings.

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Recommended Reading
Marshall AD, et al. Lancet Gastroenterol Hepatol. 2017
Published: 03 October 2017
Restrictions for reimbursement of interferon-free direct-acting antiviral drugs for HCV infection in Europe
All-oral direct-acting antiviral drugs (DAAs) for hepatitis C virus, which have response rates of 95% or more, represent a major clinical advance. However, the high list price of DAAs has led many governments to restrict their reimbursement. We reviewed the availability of, and national criteria for, interferon-free DAA reimbursement among countries in the European Union and European Economic Area, and Switzerland. Reimbursement documentation was reviewed between Nov 18, 2016, and Aug 1, 2017. Primary outcomes were fibrosis stage, drug or alcohol use, prescriber type, and HIV co-infection restrictions. Among the 35 European countries and jurisdictions included, the most commonly reimbursed DAA was ombitasvir, paritaprevir, and ritonavir, with dasabuvir, and with or without ribavirin (33 [94%] countries and jurisdictions). 16 (46%) countries and jurisdictions required patients to have fibrosis at stage F2 or higher, 29 (83%) had no listed restrictions based on drug or alcohol use, 33 (94%) required a specialist prescriber, and 34 (97%) had no additional restrictions for people co-infected with HIV and hepatitis C virus. These findings have implications for meeting WHO targets, with evidence of some countries not following the 2016 hepatitis C virus treatment guidelines by the European Association for the Study of Liver.
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