New data released at this year's World Hepatitis Summit in Sao Paulo, Brazil (1-3 November) shows that Australia is currently on track to eliminate hepatitis C thanks to its huge efforts to enable population-wide access to treatment. However, the challenge will be to keep annual treatment numbers high enough to eliminate the virus by 2030. For hepatitis B, progress is slower and more challenges remain.
The latest estimate from the Polaris Observatory (Center for Disease Analysis Foundation, Lafayette, CO, USA), which has been verified by Australian experts, shows Australia had some 202,000 people living with chronic hepatitis C infection at the end of 2016. Thanks to a pioneering risk-sharing agreement between the Australian Government and Pharmaceutical companies for the new directly acting antiviral drugs (DAAs), beginning March 2016, all Australian adults are now able to access government-funded treatment. It is thought over 32,000 patients accessed treatment from March 2016 to December 2016, around 1 in 7 of the total infected population nationwide.
Following this agreement, huge numbers of people came forward for treatment immediately (some 5,000 in March 2016 alone). However, the number treated each month has steadily declined, from over 5,000 in March 2016 to less than 2,500 in March 2017, with signs the number will decrease further still. The Polaris estimate shows that Australia must treat around 20,000 patients with hepatitis C per year to reach the WHO elimination target it endorsed (a reduction of new hepatitis B and C infections by 90% and mortality by 65% by 2030). Polaris predicts annual treatment numbers for HCV could fall to 14,000 by 2018.
"Australia set off at a cracking pace on the journey to elimination of hepatitis C due to our unrestricted and easy access to treatment," says Helen Tyrell, Chief Executive Officer, Hepatitis Australia. "From March 2016, when the cures became available, to December of that year around 14% of all people living with hepatitis C commenced treatment. However, the pace has slowed dramatically over time."
She adds: "Worryingly, the latest estimates from the Polaris Observatory should be taken as a clear warning that the elimination of hepatitis C is unlikely to be achieved by 2030 if we continue 'business as usual'. What we need now is a rapid scale up of a suite of programs to help connect all people with hepatitis C to the new cures while also continuing to prioritise evidence-based prevention. Provided Australia invests in this work and maintains a strong partnership approach across government, the community, clinicians and researchers, we can reach the goal of elimination of hepatitis C by 2030."
Australia has a very high diagnosis rate (three quarters of those with hepatitis C know they are infected, compared to 44% across rich countries generally and 1 in 5 globally). Thus, it is essential that efforts are stepped up to bring those known to be infected into care and provided with treatment. However, many people were diagnosed years or sometimes decades ago, and were told at the time to go home and "not worry about it" due to lack of treatment options. Like all countries, Australia faces challenges to find many of these patients again and connect them with care.
There are signs of progress in key populations: thanks to DAA availability, the proportion of patients injecting drugs accessing hepatitis C care increased from 1-3% from 2012-2015 to 22% in 2016. Most States and Territories are developing programs for new treatment access in drug and alcohol services, and prisons, where around one in 3 prisoners nationwide are thought to be infected with HCV.
Furthermore, new DAAs that are effective across all genotypes of hepatitis C have recently become available on Australia's Pharmaceutical Benefits Scheme, making it even easier for treatment to be prescribed by non-specialists, including general practitioners who now write around a third of all prescriptions for DAAs.
"Australia has made a fantastic inroad into its hepatitis C epidemic, but the challenge ahead is to ensure all people with chronic hepatitis C are diagnosed and linked to care. Different approaches and models of care will be needed for different population groups to achieve this so that no group is left behind," concludes Tyrrell.
For hepatitis B, the challenges are very significant as the national response is not as well advanced as that for hepatitis C. The first National Hepatitis B Strategy was launched in 2010 some ten years after the first National Hepatitis C Strategy. Australia is succeeding in turning the tide on new infections among young people under 25 years due to an effective infant and adolescent hepatitis B vaccination program. However, with one in three of those estimated to be living with chronic hepatitis B not yet diagnosed and suboptimal monitoring (just one in six patients monitored for disease progression when all patients should be) and treatment rates (6% treated versus a national target of 15%) it is clear that a significant commitment will be required to achieve the 2030 elimination goals.
"Hepatitis B is clearly lagging well behind hepatitis C at present and Australia must accelerate efforts across the board," says Tyrrell. "We are hoping that The Third National Hepatitis B Strategy, currently in development, will be the catalyst to both articulate and invest in a range of priority actions urgently needed to get hepatitis B on a track towards elimination by 2030. Improving community knowledge and diagnosis of those in higher risk populations is a top priority combined with regular liver assessments for all people with chronic hepatitis B to help stop progression to serious liver disease, liver cancer and avoidable deaths from this often silent infection."