While there is a growing consensus that
everyone with hepatitis C can benefit from treatment regardless of stage of
liver disease, some daunting barriers remain, including the high cost of
treatment and the fact that many people with viral hepatitis have not been
tested and diagnosed.
Looking at treatment cost, Andrew Hill from
the University of Liverpool presented an update to his analysis
of the cost to produce direct-acting antivirals for hepatitis C.
Generic
sofosbuvir is now being produced by several manufacturers and the cost is
coming down more quickly than expected. Originally the cost of the active
pharmaceutical ingredient was US$9000/kg, but in July the first order came in
at $4000/kg. He predicted a cost of $211 for a 12-week course by the end of
2015 – compared with the list price of $84,000 in the US (though many payers
receive substantial discounts).
Daclatasvir (Daklinza) is easier to make and requires
a smaller amount for treatment, yet in the UK it cost more than diamonds –
$53,000 vs $48,000 for the 5g needed for a 12-week course of treatment, Hill
said. He projected that the cost of daclatasvir could come down to $107 by the
end of the year.
Widespread
access to HIV treatment – which has now reached 15 million
people – is one of
the greatest success stories in medicine. "This should not stand alone,
but be repeated for mass treatment of hepatitis B and C – and this time more
quickly," Hill urged. These reduced costs "could make universal HBV
and HCV treatment in lower resource settings a realistic goal."
The co-infection
meeting concluded with a panel of experts discussing public health advocacy and
access to hepatitis C treatment.
"It is not a question of whether it's feasible, it's a
question of how can we make it feasible." Andrew Ball, World Health
Organization
Andrew Ball
from the World Health Organization (WHO) noted that hepatitis B and C have a
health burden comparable to other communicable diseases like HIV and tuberculosis
(TB), but they don't receive as much attention or funding. "Countries
mostly address hepatitis B and C as an individual clinical issue, not a public
health issue," he said.
WHO's goal is a
90% reduction in hepatitis B and C incidence by 2030, but the technologies we
have today are not going to get us there. "It is not a question of whether
it's feasible, it's a question of how can we make it feasible," he
stressed.
"I don't
think we'll see dedicated international disease-specific funding" for
hepatitis B and C as we did for HIV, he cautioned. "The future is going to
be looking at domestic solutions – but even in a country like Egypt this is
feasible."
Debate around
intellectual property and its role in high drug prices is already happening,
according to Leena Menghaney from Médecins Sans
Frontières Access
Campaign. "If treatments are not cost-effective, prices have to come down
to make them cost-effective," she said. "Patent monopolies should not
only be rejected on technical grounds, but on the grounds that companies are
not acting ethically."
Tracy Swan of
the Treatment Action Group argued for the need for a simple standardised
first-line regimen that does not require HCV genotyping or resistance testing.
"The
regimen we need right now is sofosbuvir plus daclatasvir," she said.
"It may not work for every patient, but given the number of people who die
each year, it seems cruel not to step forward. Whatever patent barriers we need
to knock down, let's knock them down!"