Reaching the World Health Organization’s proposed targets
for viral hepatitis control by 2030 could require global funding of $11 billion
per year by 2025, Stefan Wiktor of the WHO Hepatitis Programme told the World
Hepatitis Summit in Glasgow earlier this month.
Emphasising that their estimates are preliminary, and that
final figures won’t be released until after the end of the year, Stefan Wiktor
warned that the estimates would be critically dependent on the pricing of
generic versions of direct-acting antivirals for hepatitis C and antiviral
drugs for hepatitis B, and the speed at which these prices decline as a result
of competition and growth in market volume.
The modelling was carried out by WHO and an international
modelling group including researchers from Imperial College, London.
The model was designed to produce estimates of how much
funding would be needed to achieve proposed targets for viral hepatitis control,
- A 30% reduction in new infections of hepatitis B
and C by 2020, and a 90% reduction by 2030.
A 10% reduction in deaths due to hepatitis B and
C by 2020, and a 65% reduction by 2030.
- Increasing childhood hepatitis B vaccine coverage
from 81% to 90% by 2020, and increase coverage of birth-dose hepatitis B
vaccine or other interventions to prevent mother to child transmission of
hepatitis B from 38% to 50% in 2020 and to 90% in 2030.
- Increase the proportion of injections carried out
safely worldwide from 5% today to 50% in 2020 and to 90% in 2030.
- Treat 5 million people with hepatitis B by 2020
and provide treatment for 80% by 2030.
- Treat 3 million with hepatitis C by 2020 and
provide treatment for 80% by 2030.
The model assumes that it will be possible to provide
treatment for hepatitis C at $200 per course of treatment in lower-income
countries, $500 per course in middle-income countries and $10,000 per course in
higher-income countries. Hepatitis B treatment will cost $80 a year (tenofovir
will become available in generic form for higher-income countries from 2017
after its patent expires).
The financing projections assume that hepatitis C treatment
scale up will begin to grow from 2018 and reach an interim WHO target of 3
million treated by 2020, with drug prices sharply reduced by 2020.
Funding of harm reduction interventions such as needle and
syringe exchange and opioid substitution therapy will be the biggest budget
item in the period leading up to 2020, as WHO seeks to expand coverage of
needle and syringe exchange in order to reduce transmission of hepatitis C.
According to the preliminary model, the cost of viral
hepatitis control would rise from $2 billion in 2016 and $8 billion in 2020, to
just over $11 billion in 2025. Thereafter total costs would decline, to $9
billion in 2030 as harm reduction and hepatitis B treatment costs begin to go
Prevention and treatment of viral hepatitis will become
affordable if treatment costs decline, but it will be important for health
systems to identify ways in which costs can be shared with existing programmes
within the health system, such as HIV for harm reduction and for treatment of
coinfected people, and the immunisation programme for hepatitis B vaccination.
A simplified treatment package that can be delivered with less monitoring and a
standardised treatment regimen would also reduce costs. This public health
approach to treatment would prove cost saving in China for both hepatitis B and
hepatitis C by preventing progression of liver disease, and might also
eliminate spending on ineffective forms of treatment.
Opening the conference, Dr Gottfried Hirnschall, head of the
department of HIV/AIDS and Hepatitis at the World Health Organization reminded
policy makers that spending on viral hepatitis was not discretionary. Action
will be cheaper than inaction in the long run, he told delegates, because
prevention and treatment will avert the future costs of untreated viral
hepatitis, arising in the forms of management of chronic liver disease,
hospitalisation, liver transplantation and liver cancer. Investing in viral
hepatitis prevention and treatment will pave the way for elimination of two
infectious diseases that otherwise will continue to place a growing burden on
Viral hepatitis was the seventh leading cause of
death worldwide in 2013, according to the Global Burden of Disease
study, Dr Graham Cooke of Imperial College, London, told the Summit. In
particular, the burden of death and disease attributable to viral
hepatitis is growing in lower- and middle-income countries.
How hepatitis treatment can be made affordable – especially for lower-income and middle-income countries – was one of
the big questions of the World Hepatitis Summit. Daniel Lavanchy of the Viral
Hepatitis Prevention Board reported on a recent stakeholder meeting which
reviewed potential mechanisms for funding hepatitis treatment. Although some
are attracted by the idea of a specific donor funding pool for hepatitis, one
of the big problems of reproducing a model that has succeeded in expanding
treatment of HIV, tuberculosis and malaria in developing countries is that a
large proportion of the burden of viral hepatitis is in countries that no
longer qualify for development assistance, such as China, India, Brazil and
Russia. The costs of treatment will need to be met from domestic resources,
emphasising the importance of improving universal health coverage and insurance
Regardless of how treatment is financed, mechanisms to
reduce drug prices in middle–income countries will play a critical part in
making treatment affordable for governments and insurance funds. Besides
voluntary licensing (discussed
separately at the World Hepatitis Summit), discounts for large-scale payers
might enable some countries to scale up treatment – as long as the political
will exists. Innovative methods of finance are also being examined, such as
social impact bonds, in which a portion of the health care costs saved by
preventing disease are returned to investors as a reward for putting up the
money to pay for a treatment programme.