Reaching the World Health Organization’s (WHO) 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, including:
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 90% in 2030.
Increase the proportion of injections carried out safely worldwide from 5% today to 50% in 2020 and 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 down.
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 health systems.
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 systems.
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.