Elimination of viral hepatitis: a challenge, but within reach

July 28 marks World Hepatitis Day. Hepatitis B and C are the two main forms of viral hepatitis, which cause inflammation, liver damage, and sometimes cancer. Their burden is enormous: more men acquired hepatitis B (890,000 cases) in 2019-20 than HIV (720,000 cases). In 2019, HIV caused 0.7 million deaths, while hepatitis B and C combined caused 1.1 million deaths. Despite these large figures, there are reasons for optimism. The last decade has transformed the care of viral hepatitis. The development of direct-acting antivirals that can cure chronic hepatitis C and the launch of hepatitis B vaccines at birth to prevent vertical transmission have ushered in a new phase in the elimination of these diseases. But scientific advances have not been matched by equivalent political commitments.

New WHO targets, announced in May, aim to eliminate viral hepatitis by 2030 by reducing new infections and deaths to half a million from both hepatitis B and hepatitis C, as well as reducing HBsAg in children under 5 by below 0.1%. . Forecasting studies indicate that these goals are off track, with an average of 1.42 million new hepatitis C infections expected each year through the end of 2030. Global mortality from hepatitis B has stagnated, with a rate of annualized change of −0 35% (95% uncertainty interval −2 6 to 1 6) between 2015 and 2019.

An earlier target of reducing HBsAg prevalence to less than 1% by 2020 among children under 5 is one of the only WHO targets for achieving the Sustainable Development Goals that have been met. But while significant progress has been made against viral hepatitis overall, the results have been uneven and inequitable. Africa has the highest HBsAg rate at 2.7%, nearly three times the global average. Prior to the COVID-19 pandemic, Gavi’s executive committee, the Vaccine Alliance, had approved funding for the implementation of the hepatitis B vaccine at birth, but it was put on hold due to the pandemic. Quickly releasing these funds could allow the region to catch up quickly. Currently, direct-acting antivirals for hepatitis C monoinfection are not directly funded by any global health agency. The EASL-Lancet Liver Commission describes how regions such as Eastern Europe, estimated to be the region with the highest prevalence of hepatitis C in 2020, do not have access to generics and struggle to treat their populations. When countries prioritize the elimination of viral hepatitis, the results are remarkable. Egypt received $530 million from the World Bank in 2018 for its campaign to eliminate hepatitis C. In 2008, about one in ten people in Egypt had chronic hepatitis C due to a failed national attempt to treat schistosomiasis that reused needles to administer medications. Now, Egypt could be among the first countries to eliminate the disease. Unacceptable stigma and discrimination may be one of the reasons why countries do not prioritize the elimination of viral hepatitis. Many marginalized communities, such as those who inject drugs, are at increased risk of contracting viral hepatitis. Such degradation of human life is not only immoral but illogical. Most chronic hepatitis B infections occur during or after birth, something that can be prevented mainly by vaccination at birth. Evidence indicates that even treatment of hepatitis C, with its higher cost, is not only cost-effective but cost-saving.

Other practical challenges remain. Diagnosis is an important issue. Only 10% of people with chronic hepatitis B know their diagnosis and only 21% of people with chronic hepatitis C know theirs. The development of point-of-care tests and self-assessments, along with campaigns to test and treat, is desperately needed. The Lancet Commission on Diagnostics outlines how when the case for diagnostics is strong and resources are allocated, huge gains can be made, as with COVID-19. There are changes to health systems in the wake of the COVID-19 pandemic that could increase rapid testing and make it easier to deliver medicines and vaccines. A functional cure for hepatitis B is badly needed. In the meantime, streamlining care and increasing capacity to deliver simple but effective treatments will go a long way. Unlike HIV, viral hepatitis has not had the same kind of support from civil society, despite similarities in burden and affected populations. Patient advocacy is a powerful force for change and must be cultivated.

The health community has a golden opportunity to eliminate viral hepatitis. Now is the time to seize the moment, scale up efforts, formalize funding, and draw national and international attention. The 2030 goals are challenging, but within reach. It’s time to push for them.