The road to elimination of hepatitis C: analysis of cures versus new infections in 91 countries

Abstract

Background: Hepatitis C (HCV) can only be eradicated if annual rates of cure (SVR) are consistently and significantly higher than new HCV infections, across many countries. In 2016, the WHO called for a 90% reduction in new HCV infection by 2030. Direct-acting antivirals (DAA) can cure the majority of those treated, at around 90% in most populations, at potentially very low prices. We compared the net annual change in epidemic size across 91 countries using data on SVR, new HCV infections, and deaths. In a further 109 countries, we projected this figure using regional averages of epidemic size.

Methods: Epidemiological data for 2016 were extracted from national reports, publications and the Polaris Observatory. There were 91/210 countries with data on SVR, HCV-related deaths and new infections available for analysis; 109 countries had net change in epidemic size projected from the regional prevalence of HCV, extrapolated to their population size. 'Net cure' was defined as the number of people with SVR, minus new HCV infections, plus HCV-related deaths in 2016.

Results: For the 91 countries analysed, there were 57.3 million people with chronic HCV infection in 2016. In the remaining 109 countries, the projected epidemic size was 12.2 million, giving a global epidemic size of 69.6 million. Across the 91 countries, there was a fall from 57.3 to 56.9 million people in 2017, a 0.7% reduction. The projected global net change was from 69.6 to 69.3 million, a 0.4% reduction. Ten countries had at least five times more people reaching SVR than new HCV infections, including Egypt and USA. In 47/91 countries, there were more HCV infections than SVR in 2016.

Conclusion: Very few countries are on target to achieve elimination of HCV as a public health problem by 2030. While the North American, North African/Middle East and Western European regions have shown small declines in prevalence, the epidemic is growing in sub-Saharan Africa and Eastern Europe. Far higher rates of DAA treatment are required for worldwide elimination of HCV.

Keywords: direct acting antivirals; epidemiology; hepatitis C; sustained virological response.

Figure 1.

Diagram showing how the epidemic size of HCV for 2017 was estimated. This takes into account the number of cures, HCV-related deaths and new infections in 2016. Non-HCV-related deaths were not included for analysis

Figure 2.

Flowchart showing how the HCV epidemic size of Ukraine, a country with missing data, was estimated. This takes into account the regional population of the 91 countries analysed, the known epidemic size in this region and the population of Ukraine

Figure 3.

Map showing the percentage treatment rate by country for HCV. Countries shaded in grey were excluded from analysis due to a lack of reliable data

Figure 4.

Graph showing the eight countries treating the most people by percentage in 2016. Countries with a viraemic population <1000 (Iceland and Qatar) were excluded from this analysis

Figure 5.

(a) Bar chart showing the 10 countries with the highest net cure in 2016. (b) Bar chart showing the 10 countries with the lowest net cure in 2016

Figure 6.

Bar chart showing the net cure by region in 2016. Extrapolated data based on regional calculations of net cure were used to estimate the rate for missing countries and a global estimate. A negative net cure indicates that the epidemic size in the region is increasing

Figure 7.

Scatter plot showing the 10/91 countries where there were >5 times more people reaching SVR than there were new infections in 2016. The guideline represents the mark of five people reaching SVR for every single new HCV infection

Figure 8.

Scatter plot showing the 23/91 countries where there were 5 times fewer people reaching SVR than there were new infections in 2016. The guideline represents the mark of one person reaching SVR for every five new HCV infections in 2016