Australia could miss the WHO hepatitis C virus elimination targets due to declining treatment uptake and ongoing burden of advanced liver disease complications

Abstract

Australia was one of the first countries to introduce government-funded unrestricted access to direct-acting antiviral (DAA) therapy, with 88,790 treated since March 2016. However, treatment uptake is declining which could potentially undermine Australia's progress towards the WHO HCV elimination targets. Using mathematical modelling, we updated estimates for those living with chronic HCV in Australia, new cases of decompensated cirrhosis (DC), hepatocellular carcinoma (HCC), and liver-related mortality among the HCV-cured and viraemic populations from 2015 to 2030. We considered various DAA treatment scenarios incorporating annual treatment numbers to 2020, and subsequent uptake per year of 6,790 (pessimistic), 8,100 (intermediate), and 11,310 (optimistic). We incorporated the effects of excess alcohol consumption and reduction in progression to DC and HCC among cirrhosis-cured versus viraemic individuals. At the end of 2020, we estimated 117,810 Australians were living with chronic HCV. New cases per year of DC, HCC, and liver-related mortality among the HCV viraemic population decreased rapidly from 2015 (almost eliminated by 2030). In contrast, the growing population size of those cured with advanced liver disease meant DC, HCC, and liver-related mortality declined slowly. The estimated reduction in liver-related mortality from 2015 to 2030 in the combined HCV viraemic and cured population is 25% in the intermediate scenario. With declining HCV treatment uptake and ongoing individual-level risk of advanced liver disease complications, including among cirrhosis-cured individuals, Australia is unlikely to achieve all WHO HCV elimination targets by 2030.

Fig 1. HCV model schematic diagram showing disease progression (black lines: Viraemic, red lines: Cured).

Fig 2. Annual change in people living with chronic HCV, HCV incidence, treatment coverage, and liver-related mortality in Australia 2010–2030 compared to WHO HCV elimination targets (red dotted lines: 90% reduction in incidence, 80% eligible treated, 65% reduction in deaths).

Fig 3. Percentage reductions in PLHCV, new infections, new HCC cases (viraemic and cured), liver-related mortality (viraemic and cured), in 2030 compared to 2015 (blue bar: Pessimistic scenario, green bar: Intermediate scenario, purple bar: Optimistic scenario).

Fig 4. Liver-related mortality among viraemic only and viraemic and cured combined in Australia 2010–2030 compared to WHO HCV mortality target (red dotted lines: 65% reduction from 2015).