Hepatitis C: behind new wonder drugs lies a terrible dilemma

150m carriers, and rising Jarun Ontakrai

There are 160m carriers of the hepatitis C virus across the world. Combined with the hepatitis B virus, which has 240m carriers, this causes 1.4m deaths every year.

Yet there are grounds for optimism around hepatitis C. Numerous pharmaceutical companies have recently brought to market new sets of “direct-acting antiviral” medicines to combat the infection. These have been shown to permanently clear the hepatitis C virus in 90% of patients in only a few short weeks, and with negligible adverse effects. It is not an overstatement to say that these antivirals have the potential to do for hepatitis C what oral vaccination did for polio.

But there is a fly in the ointment. The new drugs are unaffordable. Take the UK as an example, where around 214,000 people live with hepatitis C. Going by the indicated list price of £35,000 per treatment course, it would cost around £7.5 billion to treat every infected person. Even the staunchest hepatitis advocate would concede that since that approaches the entire NHS annual drug budget, treating everyone is not feasible in the short term.

The moral maze

This presents a conundrum for policy professionals across the world: if we cannot afford to treat everyone in need immediately, how should we go about allocating the limited number of treatments that we can afford? With direct-acting antivirals now available in virtually all high-income countries, the two main routes available to those in charge of health budgets are as follows.

The first can be dubbed the “anti-decision” option. You allow the situation to develop organically, without exerting any guiding hand over who receives treatment now and who waits until later. This circumvents having to make a potentially unpopular decision on rationing. But not all patients have an equal need for treatment – and where demand for a medicine outstrips supply, a decision not to prioritise anyone often amounts to a tacit decision to prioritise unjustly on social criteria.

This is what happened when insulin was made publicly available in the 1920s, for instance, following its discovery by Fredrick Banting. Severe production constraints meant that demand for insulin far exceeded its possible supply and there were no formal criteria to decide who should be prioritised. As a result, the drug was largely allocated to Banting’s own patients and to the politically well-connected.

The second route is the diametric alternative. Rather than avoiding making a decision, you take the bull by the horns and prioritise explicit groups of patients to accomplish a specific public health goal. The challenge is to identify which goal, for there are several worthy candidates. One might say, for example, that hepatitis C transmission rates among people who inject drugs are too high, and so remedying this problem should be the priority.

Others may take the view that the steady year-on-year increases in people who develop severe consequences from the infection can’t be tolerated, so we should use the treatments to turn this tide. Both goals are laudable and legitimate, but the costs prohibit prioritising both. In other words, the opportunity cost of prioritising one is to forfeit the other.

Classic liver symptom: yellow skin pigmentation. Crystal Eye Studio

On the ground

So what approach are we leaning towards? In the UK a consensus is emerging that the near-term priority should be treating patients with advanced liver fibrosis – this is also being pursued by private and state-funded health insurance programmes in the US. This advanced liver fibrosis subgroup, (which accounts) for about 30% of the total hep C infected population in Scotland, exhibits by far the greatest immediate risk of severe liver complications like liver failure and liver cancer, the prognoses for which are very bleak.

The crucial fact that prioritising this group will save the most lives makes it possible to justify the policy both to individual patients and to those who want to see the biggest public health benefit. Scotland, for instance, expects to reduce new-onset liver failures and liver cancer by 75% to fewer than 50 cases a year by 2020 if this strategy is followed through. With the number of cases currently rising fast, this would be nothing less than remarkable.

But let us not lose sight of the wider picture. Viral hepatitis is a global problem whose solution depends not just on making progress in richer countries, but making inroads in poorer countries too – particularly those in Asia and Africa where the greatest viral hepatitis burden lies. A global problem requires global endeavour. Historically, most governments and the big aid donors have been lacklustre at investing in this cause.

Cue then the Glasgow Declaration, unveiled at the close of the first world hepatitis summit, which was held in the city in September. It is an open letter imploring all governments to work together to eliminate viral hepatitis as a public health concern.

World Hepatitis Summit, September 2015. GCU

Will it be heeded? Certainly the declaration has popular support, and the fact that a world hepatitis summit took place at all is an indication that the tide of apathy may be turning on this Cinderella disease. While governments debate which policies to follow in relation to the new hepatitis C drugs, it will be interesting to see how they have reacted to the declaration by the time of the second world summit in Brazil next year. Watch this space.