A World Free From Hep B
Hepatitis B has remained neglected for too long, but that is beginning to change. As we continue to gain momentum there must be a continued focus on addressing gaps in treatment in resource-limited settings.
This is the fourth time I have been here in Papua New Guinea, but this story is not the first. A 45 year old man from the Oro Province, has recently passed away from liver disease. We were told by the local nurse that the man was previously well. Without warning, he developed an abdomen full of fluid and was admitted to hospital, where he faded away in a matter of days.
If this man is like many others in PNG, he likely passed away from liver cancer or liver failure, from a lifetime of undiagnosed hepatitis B. Here, options for treatment are bleak – antiviral therapy is far out of reach. However, even if the treatment that he needed was available, by that stage it would have been too late.
The global epidemic of hepatitis B
Viral hepatitis claims the lives of over one million people each year, with chronic hepatitis B and C accounting for most of the burden worldwide. The World Health Organization estimates that there are 325 million people around the world infected with hepatitis B or C, the majority of whom live in low-income countries in the Asia-Pacific and sub-Saharan Africa.
Hepatitis B is known as a “silent killer”. The virus broods dangerously in the blood, whilst the disease shows few symptoms – or none at all. Decades of untreated chronic hepatitis B can lead to cirrhosis, and the feared endpoints of end stage liver disease: liver failure and liver cancer.
The good news is that immunisation can safely and effectively prevent hepatitis B. Most countries have incorporated hepatitis B into their childhood immunisation schedules. However, coverage is less than 100% is many countries, and the estimated global coverage with 3 doses is 84%.
Even low rates occur for birth dose vaccination, a strategy to prevent mother to child transmission, particularly in settings where it is common to give birth at home.
It is well established that high immunisation coverage is key to winning the fight against hepatitis B. However, immunisation alone is not enough. For the millions of people living with hepatitis B, safe, accessible and effective treatment is what is needed.
Pill a day treatment: addressing the burden of chronic hepatitis B
Of the 257 million people living with chronic hepatitis B, only 1 million are currently receiving treatment. Untreated, the remaining 99.6% of people with the disease remain at risk of dying within a decade or liver cancer and cirrhosis.
Whilst hepatitis B doesn’t yet have a cure, antiviral therapy offers people a chance to transform a death sentence into a treatable disease. Tenofovir and entecavir are one pill-a-day oral medications recommended as first-line treatment by WHO. These drugs are capable of achieving viral suppression in patients indicated for treatment, lowering the risk of progression to liver cancer. Tenofovir is commonly used in people living with HIV. However, whilst tenofovir can be purchased at lower costs for HIV, it remains much more expensive for use as HBV treatment.
Health is a basic human right, and addressing vast disparities in healthcare delivery in resource-poor settings is a moral imperative. However, there is also a strong economic argument for increasing hepatitis B treatment. Liver cancer and end stage liver disease, the outcomes of undiagnosed and untreated hepatitis B, drain already stretched health care systems due to medical costs – not to mention the flow-on effects of lost productivity and decreases in quality of life. As is often the case in health, early identification and treatment are key.
Hepatitis B in resource-limited settings: lessons from Papua New Guinea
The huge public health burden caused by hepatitis B in low- and middle-income countries cannot be ignored. However, countries such as Papua New Guinea face unique challenges in healthcare delivery – not only limited to hepatitis B, but across the whole health sector – and these contribute to gaps in prevention, diagnosis and treatment.
When Hepatitis B Free first began working in the Oro Province of Papua New Guinea, there was low awareness about hepatitis B, even amongst healthcare workers. Hepatitis B vaccinations were not delivered consistently in remote areas. People could not readily access testing, let alone antiviral therapy.
Rapid point-of-care testing has been one strategy we have used to improve detection of patients with positive hepatitis B surface antigen. These simple finger-prick are an affordable and accessible screening tool. This is particularly relevant for settings with limited laboratory equipment and diagnostics.
Whilst specialist physicians usually prescribe antiviral therapy in high-income countries such as Australia, PNG has a scarcity of doctors; community health workers and nurses are responsible for most health care provision. For treatment to be delivered on a community level, local health workers need to be trained and upskilled.
Access to antiviral therapy has been a long-standing barrier for low- and middle-income countries, as high costs render it unaffordable to many. Generic medications offer a more affordable option for many people in need. This has been priced around US $50 per year of treatment, compared to US $1500 in high-income countries. However, even if treatment is affordable, medicines procurement pathways are notoriously complex to navigate.
No Hep by 2030: the road towards elimination
Remarkable advances are being made in the area of viral hepatitis, but there is a long way to go. The message of World Hepatitis Day is that elimination is achievable. To meet this goal, dialogue and action need to be focused on addressing the challenges in improving treatment access for people in low- and middle-income countries.
Now is the opportunity to keep the momentum going towards a “No Hep” world. It’s an opportunity we would do well to grasp.
The views and opinions expressed in this article are those of the author and do not necessarily represent those of the Doctus Project.