May 19, 2023 — Viral hepatitis affects almost 400 million people and kills more than 1 million each year.
Yet it was left off the agenda of the Millennium Development Goals. Now, 20 years later, we have a cure for hepatitis C and a highly effective vaccine and treatment for hepatitis B — but annual deaths from the two are projected to outnumber deaths from HIV, tuberculosis, and malaria combined by 2040. As is also the case with HIV, tuberculosis, and malaria, the vast majority of people with viral hepatitis live in low- and middle-income countries in sub-Saharan Africa, Asia, and the Eastern Mediterranean.
The World Health Organization estimates that almost 90% of people living with hepatitis are unaware that they have it. The testing rates for hepatitis C recall the early years of the HIV epidemic.
But it doesn’t have to be this way.
Since 2016, all World Health Organization member states have committed to eliminate viral hepatitis by 2030, as part of the U.N. Sustainable Development Goals.
This goal is achievable. Countries including Egypt, Rwanda, Georgia, and Mongolia are well on the way to eliminating viral hepatitis. The U.S. is striving to meet this goal, too; President Biden recently called for $5 billion to eliminate hepatitis C in the U.S. by 2030.
There are comparatively inexpensive, high-quality generic drugs to cure hepatitis C and treat hepatitis B that prevent liver disease — including liver cancer and cirrhosis — and death. There are tools to prevent new infections, including a cheap and effective vaccine for hepatitis B; a vaccine and antiviral prophylaxis for pregnant women to prevent hepatitis B transmission; and harm reduction interventions to prevent hepatitis C among people who use intravenous drugs.
Aside from the public health benefits, eliminating hepatitis also makes good economic sense. According to a recent global model, investment in hepatitis C would generate $46 billion in cumulative productivity gains and become cost-saving by 2027, with a net economic benefit of $22 billion by 2030.
The lack of progress in the response to viral hepatitis comes down to a lack of financial investment by donors and countries.
One hundred and twenty-four countries have developed plans to eliminate viral hepatitis, but without funding, it’s impossible to get those plans off the ground, let alone scale them.
There are some promising signs that support may be increasing. Under its 2023-2028 strategy, the Global Fund to Fight AIDS, TB, and Malaria has recognized the importance of addressing HIV co-infections and has committed to funding viral hepatitis prevention, diagnosis, and treatment alongside its efforts to end AIDS and improve health outcomes for people living with HIV and at risk of HIV infection.
Unitaid has made strategic investments to help shape markets for the introduction of hepatitis C diagnosis and treatment resources, and to support innovative methods of harm reduction among populations that have a higher risk of hepatitis C infection, including people who are incarcerated and people who inject drugs.
Under its 2021-2025 Vaccine Investment Strategy, GAVI, the Vaccine Alliance, formally approved support for the introduction of a hepatitis B birth dose vaccine in 38 eligible countries, estimating that this could avert up to 1 million infection-related deaths and 1.5 million new cases in newborns between 2021 and 2035. Unfortunately, the Covid-19 pandemic has led to a delay in the rollout of these investments; Gavi’s board will make a decision about the future of these investments in June.
The U.K. Foreign, Commonwealth and Development Office has also made investments to support efforts to reduce the cost of hepatitis drugs and diagnostics, and direct funding toward expanding access to testing, treatment and prevention.
Despite these efforts, eliminating hepatitis B and C by 2030 will be impossible if donor investments don’t increase.
And we aren’t just talking about billion-dollar investments. Small-scale investments — as little as $250,000 per country annually — in local organizations working on hepatitis elimination can galvanize governments to make the additional domestic investments necessary to put their countries on the path to elimination.
Our organizations — the Hepatitis Fund and the Clinton Health Access Initiative — have partnered to fund and deliver these kinds of catalytic interventions, and in a very small space of time they have yielded admirable results on the ground.
During the Covid-19 pandemic, the Hepatitis Fund issued first-round grants to organizations to scale up hepatitis programs in Pakistan, Vietnam, and Zambia. Those investments have created demonstrable change in lower out-of-pockets costs for individuals, increased human resources capacity to bring care closer to those in need, and helped governments unlock domestic resources for hepatitis elimination by supporting national strategic planning and investment cases.
For instance, in Vietnam, the government now reimburses hepatitis C confirmatory testing outside of hospitalization. In Pakistan, 461 primary care centers are now offering hepatitis C screening.
Egypt and Rwanda have also had success when it comes to reducing their viral hepatitis burdens.
Egypt once had the highest rate of hepatitis C in the world, and one in 10 people were living with viral hepatitis. But since 2014, the country has made huge progress toward eliminating the disease through a partnership approach that engaged civil society, the private sector, and philanthropic organizations to mobilize the community and increase rates of screening, diagnosis, and treatment.
Step one of its strategy was to get the buy-in of various government ministries, including and beyond the health ministries. The second was to integrate hepatitis C screening with noncommunicable disease screening in primary health care facilities. This approach reached some 60 million people, including 9 million schoolchildren.
Since implementing this strategy in 2014, the prevalence of hepatitis C in Egypt has dropped from just over 6% to 2%.
Likewise, Rwanda has historically battled significant levels of hepatitis B and C infections. When the viral hepatitis program started in 2011 an estimated 4% of the population were living with hepatitis C, while hepatitis B prevalence was around 2%, with the scale of infection higher among vulnerable populations, including individuals living with HIV. The 1994 genocide that claimed more than 1 million lives is also thought to have led to widespread hepatitis transmission due to mass casualties and injuries.
As part of rebuilding its health system guided by a policy implemented in February 1995, Rwanda increased activities around tackling its hepatitis epidemic. Catalytic Global Fund investments allowed the country to integrate a viral hepatitis control program into its robust HIV program. This momentum led to a political commitment by Rwanda in 2018 to eliminate hepatitis C ahead of the 2030 elimination target date and enabled the country to negotiate the lowest-ever price for WHO pre-qualified direct-acting antivirals, $60 per person, to cure hepatitis C. This program has contributed to the screening of more than 6 million Rwandans and treatment of more than 60,000 patients to date.
Now, as announced at Wednesday’s inaugural Hepatitis Resource Mobilization Conference in Geneva, that same price will be available to low- and middle-income countries, as the Clinton Health Access Initiative and the Hepatitis Fund have signed access agreements with several generic manufacturers that will lower the cost of treatment by over 90%.
The global impact of the Hepatitis Fund’s catalytic and targeted interventions tells a similar story: 580 health workers have been trained by its grantees, and more than 200,000 clients have been screened for hepatitis B and C with 15% positively diagnosed and around 60% of those diagnosed receiving treatment. And those numbers have been achieved in a tight and challenging time frame marked by the beginning of the Covid-19 pandemic through to today.
This approach could be the blueprint the world needs for reaching the goal of eliminating viral hepatitis by 2030 — if implemented on a wider scale with donor support, the right technical assistance, and strategic deployment of resources on the ground. What are we waiting for?
By Chelsea Clinton and Finn Jarle Rode
Chelsea Clinton is vice-chair of the Clinton Foundation and the Clinton Health Access Initiative. Finn Jarle Rode is executive director at the Hepatitis Fund. The Clinton Health Access Initiative and The Hepatitis Fund are hosting the inaugural Global Hepatitis Resource Mobilization Conference in Geneva, Switzerland, this week.