By Jürgen Rockstroh, IAS Governing Council member and Head of the HIV Outpatient Clinic at the University of Bonn in Germany
Perhaps the greatest achievement of the HIV response has been its success in bringing antiretroviral therapy to 20.9 million people (as of June 2017). This historic accomplishment, which in 2016 alone averted 1.2 million deaths, was made possible by actions that led to a 99% decline in the cost of first-line regimens. As a result of these actions, the right to treatment access is broadly recognized.
Yet, there is a genuine risk that this momentous breakthrough could remain limited to HIV. To date, no similar set of actions has been undertaken to ensure access to medicines to treat cancer, heart disease, viral hepatitis or other leading killers.
Hepatitis C virus (HCV) offers a test case of whether the world will apply the lessons we have learned from HIV treatment access to other major causes of death.
HCV is nothing short of a global crisis. Worldwide, nearly twice as many people are living with HCV than are living with HIV. Each year, roughly 400 000 people die of HCV-related causes. HCV imposes a profound economic burden on affected households and to societies.
Unlike HIV, HCV can now be cured. Direct Acting Antivirals (DAAs) are available that can cure HCV in more than 95% of cases – typically in only 8-12 weeks. In addition to the lifelong health benefits conferred on people whose HCV has been cured, these medicines also avert the very costly future expenses associated with cases of liver cancer and cirrhosis that will now never occur.
As the Sustainable Development Goals call for the elimination of HCV as a public health threat, bringing DAAs to all who need them is an urgent global health priority. However, in 2016, only about 13% of people with HCV globally were receiving treatment.
These medicines are not costly to produce, but they come with prices that are extremely high. DAAs are blockbuster drugs, generating extraordinary profits to the companies that make them. To date, though, the pace at which these drugs are being rolled out is insufficient to drive meaningful progress towards the goal of HCV elimination.
HIV has taught us the importance of a treat-all approach. However, in many settings, the high costs associated with DAAs has led to rationing of the drugs, with access available only for people who have already suffered severe liver damage.
The world faces a moment of truth with HCV. Will the world follow through on its pledge to eliminate HCV? Will we heed the clear lessons of AIDS – that every person with a life-threatening disease has the right to meaningful access to life-saving medicines, and that whether one lives or dies from a communicable disease should not depend on where one lives?
There are some encouraging signs. As a result of voluntary licenses issued by patent holders, less costly generic equivalents of some DAAs are now becoming available in many countries. But these agreements do not cover all countries, including many countries with a heavy burden of HCV. As a result, a dual market has arisen, with some countries able to access more affordable generic equivalents but others lacking this access. Even when generic DAAs are available, prices can still be high. In far too many settings, financing has not been mobilized to support mass treatment programmes.
We know that smart action, coupled with strong political commitment, can produce major progress against HCV. For example, Ireland and Slovenia have focused treatment efforts on heavily affected sub-populations, effectively eliminating HCV among haemophilia patients. Egypt, which has vowed to eradicate HCV, now reaches more than 1 million people with HCV with generic DAA’s produced in the country.
Now we must build on these examples of leadership to rapidly increase access to these curative regimens. We must invest in screening programmes, as up to 80% of people with HCV are not aware they are infected. We must mobilize substantial new resources to finance HCV treatment scale-up. We must improve and expand the geographic scope of voluntary licenses, through the use of sliding royalty scales and other means, so that more countries have access to more affordable medicines. And at the same time that we invest in HCV treatment, countries must summon the political courage to support evidence-based measures to prevent HCV, including needle and syringe programmes and medication assisted therapy for opiate use.
Like HIV before it, HCV presents a test of our common humanity. Knowing that we have at our disposal the means of curing a leading cause of death, will we do what is necessary to ensure that all who need this cure will receive it?
The photograph in this post is used for illustrative purposes only; it does not imply any particular health status, attitudes, behaviors, or actions on the part of any person who appears in the photograph.