Micro-elimination – A path to global elimination of hepatitis C

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Abstract

In May 2016, the World Health Organization (WHO) released its first global strategy on viral hepatitis. 1 It takes the Sustainable Development Goal of simply ''combatting" hepatitis and makes it more concrete and ambitious-most notably by calling for the elimination of the hepatitis C virus (HCV) and hepatitis B virus as public health threats by 2030. The strategy defines elimination as an 80% reduction in new HCV infections and a 65% reduction in HCV mortality. Global elimination of a disease is hardly a new concept. Typically , it starts with elimination in a defined population or geographic area. Polio efforts, for example, targeted countries initially and then WHO regions. 2 In the human immunodefi-ciency virus (HIV) field, efforts have focused on specific populations and transmission modes, such as transmission from mother to child. 3 More recently, the ''fast-track cities" initiative has begun engaging cities around the world to accelerate their efforts to meet ambitious HIV control targets. 4 In the absence of an effective vaccine, the cornerstone of HCV elimination is treatment with the new direct-acting antivirals (DAAs). Yet the prospect of using DAAs to eliminate HCV has taken many governments by surprise. The cost of these regimens would require some high-income countries to spend the equivalent of billions of euros to achieve nationwide elimination. Instead of trying to secure the long-term savings and public health benefits that elimination would bring, many governments have turned their backs on it as a goal, reserving DAA treatment only for the sickest. Other nations have embraced it, despite uncertainty about how to finance and implement an elimination campaign. While treatment with DAAs is central to HCV elimination , prevention of infection and reinfection is essential too. This focus on prevention not only makes good sense from a public health perspective, but it also allays concerns that governments and other funders might be drawn into an endless cycle of paying for the retreatment of people who have been cured before. This, then, is the state of play: we have a global strategy to eliminate HCV, the biomedical tools that make it possible and strong interest among many stakeholders in carrying it out, despite formidable financial hurdles. How do we go about implementing the strategy? The prospect of HCV elimination is daunting because of the scale, complexity and cost of implementation. The most pragmatic approach would be to break down national elimination goals into smaller goals for individual population segments, for which treatment and prevention interventions can be delivered more quickly and efficiently using targeted methods.

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Lazarus, J. V., Wiktor, S., Colombo, M., & Thursz, M. (2017, October 1). Micro-elimination – A path to global elimination of hepatitis C. Journal of Hepatology. Elsevier B.V. https://doi.org/10.1016/j.jhep.2017.06.033

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