Eliminate Hepatitis C as a Public Health Threat: A Narrative Review of Strategies, Gaps, and Opportunities for China

Pathway to hepatitis C elimination: insights from a large tertiary hospital in South China

BACKGROUND

Although the introduction of direct-acting antiviral drugs (DAAs) has greatly enhanced the prognosis for hepatitis C, the timely diagnosis and treatment of hepatitis C virus (HCV) infection remain a severe challenge in China.

METHODS

This retrospective study involved 368,577 patients tested for hepatitis C antibodies from 2020 to 2023 at a large tertiary hospital in South China. It primarily focused on analyzing the prevalence of Anti-HCV and HCV RNA and further evaluated the impact of the 'Hepatitis C-Free Hospital' initiative.

RESULTS

Between 2020 and 2023, this large tertiary hospital in South China reported an overall Anti-HCV positivity rate of 1.08%, with males (1.06%) higher than females (0.57%). In particular, the highest rates were observed in males aged 40-49 (2.24%) and females aged 60-69 (1.00%). There was a gradual decline in the Anti-HCV positivity rate over time. As for HCV RNA testing, it indicated an overall positivity rate of 30.95%, more prevalent in males. Significantly, the 'Hepatitis C-Free Hospital' initiative increased HCV RNA testing and treatment completion rates, with sustained virological response (SVR) rates escalating from 92.86% to 99.61%.

CONCLUSIONS

This study identified specific patient groups with high HCV positivity rates. Additionally, the 'Hepatitis C-Free Hospital' initiative significantly increased HCV RNA testing and treatment rates, providing a feasible model for regional HCV elimination.

The macroeconomic burden of hepatitis C and the economic benefit of accelerated investments in China

BACKGROUND

Hepatitis C virus (HCV) poses a significant health and economic burden worldwide, with China bearing a considerable portion of this burden. Chinese treatment coverage remains low, and the full economic implications of achieving these goals are not well understood.

OBJECTIVE

This study aims to evaluate the macroeconomic burden of HCV from 2023 to 2050, as well as the investments required, health benefits, cost-effectiveness, net economic benefit, and the impact on economic growth associated with achieving WHO hepatitis C intervention coverage targets more rapidly during this period.

METHODS

A dynamic compartmental model was used to simulate the transmission, progression, and cascade of care for HCV patients in China. Intervention costs and healthcare costs were calculated using the cost-of-illness (COI) method. A health-augmented macroeconomic model projected macroeconomic outcomes. Scenarios were developed to evaluate different time points for achieving coverage targets.

RESULTS

The projected macroeconomic burden of HCV from 2023 to 2050 is $1.17 trillion. Achieving WHO targets by 2030 is expected to spend $69.72 (95% UI $66.22-$73.68) billion but will avert 0.66(95% UI 0.58-0.74) million hepatocellular carcinoma (HCC) cases, and 1.10(95% UI 1.03-1.18) million HCV-related deaths compared to status quo. Faster achievement of coverage targets is associated with investments becoming cost-effective sooner and facilitating greater economic growth.

CONCLUSION

Achieving the WHO Global Health Sector Strategy diagnosis and treatment coverage targets by 2030 in China is projected to be cost-effective and result in significant health and economic benefits. The findings underscore the importance of increased investment in hepatitis C elimination efforts in China.

Cost-effectiveness and return on investment of hepatitis C virus elimination in China: A modelling study

BACKGROUND/AIMS

The World Health Organization set the goal of eliminating hepatitis C virus (HCV) by 2030, with 80% and 65% reductions in HCV incidence and mortality rates, respectively. We aimed to evaluate the health benefits, cost-effectiveness and return on investment (ROI) of HCV elimination.

METHODS

Using an HCV transmission compartmental model, we evaluated the benefits and costs of different strategies combining screening and treatment for Chinese populations. We identified strategies to achieve HCV elimination and calculated the incremental cost-effectiveness ratios (ICERs) per disability-adjusted life year (DALY) averted for 2022-2030 to identify the optimal elimination strategy. Furthermore, we estimated the ROI by 2050 by comparing the required investment with the economic productivity gains from reduced HCV incidence and deaths.

RESULTS

The strategy that results in the most significant health benefits involves conducting annual primary screening at a rate of 14%, re-screening people who inject drugs annually and the general population every five years, and treating 95% of those diagnosed (P14-R4-T95), preventing approximately 5.75 and 0.44 million HCV infections and deaths, respectively, during 2022-2030. At a willingness-to-pay threshold of $12,615, the P14-R4-T95 strategy is the most cost-effective, with an ICER of $5,449/DALY. By 2050, this strategy would have a net benefit of $120,997 million (ROI=0.868).

CONCLUSION

Achieving HCV elimination in China by 2030 will require significant investment in large-scale universal screening and treatment, but it will yield substantial health and economic benefits and is cost-effective.

Awareness of hepatitis C prevention and treatment and high-risk behaviors among the general population in Anhui Province: a cross-sectional study

Background

The World Health Organization (WHO) set the goal of "eliminating viral hepatitis as a major public health threat by 2030" in 2016. In 2021, the National Health Commission of China (NHCC), issued an action plan to help achieve the WHO's goal of eliminating the Hepatitis C virus by 2030. Therefore, the primary objective of this study was to investigate the awareness of knowledge of hepatitis C prevention and treatment and high-risk behaviors among the general population of Anhui Province.

Methods

Stratified sampling method had been used to select participants to conduct a survey from June 2021 to September 2021 in Anhui Province. Multivariate logistic regression model was used to reveal the influencing factors of participants' awareness and the self-selected high-risk behaviors of HCV infection.

Results

The crude and standard awareness rates of hepatitis C were 56.12% (95% CI: 54.15-58.11%) and 53.74% (95% CI: 53.72-53.75%), respectively. Among the 2,423 participants, 83.2% knew that blood or blood products can lead to hepatitis C infection, but only 44.2% knew that people infected with HCV can look healthy. Multivariate logistic regression model analysis showed that age group, education level, and geographic location were the important factors influencing hepatitis C awareness. In the last year, 1,113 people (45.9%) reported that they had high-risk behaviors for hepatitis C infection. Multivariate logistic regression model analysis revealed that hepatitis C awareness, gender, marital status, and geographic location were the important factors influencing the self-selected high-risk behaviors.

Conclusion

The findings indicated that the general population in Anhui Province has low awareness of HCV prevention and treatment and a certain degree of history of high-risk behavior for hepatitis C. In the future, more information and health education on hepatitis C is needed, with particular attention to the older adult, those with low education levels, and the central and southern regions of Anhui Province. We also should strengthen the education of females and married, divorced or widowed individuals to recognize and avoid high-risk behaviors for hepatitis C in their lives. By narrowing the gap between knowledge and behavior, we can contribute to the goal of eliminating hepatitis C by 2030.

Achieving Hepatitis C Micro-Elimination in Chinese Injecting Drug Users: A Dynamic Network Modeling Study

INTRODUCTION

The World Health Organization (WHO) has established objectives for eradicating the hepatitis C virus (HCV). People who inject drugs (PWID), a major driver of HCV transmission, are an essential part of China's hepatitis C elimination program. This study aimed to estimate the requisite screening and antiviral treatment levels to achieve these goals among people who inject drugs in China and identify the most cost-effective strategy.

METHODS

This study utilized models based on dynamic social networks to simulate HCV transmission and disease progression among people who inject drugs in China, incorporating a cost-effectiveness analysis from a healthcare perspective.

RESULTS

To achieve the WHO targets, a minimum screening and treatment rate of 10% is required to meet the mortality goal, while a 25% rate is necessary for the incidence goal. The most cost-effective strategy includes a 25% screening rate and a 95% treatment rate. Compared to no intervention, this approach significantly reduces costs by - $85,873.38 (95% CI  - $94,311.16 to  - $77,435.59) and adds 24.66 (95% CI 23.68 to - 25.64) quality-adjusted life years. The intervention is dominant, with a cost-effectiveness ratio of - $3482.29 (95% CI  - $3982.73 to  - $3020.11) per quality-adjusted life year.

CONCLUSION

Achieving the WHO's hepatitis C virus elimination targets among people who inject drugs in China is feasible and cost-saving.

Effects and Costs of Hepatitis C Virus Elimination for the Whole Population in China: A Modelling Study

BACKGROUND AND OBJECTIVE

China has the highest number of hepatitis C virus (HCV) infections in the world. However, it is unclear what levels of screening and treatment are needed to achieve the WHO 2030 hepatitis C elimination targets. We aimed to evaluate the impact of scaling up interventions on the hepatitis C epidemic and determine how and at what cost these elimination targets could be achieved for the whole population in China.

METHODS

We developed a compartmental model incorporating HCV transmission, disease progression, and care cascade for the whole population in China, calibrated with data on demographics, injecting drug use, HCV prevalence, and treatments. Five different scenarios were evaluated for effects and costs for 2022-2030. All costs were converted to 2021 US dollar (USD) and discounted at an annual rate of 5%. One-way sensitivity analyses were conducted to assess the robustness of the model.

RESULTS

Under the status quo scenario, the incidence of hepatitis C is projected to increase from 60.39 (57.60-63.45) per 100,000 person-years in 2022 to 68.72 (65.3-73.97) per 100,000 person-years in 2030, and 2.52 million (1.94-3.07 million) infected patients are projected to die between 2022 and 2030, of which 0.76 (0.61-1.08) million will die due to hepatitis C. By increasing primary screening to 10%, conducting regular rescreening (annually for PWID and every 5 years for the general population) and treating 90% of patients diagnosed, the incidence would be reduced by 88.15% (86.61-89.45%) and hepatitis C-related mortality by 60.5% (52.62-65.54%) by 2030, compared with 2015 levels. This strategy would cost USD 52.78 (USD 43.93-58.53) billion.

CONCLUSIONS

Without changes in HCV prevention and control policy, the disease burden of HCV in China will increase dramatically. To achieve the hepatitis C elimination targets, China needs to sufficiently scale up screening and treatment.

HCV RNA positivity among hepatitis C patients in Chongqing, China from 2004 to 2021: a cross-sectional study

BACKGROUND

A substantial number of hepatitis C virus (HCV) infections have been diagnosed and reported, yet not all reported patients have received treatment, leading to uncertainties in the progression of the virus within these cases. This study aimed to assess the rate of HCV RNA positivity in the reported cases in Chongqing, China and identify key groups.

METHODS

An investigation was conducted on 6,333 hepatitis C cases who were reported in the China Information System for Disease Control and Prevention in 17 districts of Chongqing, China from 2004 to 2021. The process involved collecting venous blood for HCV RNA and genotype testing, as well as gathering case information through a questionnaire. The analysis focused on comparing the HCV RNA positive rates among patients with different characteristics to identify key groups.

RESULTS

The HCV RNA positive rate was 37.7% among 6,333 cases. Patients who had never received treatment (47.6%) and those treated with interferon (25.6%) showed higher positive rates than those treated with DAAs (8.1%). HCV RNA positive rates were generally higher in the following groups: males, aged 40-49 years and 50-59 years, farmers or manual laborers and the unemployed or job-seeking. Patients with higher income exhibited lower HCV RNA positive rate.

CONCLUSIONS

A considerable portion of reported hepatitis C cases in Chongqing remained HCV RNA positive. Multiple factors contributed to HCV RNA positivity among these patients, necessitating comprehensive interventions to promote adherence to treatment.

Is it time for China to prioritize pan-genotypic regimens for treating patients with hepatitis C?

INTRODUCTION

The treatment of hepatitis C has entered the pan-genotypic era, but the effectiveness is not good for the genotype 3b patients who have a large proportion in China. The guidelines for hepatitis C recommend the use of gene-specific regimens when the regional 3b prevalence rate greater than 5%. This study is to explore rationality of this proportion and the cost-effectiveness to implement pan-genotypic regimens in China.

METHODS

A decision Markov model was developed from the health system perspective to evaluate the effectiveness and cost-effectiveness between pan-genotypic and gene-specific treatment regimens for hepatitis C patients. Additionally, we set a regional genotype 3b patient proportion of 0-100% to explore at which proportion it is necessary to perform genotype identification and typing therapy on patients. Model parameters were derived from published literature and public databases. Effectiveness was measured by cured patient numbers, newly diagnosed cases of decompensated cirrhosis, hepatocellular carcinoma, need for liver transplantation, and quality-adjusted life years (QALYs). Cost-effectiveness outcomes included costs and the incremental cost-effectiveness ratio (ICER). The 1-3 times 2022 Chinese per capita gross domestic product was used as the willingness-to-pay threshold. One-way and probabilistic sensitivity analyses were performed to assess the uncertainty of the model parameters.

RESULTS

Compared with gene-specific regimens, pan-genotypic regimens resulted in an additional 0.13 QALYs and an incremental cost of $165, the ICER was $1,268/QALY. From the view of efficacy, the pan-genotypic regimens cured 5,868 more people per 100,000 patients than gene-specific regimens, avoiding 86.5% of DC cases, 64.6% of HCC cases, and 78.2% of liver transplant needs. Identifying 3b patients before treatment was definitely cost-effectiveness when their prevalence was 12% or higher. The results remained robust in sensitivity analyses.

CONCLUSIONS

In China, the prioritized recommendation of pan-genotypic therapeutics proves to be both cost-effective and efficacious. But, in regions where the prevalence of genotype 3b exceeds 12%, it is necessary to identify them to provision of more suitable therapies.

Uptake of hepatitis C direct-acting antiviral treatment in China: a retrospective study from 2017 to 2021

BACKGROUND

Direct-acting antivirals (DAAs) for hepatitis C treatment in China became available since 2017. This study expects to generate evidence to inform decision-making in a nationwide scale-up of DAA treatment in China.

METHODS

We described the number of standard DAA treatment at both national and provincial levels in China from 2017 to 2021 based on the China Hospital Pharmacy Audit (CHPA) data. We performed interrupted time series analysis to estimate the level and trend changes of the monthly number of standard DAA treatment at national level. We also adopted the latent class trajectory model (LCTM) to form clusters of the provincial-level administrative divisions (PLADs) with similar levels and trends of number of treatment, and to explore the potential enablers of the scale-up of DAA treatment at provincial level.

RESULTS

The number of 3-month standard DAA treatment at national level increased from 104 in the last two quarters of 2017 to 49,592 in the year of 2021. The estimated DAA treatment rates in China were 1.9% and 0.7% in 2020 and 2021, which is far below the global target of 80%. The national price negotiation at the end of 2019 resulted in DAA inclusion by the national health insurance in January 2020. In that month, the number of treatment increased 3668 person-times (P < 0.05). LCTM fits the best when the number of trajectory class is four. PLADs as Tianjin, Shanghai and Zhejiang that had piloted DAA price negotiations before the national negotiation and that had explored integration of hepatitis service delivery with prevention and control programme of hepatitis C within the existing services demonstrated earlier and faster scale-up of treatment.

CONCLUSIONS

Central negotiations to reduce prices of DAAs resulted in inclusion of DAA treatment under the universal health insurance, which are critical elements that support scaling up access to hepatitis C treatment in China. However, the current treatment rates are still far below the global target. Targeting the PLADs lagged behind through raising public awareness, strengthening capacity of the healthcare providers by roving training, and integrate prevention, screening, diagnosis, treatment and follow-up management of hepatitis C into the existing services are needed.