What China can learn from Malaysia to achieve the goal of "eliminate hepatitis C as a public health threat" by 2030 - a narrative review

Diagnosis, Treatment, and Associated Factors Among Patients with HCV Infection - Jiangsu Province, China, 2004-2020

What is already known on this topic?

The global efforts to address the hepatitis C virus (HCV) are progressing, but there are still significant gaps in the diagnosis and treatment of HCV, leading to an increasing number of deaths related to HCV.

What is added by this report?

An extensive investigation was conducted to assess HCV RNA diagnosis, treatment uptake, and associated factors among individuals infected with HCV within Jiangsu Province. The study encompassed a large geographical area and utilized a substantial sample size.

What are the implications for public health practice?

Implementing focused interventions to improve the timely diagnosis of HCV RNA and increase the uptake of HCV treatment could effectively reduce the future burden of HCV-related health problems, deaths, and healthcare expenses. This is essential for achieving the global target of eliminating hepatitis C.

Usability and acceptability of oral fluid- and blood-based hepatitis C virus self-testing among the general population and men who have sex with men in Malaysia

Hepatitis C self-testing (HCVST) is emerging as an additional strategy that could help to expand access to HCV testing. We conducted a study to assess the usability and acceptability of two types of HCVST, oral fluid- and blood-based, among the general population and men who have sex with men (MSM) in Malaysia. An observational study was conducted in three primary care centres in Malaysia. Participants who were layman users performed the oral fluid- and blood-based HCVST sequentially. Usability was assessed by calculating the rate of errors observed, the rate of difficulties faced by participants as well as inter-reader (self-test interpreted by self-tester vs interpreted by trained user) and inter-operator concordances (self-test vs test performed by trained user). The acceptability of HCV self-testing was assessed using an interviewer-administered semi-structured questionnaire. Participants were also required to read contrived test results which included "positive", "negative", and "invalid". There was a total of 200 participants (100 general population, 100 MSM; mean age 33.6 ± 14.0 years). We found a high acceptability of oral fluid- and blood-based HCVST across both general population and MSM. User errors, related to timekeeping and reading within stipulated time, were common. However, the majority of the participants were still able to obtain and interpret results correctly, including that of contrived results, although there was substantial difficulty interpreting weak positive results. The high acceptability of HCVST among the participants did not appreciably change after they had experienced both tests, with 97.0% of all participants indicating they would be willing to use HCVST again and 98.5% of them indicating they would recommend it to people they knew. There was no significant difference between the general population and MSM in these aspects. Our study demonstrates that both oral fluid- and blood-based HCVST are highly acceptable among both the general population and MSM. Both populations also showed comparable ability to conduct the tests and interpret the results. Overall, this study suggests that HCVST could be introduced as an addition to existing HCV testing services in Malaysia. Further studies are needed to establish the optimal positioning of self-testing alongside facility-based testing to expand access to HCV diagnosis in the country.

Pay-it-forward incentives for hepatitis virus testing in men who have sex with men: a cluster randomized trial

Pay-it-forward incentives involve having a person receive a free test with community-generated messages and then asking if those who received a free test would like to donate money to support others to receive free testing. Here we undertook a two-arm cluster-randomized trial to evaluate pay-it-forward incentives with active community participation to promote hepatitis B virus (HBV) and hepatitis C virus (HCV) testing among men who have sex with men in China. Men randomized to the pay-it-forward arm received free HBV and HCV testing and were offered a chance to pay-it-forward by donating money to support the testing of another anonymous person. Each participant paid for their HCV and HBV test at 7.7 USD per test in the standard-of-care arm. The primary outcome was the proportion of men who tested for HBV and HCV. Between 28 March and 6 November 2021, 32 groups (10 men per group) of men were randomized to the pay-it-forward (n = 160, 16 clusters) and standard-of-care (n = 162, 16 clusters) arms, respectively. HBV and HCV rapid testing were higher in the pay-it-forward arm (59.4%) than in the standard-of-care arm (25.3%) (proportion difference 35.2%, 95% confidence interval 24.1-46.3%). No adverse events were reported. The community-led pay-it-forward incentives improved HBV and HCV testing among men who have sex with men. Clinical Trial registration: ChiCTR 2100046140.

Expanding hepatitis C virus test uptake using self-testing among men who have sex with men in China: two parallel randomized controlled trials

BACKGROUND

HCV self-testing (HCVST) may be an effective strategy to address low rates of HCV test uptake among men who have sex with men (MSM). We evaluated the effectiveness and cost of providing HCVST to increase HCV test uptake among MSM in China.

METHODS

Two parallel, unmasked, individual-level randomized controlled trials were conducted. HIV-negative MSM and MSM living with HIV were enrolled from 22 cities in China. Men in both trials were randomly assigned (1:1) into standard-of-care (SOC) or HCVST arms. The primary outcome was the proportion of participants who tested for HCV during the trial period. Intervention effects were estimated using multiply imputed data in the main analysis. Costs were measured using a micro-costing approach.

RESULTS

A total of 84 men who were HIV-negative (trial 1) and 84 men living with HIV were enrolled (trial 2). Overall, the proportion of individuals who underwent HCV testing during the trial period was higher in the HCVST arm compared to SOC in trial 1 (estimated risk difference (RD): 71.1%, 95% CI: 54.6 to 87.7%) and trial 2 (estimated RD: 62.9%, 95% CI: 45.7 to 80.1%). Over half (58.6%, 34/58) of HCV self-testers reported the self-test was their first HCV test. The cost per person tested in trial 1 was $654.52 for SOC and $49.83 for HCVST, and in trial 2 was $438.67 for SOC and $53.33 for HCVST.

CONCLUSIONS

Compared to the standard of care, providing HCVST significantly increased the proportion of MSM testing for HCV in China, and was cheaper per person tested.

TRIAL REGISTRATION

Chinese Clinical Trial Registry.

REGISTRATION NUMBER

ChiCTR2100048379.

Assessing feasibility of a modified same-day test-and-treat model for hepatitis C among rural people who inject drugs

BACKGROUND

Despite advancements in hepatitis C virus (HCV) treatment, low uptake among hard-to-reach populations remains a global issue. The current study aimed to assess the feasibility of a modified same-day test-and-treat model in improving HCV care for people who inject drugs (PWID) living in resource-constrained rural areas.

METHODS

A pilot study was conducted in four primary healthcare (PHC) centers in Malaysia. The model's key features included on-site HCV ribonucleic acid (RNA) testing using a shared GeneXpert® system; noninvasive biomarkers for cirrhosis diagnosis; and extended care to PWID referred from nearby PHC centers and outreach programs. The feasibility assessment focused on three aspects of the model: demand (i.e., uptake of HCV RNA testing and treatment), implementation (i.e., achievement of each step in the HCV care cascade), and practicality (i.e., ability to identify PWID with HCV and expedite treatment initiation despite resource constraints).

RESULTS

A total of 199 anti-HCV-positive PWID were recruited. They demonstrated high demand for HCV care, with a 100% uptake of HCV RNA testing and 97.4% uptake of direct-acting antiviral treatment. The rates of HCV RNA positivity (78.4%) and sustained virologic response (92.2%) were comparable to standard practice, indicating the successful implementation of the model. The model was also practical, as it covered non-opioid-substitution-therapy-receiving individuals and enabled same-day treatment in 71.1% of the participants.

CONCLUSIONS

The modified same-day test-and-treat model is feasible in improving HCV care for rural PWID. The study finding suggests its potential for wider adoption in HCV care for hard-to-reach populations.

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.

Hepatitis B and C mortality from 1990 to 2019 in China: a Bayesian age-period-cohort analysis

Background

Significant decreases in hepatitis B virus (HBV) and hepatitis C virus (HCV) infections have been observed in China, but both remain leading public health challenges. Estimating the components and trends in HBV and HCV mortality is vital for disease control planning. The current analysis investigated time trends in hepatitis B and C mortality and the relationships with age, period, and birth cohort from 1990 to 2019. We also made projections for 2030-2034 in China.

Methods

Mortality data related to hepatitis B and C were obtained from the Global Burden of Disease (GBD) study, which was stratified by complications, age, sex, and specific geographical locations. An age-period-cohort (APC) analytical framework was adopted to measure age, period, and cohort effects, which fits a log-linear Poisson model over a Lexis diagram of observed rates and quantifies the additive effects of age, period, and birth cohorts. We estimated longitudinal age curves (expected longitudinal age-specific rates), net drift (overall annual percentage change), local drift (annual percentage change in each age group), period, and cohort relative risks. A Bayesian APC analysis was used to project future age-specific hepatitis B and C deaths.

Results

In China, the age-standardized mortality rate (ASMR) of hepatitis B and C decreased by 67% and 58% from 1990 to 2019, respectively. The overall annual percentage changes in hepatitis B and C were -4.97% and -6.49% for males and -3.85% and -6.09% for females, respectively. After adjusting for period and cohort effects, we observed an exponential increase in hepatitis C mortality with age, with the Bell-like curves peaking at approximately 50 years old for hepatitis B. The Bayesian APC analysis projected that hepatitis B and C deaths would decrease dramatically by 42% and 22% for the periods 2016-2019 and 2030-2034, respectively. The declines in ASMRs related to hepatitis B and C were associated with the improvements in the Chinese Socio-Demographic Index.

Conclusions

Although the burden of hepatitis B and C mortality is likely to continue declining in China, the hepatitis B and C mortality was still high. Therefore, the national efforts should still be strengthened to achieve the global hepatitis elimination targets.

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

INTRODUCTION

As a country that is heavily burdened by hepatitis C, China's successful responses to this public health threat have significant implications for the achievement of the global elimination goal.

METHODS

This article reviews China's strategies for prevention, screening, diagnosis, access to direct-acting antiviral agents (DAA) therapy, and patient management of hepatitis C. It also analyses the major challenges and summarizes the valuable successful international experiences that have implications for China to achieve the elimination goal.

RESULTS

To promote the achievement of elimination, China has taken a series of proactive measures to promote the prevention and treatment of hepatitis C. Compared with other middle-income countries, there is still much room for China to achieve universal screening, diagnosis and treatment based on a streamlined disease management procedure. A stronger role of primary care in an integrated healthcare delivery system and integration of hepatitis C with other infectious disease programs should also be the focus of China's efforts.

CONCLUSIONS

As a developing country with a large population, a "micro-elimination" strategy with focused screening and proactive diagnosis and treatment for the vulnerable population may be a more practical approach to eliminating hepatitis C in China. Continued efforts are needed to fully overcome the intellectual property barriers of sofosbuvir for forming the more competitive pan-genotype DAA combinations based on the locally developed DAAs. Meanwhile, the safety net for patients in economic hardship needs to be further strengthened. More importantly, it is necessary to promote patients' willingness and compliance with standard treatment through increased awareness of hepatitis C. The development of an integrated healthcare delivery system, a disease management procedure which is suitable for primary care, and full compliance of the primary care providers are also important to achieve effective cascade care management.

Cost-Effectiveness of a Core Antigen-Based Rapid Diagnostic Test for Hepatitis C

OBJECTIVES

Hepatitis C virus (HCV) affects 58 million worldwide and > 79% of people remain undiagnosed. Rapid diagnostic tests (RDTs) for HCV can help improve diagnosis and treatment rates. Nevertheless, the high price and infrastructure needed to use current molecular HCV RDT options present a barrier to widespread use-particularly in low- and middle-income countries. We evaluated the performance and cost-effectiveness of a theoretical core antigen (cAg) RDT for HCV viremia confirmation, which requires fewer resources.

METHODS

We adapted a previously validated microsimulation model to simulate HCV disease progression and outcomes under different HCV testing algorithms in Georgia and Malaysia. We compared standard of care testing with laboratory-based ribonucleic acid HCV to a cAg-based RDT for HCV confirmation. We simulated a cohort of 10 000 adults in each country, with an HCV-ribonucleic acid prevalence of 5.40% in Georgia and 1.54% in Malaysia. We projected the cumulative healthcare costs, quality-adjusted life-years, and diagnosis coverage rates over a lifetime horizon.

RESULTS

Compared with the standard of care testing, the cAg-based RDT would increase quality-adjusted life-years by 270 in Georgia and 259 in Malaysia per 10 000 people. The high diagnosis rate and treatment rate of the cAg-based RDT result in substantial cost savings because of averted HCV sequelae management costs. Cost savings are $281 000 for Georgia and $781 000 for Malaysia.

CONCLUSIONS

We found that a cAg-based RDT for HCV could improve the diagnosis rate and result in cost savings. Such a test could have a substantial impact on the feasibility and cost of HCV elimination.

Feasibility of Hepatitis C Elimination in China: From Epidemiology, Natural History, and Intervention Perspectives

Hepatitis C imposes a heavy burden on many countries, including China, where the number of reported cases and the incidence of hepatitis C virus (HCV) increased yearly from 2005 to 2012, with a stable trend after 2012. The geographical distribution of HCV infections varies widely in China, with the northwest and southwest regions and the Henan Province showing a high disease burden. Elderly, men, sexually active people, drug users, migrants, blood transfusion recipients, and renal dialysis patients have become the target populations for hepatitis C prevention and control. It is important to improve the diagnosis rate in high-risk groups and asymptomatic people. Identifying secondary HCV infections, especially in HCV patients co-infected with the human immunodeficiency virus (HIV) is a priority of hepatitis C prevention and control. Enhancing universal access to direct antiviral agents (DAAs) treatment regimens is an effective way to improve the cure rate of HCV infection. For China to contribute to the WHO 2030 global HCV elimination plan, strategic surveillance, management, and treatment program for HCV are needed.

TRIPS to Where? A Narrative Review of the Empirical Literature on Intellectual Property Licensing Models to Promote Global Diffusion of Essential Medicines

Governed through the World Trade Organization Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) since 1995, the current medical R&D system requires significant trade-offs between innovation and high monopoly prices for patented drugs that restrict patient access to medicines. Since its implementation, few amendments have been made to the original TRIPS agreement to allow low- and middle-income countries (LMICs) to facilitate access by generic manufacturers through flexible provisions, such as compulsory licensing and parallel import. Although a useful policy tool in theory, the routine use of TRIPS flexibilities in LMICs in the procurement of new essential medicines (EMs) is regarded as a 'last resort' due to strong political response in high-income countries (HICs) and new trade agreements' restrictions. In this context, access-oriented biomedical Public-Private Partnerships (PPPs) have emerged. More recently, leading multilateral health organizations have recommended different types of intellectual property (IP) interventions, voluntary biomedical patent pools, as strategies to reduce prices and increase the diffusion of novel EMs in LMICs. Nevertheless, the recent Ebola and COVID-19 outbreaks highlight growing concerns regarding the use of TRIPS flexibilities and the limited success of voluntary mechanisms in promoting access to medicines in the Global South amidst health crises. This review aims at describing the state-of-the-art empirical research on IP-related options and voluntary mechanisms applied by emerging PPPs to guarantee timely and affordable access to EM in LMICs and reflect on both models as access paradigms. Some suggestions are put forward for future research paths on the basis of these analyses and in response to contemporary debates on waiving key IP rights on COVID-19 therapies, diagnostics, and vaccines.