World Hepatitis Day is one of the most important dates in the Asia health calendar, with an estimated 340 million people living with either viral hepatitis B or C in the region. Despite this, these infections are low on the global and Asia health priority list – falling way behind the likes of HIV, TB and malaria, and often behind other less prevalent and life-threatening diseases.
A new global policy framework, Prevention and Control of Viral Hepatitis Infection: Framework for Global Action, published by the World Health Organization this week represents an opportunity to recalibrate and revitalize the global response to viral hepatitis. To do that, it is essential that we learn the lessons of the past and crucially, recognize that in the case of viral hepatitis, Asia has to be central to the global response.
Looking at the impact of these infections, the story for Asia is particularly stark – with the number of people infected with hepatitis B and C across the Western Pacific and South East Asian regions, as defined by the World Health Organization, being approximately eight times that for HIV, TB and malaria – which together affect an estimated 42 million people. More than 500,000 people die annually as a result of infection with hepatitis B and hepatitis C. Over the last decade, the lack of a coordinated response to viral hepatitis has directly affected 340 million people, and arguably their human rights. In recognizing this lack of attention the WHO states: These strategies will help combat the disease that, despite affecting 500 million people worldwide, remains largely unknown, undiagnosed and untreated.
Asia is the region with the largest number of people living with viral hepatitis of anywhere in the world. It accounts for 56% of the global hepatitis C population and 70% of the hepatitis B population. Based on these facts you would be forgiven for assuming that each and every country across the region would have a dedicated person leading a strategic response to these diseases, but that isn’t the case.
Without coordination and commitment of countries in the region, it will require a monumental effort to convert the new World Health Organization framework into sustainable action. This is particularly important in countries whose health systems are still in development. There are plenty of agencies, advocacy groups and seeming goodwill however – so what’s missing?
Earlier this year, the Coalition to Eradicate Viral Hepatitis in Asia Pacific (CEVHAP) convened a meeting of viral hepatitis experts, and crucially from the HIV sector to look at what lessons could be learnt from their experiences in driving political change. As the XVIII International AIDS Conference sees the HIV community gravitate to Washington this week, the hepatitis community is rallying around a day which after years of lobbying and tireless advocacy finally became an official World Health Organization-endorsed event last year.
There are many lessons that can be learnt from the HIV community when looking at ways to turn the tide on a disease that is as devastating to Asia as malaria has been to Africa. Some of these include:
Lesson 1: Prevention is better than treatment – there is a safe and effective vaccination for hepatitis B. The successful implementation of the vaccine program in the Asia Pacific region will eventually eliminate new infections. In terms of hepatitis C, prevention is more challenging, although ensuring a safe blood supply and implementing comprehensive infection control practices within health services, and more broadly within the community will reduce new infections. A poor understanding among the general community and populations most at risk, especially health care workers, initially undermined efforts to reduce the burden of HIV/AIDS. With approximately one in ten people living with viral hepatitis across Asia Pacific the same is happening today with hepatitis B and C, and strategies aimed at preventing new infections are vital if we are to begin the process of reducing the human and societal impact of these diseases.
Lesson 2: Treatment saves lives – much work has been done to develop new treatments and technologies across both HIV and viral hepatitis. The widespread use of antiretroviral therapy in the mid-1990s had an immediate impact on HIV related mortality. Not all people with chronic hepatitis B need pharmaceutical treatment, but they do need to be monitored to identify the progression of the infection. For hepatitis C, there have recently been significant advances in treatment of the infection which mean that treatment is more successful, in more people, more often. Simply put – treating viral hepatitis can also save lives.
Lesson 3: Coordination is the cornerstone of any framework – yes national strategies and policies are important, but the sum of these strategies is greater than their component parts. The work of organizations such as The Global Fund shows that individual countries can derive great benefits from coordinated national responses. A policy framework to combat viral hepatitis B and hepatitis C to prevent new infections, ensure patients receive timely treatment and clinical care, and that reduces the burden of infection at an individual, country and regional level are essential.
Lesson 4: Investment is critical – by 2000, when antiretroviral therapy had markedly reduced the impact of HIV in the United States, Europe and Australia, HIV-related mortality in Africa was still increasing. The reason for this was that access to the same medicines was extremely limited or not available at all. The Global Fund and United States PEPFAR, invested billions of dollars for AIDS care, and by 2010 the World Health Organization estimated that 6.6 million persons in low- and middle-income countries were on antiretroviral therapy. Viral hepatitis is an exclusion criterion for access to treatment provided by the Global Fund. In the case of hepatitis C, treatment can be measured in months, not years, and the example of HIV proves that investment works.
The agreement of resolution WHA63 R18 at the World Health Assembly in May 2010 and the new global framework are monumental steps in addressing viral hepatitis, but they risk falling flat unless lessons from the past are learnt and funding is increased significantly.
As with other global health threats, CEVHAP believes that the World Health Organization must establish a sustainable mechanism for international funding and implementation of the Global Hepatitis Programme similar to those for HIV, TB and malaria. International development agencies, governments as well as donor and philanthropic organizations must support the Global Hepatitis Programme.
While HIV/AIDS, TB and malaria are undeniably serious global threats, particularly for the African continent, for Asia Pacific viral hepatitis is arguably a greater threat. Its exclusion from initiatives such as the Millennium Development Goals has pushed viral hepatitis to the fringes of global health and for many the last ten years represent a lost decade. The future holds great promise, but we must all redouble our efforts to tackle these diseases.
Professor Stephen Locarnini is Joint Secretary of the Coalition to Eradicate Viral Hepatitis in Asia Pacific (CEVHAP) and Head, WHO Regional Reference Laboratory for Hepatitis B, Victorian Infectious Diseases Reference Laboratory, Melbourne, Australia. Jack Wallace is a Research Fellow at the Australian Research Centre in Sex, Health and Society at La Trobe University, Melbourne and a Founding Member of CEVHAP.