Editorial
Viral hepatitis: setting sights on the right target
Viral hepatitis is gaining greater attention as the scale
of the disease burden has become impossible to ignore.
This recognition was reaffirmed earlier this year by the
World Health Assembly’s resolution on viral hepatitis,
which outlined that these infections were responsible
for 1·4 million deaths each year. Meaning they are
major causes of infection attributable deaths, such
as HIV (1·6 million deaths), tuberculosis (1·3 million),
and malaria (600 000). More worrying still, it was
acknowledged that most people infected with hepatitis B
or C virus were unaware that they were infected.
A key element of this resolution was a commitment to
assess the feasibility of eliminating hepatitis B and C with
a view to potentially setting targets. Elimination of these
infections will be an enormous task, but that this is now
being contemplated is some indication of the advances
made so far. However, a major obstacle on the path
towards elimination will be ensuring that treatments
are accessible to people in low-income and middle-
income countries and that prevention and treatment
measures reach marginalised groups. In the context of
hepatitis C, people who inject drugs must be placed at
the centre of prevention and treatment planning since
they are disproportionately affected by this infection.
This month in The Lancet Infectious Diseases Sunil
Solomon and colleagues assess the burden of hepatitis C
in people who inject drugs in India. They highlight that so
far this population, which is at the intersection of groups
(ie, injection drug users and from a low-income country)
that should be proactively targeted for prevention
and treatment, are not a health priority in India. In an
accompanying Comment Avina Sarna and Samiran
Panda express a lack of surprise in what they describe as
the neglect of hepatitis C. A major problem identified in
the research was that only 5% of seropositive people who
inject drugs were aware of their serostatus. Awareness
of serostatus is a pillar of hepatitis C prevention and
treatment.
Also this month, Rajender Reddy and colleagues report
their non-inferiority phase 3 trial comparing simeprevir
versus telaprevir for the treatment of hepatitis C virus
infection in patients who have previously not responded
to treatment. They found that simeprevir was non-
inferior, and they postulated that simeprevir might
improve compliance since it is taken as a single capsule
www.thelancet.com/infection Vol 15 January 2015
rather than the six tablets of telaprevir. Good adherence
to antivirals will be key to any plans to eliminate viral
hepatitis. In a Comment accompanying this trial,
Geoffrey Dusheiko points out that the important
Tek Images/ Science Photo Library
finding is that simeprevir has a better safety profile than
telaprevir. Also he suggests that the real advantage of
this drug is that it can be used in combination with other
direct-acting antiviral drugs in interferon-free regimens.
In one sense short-duration interferon-free regimens
will bring the goal of viral hepatitis elimination much See Comment pages 2 and 4
See Articles pages 27 and 36
closer, but they will also introduce new complications.
For the WHA’s resolution on
These new drugs have been coming to market with very viral hepatitis see http://www.
high prices, clearly aimed at high-income countries. who.int/mediacentre/news/
releases/2014/WHA-20140522/
The danger here is that this pricing ignores low-income en/
and middle-income countries where the bulk of the For more on cost of hepatitis C
drugs see Newsdesk
disease burden is present. Dusheiko emphasises that it is Lancet Infect Dis 2014;
inadvisable to operate a two-tier system where patients 14: 452–53
in low-income and middle-income countries receive For more on the Viral Hepatitis
summit see http://www.
current interferon-based regimens and patients in rich viralhepsummit.com/
countries are given the new interferon-free regimens. For The Lancet Commission on
liver disease in the UK see
Efforts need to be made to harmonise access to these
http://www.thelancet.com/
more effective drugs. commissions/crisis-of-liver-
disease-in-the-UK
The cost of these drugs does not only hinder access
in poorer countries. In the recent Lancet Commission
on liver health in the UK, the authors point out that,
even if renegotiated, the cost of these drugs would
mean that their availability would need to be restricted.
Not a strategy conducive to the elimination of viral
hepatitis. Particularly since this will add to the logistical
and financial costs by creating a need to identify and
prioritise patient groups. Despite the logic of targeting
people who inject drugs, it is easy to imagine that these
people will not initially be among the prioritised groups
who receive these expensive medicines.
To contribute to the debate and help drive progress,
The Lancet Infectious Diseases will be hosting a meeting
on viral hepatitis in Shanghai, China, on April 10–12,
2015. If elimination of viral hepatitis is to become a
reality, bold steps will need to be taken. One lesson
from tackling HIV is that marginalised groups only
become an important focus of policy after other
groups are reached. To effectively deal with viral
hepatitis goals from the outset must primarily target
marginalised people and low-income and middle-
income countries. ■ The Lancet Infectious Diseases
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