Challenges of Viral Hepatitis Treatment In Ethiopia

Mengistu Erkie.MD
Consultant Internist,Gastroentrologist & Hepatologist
Department of Internal Medicine
Division of Gastroenterology & Hepatology
August -2021
Introduction
• High disease burden globally and regionally
• Sixty million people in sub-Saharan Africa were living with chronic hepatitis
B infection in 2015.
• Annually more than 200,000 people in Africa are dying from complications
of VH-related liver disease.
• High burden in Ethiopia
• Prevalence of HBV is 9.4%
• Prevalence of HCV 3.1%
• Risk of developing cirrhosis -20%, about 20% develops
decompensation, 10% HCC.
• Only few are aware of their status
• Very limited are linked to care for treatment
 WHO Goals for Viral Hepatitis Elimination

Eliminate viral hepatitis as a

major public health threat by
2030

Prevention targets
 90% of infants have HBV birth
dose vaccination
 100% of blood donations
screened
 90% have access to safe
injections
Testing targets
 90% of people aware of infection

Treatment targets
 80% of eligible people treated
WHO. Global health sector strategy on viral hepatitis, 2016-2021. Slide credit: clinicaloptions.com
WHO: 2020 and 2030 Impact Targets
10
Hepatitis B + C

New Infections and Deaths (Millions)

8 New Infections
Deaths
6

4
30% 90%
Reduction Reduction
2

10% 65%
Reduction
Reduction
0.5

0
2015 2020 2025 2030

WHO. Global health sector strategy on viral hepatitis, 2016-2021. Slide credit: clinicaloptions.com
How Can We Achieve the WHO Elimination Goals?
Prevention Measures Diagnosis and
Treatment

Improve blood Vaccinatio Extend Prevent Expand

safety and n harm MTCT testing and
infection reduction treatment for
control measures those already
infected

WHO. Global health sector strategy on viral hepatitis, 2016-2021 . Slide credit: clinicaloptions.com
Identifying Priorities to Improve HCV Outcomes
100% HCV Care Cascade in the United States
100

80
Patients (%)

60
50%
43%
40
27%
20 17% 16%
9%
0
Chronic Diagnosed Access HCV RNA Liver Prescribed Achieved
HCV and to Care Confirmed Biopsy HCV SVR
Infected Aware Treatment
n = 3,500,000 1,743,000 1,514,667 952,726 581,632
555,883 326,859 Slide credit: clinicaloptions.com
Yehia. PLoS One. 2014;9:e101554.
Challenges (Weakness and threat)

 Highly centralized selected treatment centers.

 Lack of systematic screening for high risk groups (HIV, pregnant etc.)
 Inadequate trained health care providers
 Low public awareness
 Limited/expensive access to diagnostics
 Lack of linkage service from screening centers
 Lack of complete national data
 Absence of Key indicators
 Non existent organized systematized Hepatitis surveillance
 High cost of the drugs and the diagnostics
 Gap on establishing social insurance system instead of out of pocket service.
 Less attention at global and national levels
• Limited donors to support the program
Challenges (HBV)

●
Investigations are not readily available/expensive
●
Diagnostic:
– HBsAg- Rapid, ELISA
– Anti HBc Ab, HBeAg
– HBV Viral load (PCR)
●
Liver disease assessment
●
Clinical skills and workup
●
Grading of liver fibrosis- significant proportion are late
presenters with advanced liver disease
Challenges -HBV

●
Drugs are not readily available/expensive:
●
TDF, TAF
●
ETV
●
Lack of resources for monitoring:
– Viral load
– HBsAg titers, HbeAg
– HCC monitoring.
Challenges-HCV
●
Lack of/ unaffordable:
●
Diagnostics
– HCV- Rapid, ELISA
– HCV RNA Viral load-PCR , HCV Ag
– Genotyping
●
Liver disease severity assessment
●
Liver stiffness or other non invasive measurement
●
Liver biopsy service
●
Treatment related
●
Cost of drugs
●
Post treatment Monitoring- SVR and surveillance for HCV
Challenges -Advanced liver disease

●
Late presenters with advanced clinical stages
●
Life long therapy
●
Affordability, availability
●
Drug side effect and burn outs
●
Lack of advanced therapies: including transplantation
Guiding Principle- MOH

Under guidance of universal health converge which includes:

- Accessibility
- Affordability
- Availability
- Equity
- Government Ownership
- Partnership:.
Enablers

 Availability of policy documents (National guidelines and NSP)

 Presence of coordination platform/TWG
 High Childhood hepatitis vaccination coverage
 Piloting of birth dose initiated aiming national scale-up
 Presence of IPC program -injection and blood safety
 Availability of blood safety program
 Availability of M&E tools with standard indicators
 Commitment of stakeholders to support the national program
 Availability of antiviral that cure/treat Hepatitis C/B
 Possibility of getting drugs through price negotiation
• Presence of global hepatitis elimination strategy by 2030.
 National guideline

• Policy and planning

• Prevention and promotion
(Vaccination, safety
• Access to care
• Information system
VH targets in 5 years (2025)

• HBV Vaccine coverage

• Child hood –from 67% to 95 %
• Birth dose vaccine from 0% to 92%
• Blood safety: 100%
• Safe injection: 100%
• HBV diagnostic from<1% to 65%
• HCV diagnostic from <1% to 65%
• HBV and HCV treatment from <1% to 60%
The way forward (according to the NSP)
Treatment coverage target 60% by 2025, 80% by 2030.

key interventions include:

– Scale-up treatment services for VH-public health approach

– Setting package of services to be provide at each level
– Regularly update treatment protocols
– Provide quality treatment
– Appropriate disease staging,
– Timely treatment initiation,
– Toxicity monitoring,
– Management of Advanced LD
– Address common comorbidities (HIV, Alcohol abuse)
– Equitable distribution of drugs