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AASLD 2016: U.S. Veterans Health System and Australia Show Potential for Rapid Hepatitis C Elimination


If sufficient money is available to pay for direct-acting antivirals (DAAs), the U.S. Veterans Health Administration could cure hepatitis C in the majority of veterans under its care within 3 years, and has already shown it has the capacity to start almost 7000 people on treatment in a single month, George Ioannou of the University of Washington in Seattle reported at the AASLD Liver Meeting last week in Boston.

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Data from Australia presented at the conference showed what happens when another big health system begins scaling up treatment. Since March 2016, 26,000 people are estimated to have begun DAA treatment in Australia, according to research carried out by researchers at the Kirby Institute at the University of New South Wales.

VA Cured 28,000 Patients of Hepatitis C in 2015 Alone

The U.S. Veterans Affairs Health Administration is the largest provider of hepatitis C care in the United States. Approximately 174,000 veterans who receive care through its clinics had been diagnosed with chronic hepatitis C virus (HCV) infection by 2013 and a further 45,000 were estimated to be undiagnosed.

As part of a larger analysis of treatment patterns within the VA system, Ioannou and colleagues examined the annual uptake of treatment. They found that 57,445 people have been cured of HCV in the VA system since 1999. Almost half of these patients -- 28,084 -- were cured in 2015, and almost half of all people cured in the VA system in 2015 began treatment in August and September of that year.

The reason for the sudden explosion in treatment numbers was a congressional decision to approve $500 million in funding for hepatitis C treatment for the VA, on condition that the money was spent in August and September 2015. This decision resulted in a jump in treatment initiations, from less than 1000 in July 2015 to over 4000 in August 2015 and almost 7000 in September 2015. Treatment numbers fell back after September 2015, but in 2016 restrictions on who can be treated were lifted after the cost of medication fell and funding for hepatitis C treatment was doubled. The investigators estimate that it will be possible to treat at least half the remaining 124,000 people with hepatitis C in the next 3 years if funding remains stable, achieving cure rates above 90% for genotype 1 HCV infection.

Australia: 26,000 Started Treatment in 5 Months

At the beginning of 2016 the Australian government announced that it would fund DAA treatment for anyone with hepatitis C, regardless of liver disease stage. The decision followed extensive campaigning by patient groups and negotiations with the pharmaceutical industry that resulted in an innovative pricing agreement. In return for committing to spend $1 billion on DAAs over 3 years, manufacturers agreed to provide treatment for that sum to everyone who sought treatment during that period.

Liver specialists and patient groups expected high demand, reflecting years of pent-up demand for treatment in Australia, but the pace of uptake has surprised everyone. In a poster presentation at The Liver Meeting, Behzad Hajarizadeh and colleagues at the Kirby Institute showed estimates of treatment uptake during the first 5 months of availability of DAAs through Australia’s Pharmaceutical Benefits Scheme (PBS), which covers almost all the cost of prescribed medicines for Australian citizens.

Data were gathered from PBS records and wholesale drug expenditure figures, and used to estimate the number of people starting treatment and the distribution of treated people across Australian states. The study also looked at which types of prescribers were starting people on treatment.

As its baseline, the study assumed that around 227,000 people were living with diagnosed HCV infection in March 2016. Analysis of the PBS records found that 18,581 people started treatment during the first 5 months of DAA availability, but due to the time lag between prescription filling and processing of the claim by the PBS, the number who started treatment was much higher. Analyzing the amount of money spent on medication led the researchers to estimate that around 26,000 people had begun treatment during the 5-month period (although this figure could be as high as 30,415 or as low as 22,304).

In March and April 2016 around 7000 people started treatment during each month. In subsequent months the numbers starting treatment fell below 4000 per month. The researchers estimate that around 12% of people with hepatitis C had begun treatment by the end of July 2015, although the proportion treated appears lower in Western Australia (7%) and Northern Territory (8%).

More than half of people (58%) started treatment with sofosbuvir/ledipasvir (Harvoni), and in the vast majority of cases this was a 12-week treatment course. Sofosbuvir plus daclatasvir (Sovaldi and Daklinza) was prescribed in 38% of cases. Paritaprevir/ritonavir/ombitasvir and dasabuvir (Viekira Pak or Viekirax) was prescribed to only 1% of people.

Taking into account people previously treated through clinical trials or early access programs, and those who obtained generics, the researchers estimate that two-thirds of people with cirrhosis have already begun treatment, the vast majority since March 2016.



AM Moon, P Green, K Berry, GN Ioannou, et al. Towards eradication of hepatitis C virus infection in the Veterans Affairs national healthcare system: a study of 107,079 antiviral treatment regimens administered from 1999-2015. AASLD Liver Meeting. Boston, November 11-15, 2016. Abstract 227.

B Hajarizadeh, J Grebely, G Matthews, et al. Treatment uptake for chronic hepatitis C in Australia following universal access to interferon-free treatments.AASLD Liver Meeting. Boston, November 11-15, 2016. Abstract 1917.

AASLD. 3 Years: The Time It Could Take To Cure Nearly Every Veteran with Hepatitis C. Press release. November 12, 2016.