Sub-Saharan Africa is home to 9% of the global PWID population. Globally, an estimated 52% of PWID have hep C infection, however, Saayman et al found that the infection rate of PWID living in Pretoria are much higher. Their study showed that 84% of PWID were infected, with genotypes 1 and 3 predominating.^1,2 

A systematic review by Jin et al found that the global prevalence of hep C infection is 1.5% in HIV-negative MSM and 6.3% in HIV-positive MSM. The pooled prevalence of hep C in MSM is highest in Africa (5.8%). Infection is substantially higher in MSM who injected (30.2%) or currently inject drugs (45.6%) than in those who have never injected drugs.³  

According to Sonderup et al, unsafe blood supply in many parts of sub-Saharan Africa has contributed to hep C transmission. In the late 1990s, only 19% of blood was screened for the hep C virus in sub-Saharan Africa, due to high costs. Blood transfusions were therefore a major source of transmission.⁴  

Other healthcare-related factors that contributed to hep C transmission include therapeutic injections with re-used syringes or unsterilised needles and unsafe injection practices during vaccination campaigns.⁴  

What are some of the challenges that need to be overcome to eliminate hep C?  

According to the World Health Organization (WHO), the following challenges pose a risk to the effective implementation of elimination strategies:⁵  

1. Data are inadequate: The true impact of hepatitis epidemics are poorly understood in many countries.  
2. Coverage of prevention programmes is limited: Prevention programmes, particularly for specific populations that are most affected and at risk, are often of limited in scope and coverage. Global coverage of harm reduction programmes for PWID, including needle and syringe programmes, is less than 10%.  
3. Most people do not know their hepatitis status: Simple and effective hepatitis testing strategies and tools are lacking, with less than 5% of people with chronic infection knowing their status.   
4. Few have access to treatment and care services: It is estimated that less than 1% of individuals with chronic infection have access to effective antiviral therapy.  
5. Medicines and diagnostics are unaffordable for most: The high prices of medicines and diagnostics are major barriers to access in most countries.  
6. A public health approach to hepatitis is lacking: Hepatitis programmes need to be overhauled and require people-centred health services that can reach populations that are most affected.  
7. Structural barriers increase vulnerability and prevent equitable access to services: Key groups at highest risk of hep C infection (eg PWID, MSM, prisoners, and sex workers) often experience stigmatisation as well as discrimination, hindering their access to healthcare services.

Schröeder et al highlighted the following key challenges in South Africa that need to be addressed:²  

• Lack of funding allocated to programmes aimed at eliminating hepatitis 
• A shortage of trained healthcare workers  
• Lack of knowledge about viral hepatitis in the general public  
• Punitive drug laws. 

How can these challenges be overcome?  

In 2016 the World Health Assembly adopted the Global Health Sector Strategy on Viral Hepatitis. The strategy outlines five prevention and treatment targets aimed at the elimination of viral hepatitis by 2030 (see figure 1). Key recommendations include the reduction of new infections by 90% and hep C virus-related liver mortality by 65%.²  

Underdiagnosis and undertreatment 

 According to the WHO, the number of people receiving treatment for chronic hep C increased almost 10-fold since 2015, reducing hep C-related mortality, however, nearly 80% of people remain undiagnosed, and affordable treatments are not being accessed.⁶  

Terrault points out that underdiagnosis is the largest gap in the cascade of care. To meet the 90% diagnosed target by 2030, the WHO strategy calls for the reduction of ~500 000 new cases by 2025 (from 20 per 100 000 population from the 2020 baseline to 13 per 100 000) and a reduction of ~1.2 million by 2030 (five per 100 000).⁷   

Terrault stresses that innovative strategies are needed to increase screening and testing if the 90% target is to be met. She calculated that this means that 89 000 diagnoses per year must be made between 2020 and 2024, and more than 70 000 per year between 2025 and 2030.⁷   

The Centers for Disease Control and Prevention recommend hep C screening at least once in a lifetime for all adults aged 18 years and older, and all pregnant women during each pregnancy, except in settings where the prevalence of hep C viral infection is less than 0.1%.⁸  

Screening and testing opportunities are available in the emergency room department setting at retail pharmacies, sexually transmitted disease clinics, and prenatal clinics, but follow-up is challenging.⁷    

Another reason why hep C goes undiagnosed for many years, write Stacey et al, is that symptoms are often non-specific and frequently attributed to other illnesses. These include depression, fatigue, difficulty concentrating, skin problems, insomnia, pain, and digestive disorders.⁹  

“In fact, hep C infection is often picked up by doctors when they do a liver function test while monitoring for another medical condition. Infection is then confirmed with hep C viral antibody and viral RNA testing. For these reasons, hep C is often referred to as the ‘silent epidemic’,” add the authors.⁹   

Undertreatment 

In the past, treatment of hep c was complex, associated with frequent side effects, and was lengthy (24 to more than 48 weeks). Furthermore, injections had to be administered by a specialist physician, resulting in the undertreatment of patients. Direct-acting antivirals (DAAs) provide a simple, well-tolerated, and highly effective treatment, and cure rates are approaching 100% in adherent patients.⁷  

According to the WHO, the development of DAAs has revolutionised the treatment of hep C infection, making it possible to treat patients without advanced fibrosis in primary care. An estimated 3.26 million children and adolescents globally have hep C. The WHO now recommends hep C treatment for adolescents.^5,6,7  

How is South Africa faring?  

According to Schröeder et al, South Africa's National Action Plan 2017‐2021 was one of the first that combined costing, impact modelling, cost-effectiveness, and a fiscal analysis for scaled-up hep B and C disease control.²  

The action plan assessed cost and affordability, health impact, and cost-effectiveness for four priority interventions: hepatitis B birth dose vaccination, prevention of mother-to-child-transmission, and treatment for hep B and C.² For the purposes of this article, the focus will be on hep C.  

The modelling data suggest that the initial five‐year investment could avert an estimated 7000 hep C-related deaths. Moreover, a continued expansion of the treatment programme beyond 2021 has the potential to avert 60 000 deaths from hep C-related liver disease, which would put South Africa firmly on the path to achieve elimination by 2030.² 

 However, at the time of developing the action plan, one of the key challenges facing effective implementation, according to Schröeder et al, was the fact that DAAs were not yet approved in South Africa.²   

The good news is that Gilead Sciences, a biopharmaceutical company, recently announced the launch of fixed-dose co-formulation sofosbuvir (NS5B inhibitor) and velpatasvir (NS5A inhibitor).¹⁰  

According to the data derived from the action plan, treatment using DAAs is cost-effective and affordable in the South African context.² In South Africa, co-formulation sofosbuvir-velpatasvir is indicated for the treatment of chronic hep C infection irrespective of genotype in treatment naïve or treatment-experienced patients aged 12-years and older and weighing at least 30kg:  

• Without cirrhosis, or with compensated cirrhosis  
• With decompensated cirrhosis in combination with ribavirin.¹⁰ 

Conclusion  

In 2019, the WHO presented its first hepatitis scorecard for Africa and unfortunately, it showed that South Africa was not on track to achieve hep C elimination by 2030.11  Can the approval of sofosbuvir-velpatasvir make a difference?  

Sonderup et al certainly think so. They write that the advent of DAAs, with few side-effects, short treatment course, and a sustained virological response rate above 90%, has made treatment of hep C infection simpler and provides the potential to achieve elimination.⁴   

REFERENCES: 

1. Saayman E, Hechter V, Kayuni N, et al. A simplified point-of-service model for hepatitis C in people who inject drugs in South Africa. Harm Reduct J 20, 27 (2023). https://doi.org/10.1186/s12954-023-00759-0 
2. Schröeder SE, Pedrana A, Scott N, et al. Innovative strategies for the elimination of viral hepatitis at a national level: A country case series. Liver Int, 2019 Oct;39(10):1818-1836. doi: 10.1111/liv.14222. Epub 2019 Sep 4. PMID: 31433902; PMCID: PMC6790606. 
3. Jin F, Dore GJ, Matthews G, Luhmann N, et al. Prevalence and incidence of hepatitis C virus infection in men who have sex with men: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol, 2021 Jan;6(1):39-56. doi: 10.1016/S2468-1253(20)30303-4. Epub 2020 Nov 18. PMID: 33217341. 
4. Sonderup MW, Afihene M, Ally R, et al. Hepatitis C in sub-Saharan Africa: the current status and recommendations for achieving elimination by 2030. Lancet Gastroenterol Hepatol 2017; 2: 910–19. 
5. World Health Organization. (‎2016)‎. [Internet]. Global health sector strategy on viral hepatitis 2016-2021. Towards ending viral hepatitis. Available from: https://apps.who.int/iris/handle/10665/246177. 
6. World Health Organization. (2022).[Internet] Global health sector strategies on, respectively, HIV, viral hepatitis and sexually transmitted infections for the period 2022-2030. Available from: https://cdn.who.int/media/docs/default-source/hq-hiv-hepatitis-and-stis-library/full-final-who-ghss-hiv-vh-sti_1-june2022.pdf?sfvrsn=7c074b36_13 
7. Terrault NA. Hepatitis C elimination: challenges with under-diagnosis and under-treatment. F1000Res. 2019 Jan 14;8:F1000 Faculty Rev-54. doi: 10.12688/f1000research.15892.1. PMID: 30687501; PMCID: PMC6338244. 
8. Centers for Disease Control and Prevention. Testing Recommendations for Hepatitis C Virus Infection. Available from: https://www.cdc.gov/hepatitis/hcv/guidelinesc.htm 
9. Stacey M, Lane T, Ofield-Kerr A, Orte O. [Internet]. Hepatitis C in South Africa: A primer for civil society on the need for action. May 2019. Available from: https://www.spotlightnsp.co.za/2019/05/16/hepatitis-c-in-south-africa-a-primer-for-civil-society-on-the-need-for-action/ 
10. Bosman R. New hope for South Africans living with hepatitis C. Specialist Forum, May 2023. Available from: https://www.medicalacademic.co.za/news/new-hope-for-south-africans-living-with-hepatitis-c/ 
11. World Health Organization. [Internet]. Hepatitis Scorecard for the WHO Africa Region Implementing the hepatitis elimination strategy. 2019. Available from: https://www.afro.who.int/publications/hepatitis-scorecard-who-africa-region-implementing-hepatitis-elimination-strategy