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03 Dec 2018

Some years back, whilst I was still studying Global Health Policy and Management in Boston, Massachusetts, USA, I received an invitation to write two papers on former President Ian Khama’s response to the Country’s health challenges. I gladly accepted the invitation. 

The two papers were titled “The Game Changer: Khama at 5, Looking Back & Moving Forward in the control of Alcohol Abuse & Fighting HIV/AIDS” and another one titled “Non Communicable Diseases: Time for Botswana to take notice and Act.”

This piece dear reader provides an overview of accessibility to Hepatitis C Treatment, which presents itself as a neglected disease and yet it is a global health problem. 

It must be noted that when I served as a Global Health Fellow at WHO, Geneva Switzerland I was attached to the department of pandemic and epidemic diseases, policy unit. Amongst the many assignments I had was to develop Viral Hepatitis Self-Assessment Tools.

There is a reason why, I had to start the piece the way I did. There is also a reason for the reference on the development of the self assessment viral hepatitis tool at WHO as a Global Health Fellow.  It is mainly for the benefit of some village professor and a loud mouthed errand boy who are still finding it hard to make a connection of public health to the disciplines of public administration, political science, economics etc.

According to the World Health Organization (WHO), it is estimated that globally approximately 130 million to 150 million people live with a chronic hepatitis C virus (HCV) infection and it is estimated that 700,000 people die each year from hepatitis C - related liver diseases. 

Viral hepatitis is an international public health challenge, comparable to other major communicable diseases, including HIV, tuberculosis and malaria. Despite the significant burden it places on communities across all global regions, hepatitis has been largely ignored as a health and development priority until recently.

Although it is leading infectious cause of death and claims the lives of many people globally each year, it remains virtually unknown to the general public, at risk populations and policy makers, even health care providers lack knowledge and awareness about these infections. 

As a consequence most of the people living with Viral Hepatitis do not know that they are infected, placing them at greater risk for severe fatal complications from the disease and increasing the likelihood that they will spread the virus to others.

Given the difference in the geographical distribution, transmission, diagnosis and treatment A, B, C, D and E infections, tailored prevention and control strategies are required. A comprehensive approach to the prevention of the viral hepatitis includes a number of strategies. 

Primary Prevention. It aims to take into account the following: Advocacy and awareness creation about all types of Viral Hepatitis Infections. Availability of safe and effective vaccines for prevention of HAV,HBV and HEV effective public education as well as implementation of blood safety strategies including reliance on voluntary non-remunerated blood donations,   Prevention and control of transmission of viral hepatitis infection in different community settings. Safe injection practices against HBV and HCV transmission. Harm reduction practices for injecting drug users to prevent HAV,HBV and HCV transmission Safe food and water 

Secondary and Tertiary Prevention : It also allows the infected persons to take steps to prevent transmission of the disease to others. Early diagnosis of those with chronic infection also allows people to take precautions to protect the liver from additional harm, specifically by abstaining from alcohol and tobacco consumption and avoiding certain drugs which are known to be hepatotoxic.

Until the end of 2013, the standard treatment for Hepatitis C consisted of pegylated interferon injections over 24 to 48 weeks and complemented with ribavirin tablets twice a day. This treatment was costly, toxic, complicated to administer and with healing rates of less than 50 per cent. In late 2013, a new Hepatitis C treatment called direct - acting antivirals (or DAAs) was introduced in the market. In eight to twelve weeks of treatment these medicines could heal more than 90 per cent of persons with a chronic HCV infection. 

The new DAAs treatments were introduced by the firms Gilead Sciences and Bristol Meyer Squib (BMS) in 2014. Gilead has patented or applied for patents for three DAA compounds: sofosbuvir, ledipasvir and velpatasvir.  BMS has patented or applied for a patent on daclatasvir. As treatment in many cases must include both sofosbuvir and daclatasvir it means that there is a double barrier, two or more patents belonging to different firms.

Other transnational firms such as AbbVieand Janssen have also put DAAs on the market, while 

additional products are in the “pipe line” of these and other firms. However, for the foreseeable future, sofosbuvir will likely remain the dominant DAA. The first DAA launched by the North American firm Gilead Sciences, sofosbuvir, was put on the market at the exorbitant price of 84,000 US dollars for a twelve - week treatment. 

According to WHO, 18i n 2015, two years after the first DAAs came out, of the estimated 130 to 150 million people living with HCV only 275,000 persons received the new DAAs treatment, from which 170,000 were patients in Egypt, which is the country with the largest prevalence of Hepatitis C in the world. 

It is important to note that, there have only been a limited number of curative medicines launched by the pharmaceutical industry in the last 20 years. The new orally administered DAA medicines are effective and until now appear to be well tolerated. In April 2015, several DAAs were included in the WHO List of Essential Medicines, confirming once more that price is not an obstacle for a medicine to be considered an essential one. 

At the World Health Assembly in May 2016, WHO member countries approved the Global Health Strategy for Viral Hepatitis for the period 2016 -2021.  This strategy aims to eliminate Hepatitis B and C as a public health menace by 2030.  

As already indicated in this piece, in 2014 the American firm Gilead Sciences launched on the Market at a price of 84,000 US$ for a 12 -week treatment the Hepatitis C medicine known as Sofosbuvir. A group of British academics estimated that production costs for a twelve week treatment could reach in a figure that includes a profit margin of 50 per cent a price of 62 US$. Nevertheless, Gile ad Sciences has managed to negotiate prices with several governments that reveal large price differences between countries and, above all, prices that have nothing to do with production costs. 

Furthermore, the Gilead’s new business model reveals a philosophy of maximizing profits and ignoring any relationship between a medicine’s profits and R&D costs. In short, Gilead goes in search of the highest price governments are willing to pay even if governments are forced to pay prices that will make universal access impossible.

Do the rich world’s patents abandon the poor to die or is it their wealth or our lives? 

As to whether Botswana has put mechanisms in place to deal with the viral hepatitis C remains to be seen. 

Is there an underground health genocide going on in the country, where patients can no longer be taken to the hospitals in South Africa due to financial constraints. Perhaps it is about time the country looks into Universal Health Care Coverage, as there is also a greater need to look closely at Botswana National Health Accounts. 

*Thabo Lucas Seleke, Researcher & Scholar, Global Health Policy & Health Systems Strengthening

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