It’s seldom spoken about and the biggest cause of liver cancer in South Africa, but experts warn if the aggressive sting of hepatitis, often a silent killer, is not tamed the viral infection could kill more people than HIV and TB in the next 15 years.
Despite being vaccine-preventable, hepatitis B virus (HBV) infection remains the world's seventh leading cause of mortality. In South Africa it is endemic, with hepatitis B affecting about 3.4-million people — almost half the number of HIV cases (7.5-million). Hepatitis C, which is curable, affects about 400,000 people in South Africa and the prevalence among those injecting drugs is more than 90%.
Despite the government making inroads in hepatitis prevention, such as introducing childhood vaccination, public health experts argue political will and investment to prevent and treat hepatitis is needed to turn the tide.
“Hepatitis B infection is preventable via vaccination and hepatitis C is curable using very effective direct acting antivirals, but unfortunately only two hospitals have such medications in South Africa — Groote Schuur Hospital in Cape Town and Steve Biko Academic Hospital [in Gauteng]. The rest of the population doesn’t have access to such treatment as they are not widely available in the public sector. In the private sector these drugs are unaffordable and cost about R25,000 per course,” said Dr Andrew Scheibe, a harm reduction expert and technical adviser at TB HIV Care.
We are sitting on the precipice of a public health emergency.
— Finn Jarle Rhode, executive director of the Hepatitis Fund
Despite evidence showing hepatitis C among drug users is transmitted through sharing needles, Scheibe said not much is being done to scale up harm reduction programmes and the handful South Africa has are donor-funded.
“One of the key things for preventing hepatitis C is to have access to clean needles and syringes, but we are still relying on donors for needle and syringe services and also opioid substitution therapy, which is the treatment for heroin dependence. It’s problematic that we're relying on donors and the demand for harm reduction is not being met. Hepatitis is not getting enough attention or the resources it requires, and there is no hope we will end [it] any time soon unless we do something drastic,” said Scheibe.
Hepatitis is in the spotlight after last week's inaugural Global Hepatitis Resource Mobilisation Conference in Geneva, which aimed to raise $150m (R2.8bn) to support countries committed to the elimination of viral hepatitis and which have taken action to implement programmes to this end.
Hosted by the Hepatitis Fund and Clinton Health Access Initiative (CHAI), Saudi Arabia and Egypt, the pledging conference is similar to other pledge meetings around HIV, TB and malaria conducted by The Global Fund. Two new memorandums of understanding were signed that resulted in generic manufacturers Viatris and Hetero pledging their support to hepatitis elimination by 2030.
Both manufacturers will offer WHO pre-qualified Sofosbuvir and Daclatasvir, a 12-week, once daily oral treatment for hepatitis C, at a ceiling price of US$60 (R1,154) per patient course of treatment.
The pharmaceutical companies will also offer FDA-approved Tenofovir disoproxil fumarate (TDF) tablets, used for hepatitis B treatment at a ceiling price of $29.
Finn Jarle Rhode, executive director of the Hepatitis Fund, said: “We are sitting on the precipice of a public health emergency, one that threatens to kill more people than HIV, TB and malaria combined if nothing changes. This pricing commitment marks the beginning of that change.”
Dr Mark Sonderup, a hematologist Groote Schuur Hospital's liver clinic, said despite the devastating effects of the virus — which causes inflammation of the liver, resulting in cirrhosis, liver failure and cancer — it remains neglected and highly stigmatised in South Africa.
“It’s encouraging that the global health sector is showing commitment to eliminate hepatitis or drive down new infections of hepatitis, which remains heavily stigmatised, not spoken about and, most importantly, poorly known about. Because patients don’t have symptoms they often present to us when they have already developed liver cancer and often it's too late to do anything.”
While the country’s childhood vaccination scheme was introduced in 1995, Sonderup said more political will was needed, including routine screening at clinics, prevention of mother-to-child transmission and by introducing hepatitis vaccination at birth.
Sonderup said such political will enabled countries such as Egypt, which had the highest prevalence of hepatitis C in the world, to conduct a successful screening programme that covered more than 50-million people and treated more than 4-million people. It is the first country in the world poised to eliminate hepatitis C within its borders.
“We need to start upscaling primary healthcare clinics to screen people for hepatitis B and C. Then we need to make sure treatments are available. We need to make sure we have requisite skills to link people to care. It’s not difficult ... we did it with HIV and we can do it again with hepatitis where nurses treat patients, for instance, as opposed to a doctor.
“If we leverage that platform, not destabilise that platform but build on it, then we can get going because the tools are there. The treatment is there for those who need treatment, we just need to do it.”
Sonderup said one of the promising interventions the government “has been talking about but not yet implemented”, is the WHO-recommended introduction of hepatitis B vaccine at birth, a move that would help eliminate new infections as many children often missed certain doses of hepatitis vaccine, offered at ages between one and six months.
Health department spokesperson Foster Mohale said: “South Africa ascribes to the WHO recommendations as it regards the management of hepatitis B and hepatitis C virus and welcomes the agreements made at the mobilisation conference. This includes recognising and working collectively towards the triple elimination of HIV, viral hepatitis and syphilis.”
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