Hepatitis: it’s cheaper to treat than not to treat

By Dr Bernhard Schwartländer, WHO Representative in China

Vaccination of babies against hepatitis B over the last quarter of a century is one of China’s greatest public health success stories. Hundreds of millions of children have been saved from hepatitis B infection, their risk of developing liver cirrhosis and liver cancer later in life massively reduced. This is China at its best – a problem was identified, and a determined, methodical, and evidence-based approach was deployed to fixing it, with remarkable results.

It is now time to apply that same approach to the pressing issue of access to treatment for the tens of millions of people living with chronic hepatitis B or C in China who need treatment right now.

Viral hepatitis is a silent killer. Currently, there are about 100 million Chinese with chronic hepatitis B and C infection, but the majority of those infected are not aware they carry the virus. Without treatment, up to 3 in 10 chronically infected people will go on to develop life-threatening illnesses like cirrhosis and liver cancer.

The good news is that effective treatments for hepatitis are now available. Hepatitis B cannot be cured, but it can be effectively managed with drugs like tenofovir, also used to treat HIV. But currently, the same drug that is provided to people with HIV under China’s successful public health program costs 10 times as much for hepatitis B, because there is no public health program for hepatitis B. Further, this drug is not reimbursed under most health insurance schemes for hepatitis B – rendering it well and truly out of reach for most. Yet there are around 28 million people who need hepatitis B treatment in China – and among them, 7 million of whom need treatment urgently because they already have advanced liver disease and at high risk of developing liver cancer.

Advances in the science have now made it possible to cure hepatitis C completely, with drugs called ‘direct acting antiviral agents’. But for the 2.5 million people in China who have advanced liver disease caused by hepatitis C, these drugs are not yet available – because of the time it takes in China to have new drugs registered and approved for use. Currently, the only treatments for hepatitis C which are available are lengthy (they take 6 to 12 months of injections), much less effective, and come with a range of unpleasant side effects.

The gravity of the hepatitis epidemic in China can no longer be ignored. Too many people are suffering, and millions are dying deaths that could be avoided. So why don’t we just give all those in need the drugs that can save their lives? The answer we often hear is that it’s too expensive.

But the equation that produces this answer is wrong. Looking only at the current market price of the drugs and multiplying by the number of people in need only paints half the picture: people with advanced liver disease become sick, cannot work, and in the worst cases, die young. This comes at enormous cost to individuals, families, the economy, and broader society – which must be weighed against the cost of effective treatments. Further, about 85 million RMB ($14 billion USD) is already spent on less effective hepatitis treatment in China every year. If this amount were invested in more effective treatments, at a rational price, millions of people would be spared life-threatening liver disease. In other words: it is not treatment which is too expensive, it is the lack of treatment!

The solution lies in adjusting the way funding for hepatitis treatment is distributed. In the absence of a public health program, individuals can only access hepatitis B treatment through the private sector, with very high out-of-pocket costs. This needs to change. And for hepatitis C, we must find a way to fast track registration of the world’s best drugs for use in China to speed up access to cure.

Re-booting payments and distribution of finances within the health system is an enormous challenge. And of course, changing drug registration procedures cannot be done lightly: drug safety is crucially important, and a responsibility we know the Chinese government takes very seriously, as it should. But lives are at stake here.

China knows how to deliver successful, large-scale public health programs: the current generation of Chinese children, the first to be almost completely hepatitis B free, is testament to that. Now, it’s time to act to ensure that, in the future, no-one in China dies a hepatitis-related death that could have been avoided. Another chapter in the book on public health success stories in China is waiting to be written.

Note: An edited version of this opinion piece was published in China Daily.

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