Author: Tido von Schoen-Angerer, Jennifer Cohn, Tracy Swan, Peter Piot
In the first days of March, the governing body of UNITAID, the organisation financed mainly through a levy on air tickets, will decide on a new 4-year strategy. A 5-year evaluation1praised UNITAID's successful “market impact” model for improving access to HIV, tuberculosis, and malaria products through lowering prices, improving supply, or introducing new products. We believe UNITAID's new strategy should also include tackling a prevalent and serious, but curable, HIV co-morbidity: hepatitis C virus (HCV) infection.
Worldwide, an estimated 4—5 million people are HCV/HIV co-infected.2HCV is a leading cause of death in people with HIV in western settings and causes substantial morbidity and mortality in the many co-infected people in low-income and middle-income countries. HIV accelerates HCV progression, and HCV co-infection is associated with higher rates of all-cause, liver-related, and AIDS-related death.3,4
Access to treatment with pegylated interferon alfa and ribavirin is extremely limited in low-resource settings owing to the regimen's complexity, duration (48 weeks), and cost (up to US$30 000). Outcomes in low-income and middle-income countries are similar to those reported in high-income countries; sustained virological response for co-infection can be as high as 60% depending on genotype.5
Fortunately, the HCV drug pipeline is extremely promising, thanks to profitable markets in high-income countries. New, more tolerable, all-oral regimens are showing remarkable cure rates in clinical trials. These shorter regimens might no longer require genotyping or complex monitoring. Simpler, better treatment is key for resource poor settings—but new drugs must become available and affordable.
UNITAID is already committed to HIV co-morbidities; its expertise and track record in lowering antiretroviral prices for developing countries should now be applied to HCV. UNITAID can guarantee and pool initial drug demand, negotiate price reductions, and facilitate generic competition as appropriate and feasible, support quality assurance through WHO's Pre-Qualification Programme, introduce simpler diagnostics when becoming available, and generate demand forecasts, as countries start increasing access to HCV treatment. UNITAID's unique role is to lower prices; organisations such as the Global Fund to fight AIDS, Tuberculosis and Malaria and the US President's Emergency Plan for AIDS Relief should help in scaling up treatment.
Inclusion of HCV/HIV co-infection in UNITAID's new strategy would have a dramatic effect on health and keep UNITAID at the forefront of market impact interventions.
1ITAD. UNITAID 5 year evaluation. (accessed Feb 12, 2013).
2 Alter MJ. Epidemiology of viral hepatitis and HIV co-infection. J Hepatol 44 suppl 1): S6-S9. CrossRef;| PubMed
3 van der Helm J, Geskus R, Sabin C, et alfor the CASCADE collaboration in EuroCoord. Effect of HCV infection on cause-specific mortality following HIV seroconversion before and after 1997. Gastroenterology 2012. published online Dec 22.
4 Hernando V, Perez-Cachafeiro S, Lewden C, et al. All-cause and liver-related mortality in HIV positive subjects compared to the general population: differences by HCV co-infection. J Hepatol; 57: 743-751. CrossRef | PubMed
5 Davies A, Singh KP, Shubber Z, duCros P, et al. Treatment outcomes of treatment-naïve hepatitis C patients co-infected with HIV: a systematic review and meta-analysis of observational cohorts. PLoS One 2013; 8: e55373. CrossRef | PubMed
This article originally appeared in The Lancet on 23 February 2013.