1. Putting the Radar on Hepatitis B and C in Africa Olufunmilayo LESI Associate Professor of Medicine College of Medicine, University of Lagos & Lagos University teaching Hospital. Nigeria ICASA 2015, Zimbabwe, December 2015

2. Outline Introduction to viral hepatitis Burden of Hepatitis in HIV patients in Africa Challenges of diagnosis and treatment Treatment access in resource limited environment

3. An innovative theme to create mass awareness of viral hepatitis

4. World Hepatitis day 2011: Viral Hepatitis is closer than you think.

5. This is Hepatitis,…. Know it. Confront it. Get tested

6. HBV is a Significant Cause of Morbidity & mortality worldwide >2 billion have been infected 1 >2 billion have been infected 1 4 million acute cases per year 1 4 million acute cases per year 1 1 million deaths per year 1 1 million deaths per year 1 250 million chronic carriers 1 250 million chronic carriers 1 25% of carriers die from severe liver disease like cirrhosis, or liver cancer 1 25% of carriers die from severe liver disease like cirrhosis, or liver cancer 1 2nd most important carcinogen behind tobacco 3 2nd most important carcinogen behind tobacco 3 Causes 60% – 80% of all primary liver cancer 1 Causes 60% – 80% of all primary liver cancer 1 1. WHO. Hepatitis B. 2002. 2. Maynard JE, et al. In: Viral Hepatitis and Liver Disease. New York: Alan R. Liss, Inc. 1988. 3. CDC. Epidemiology & Prevention of Vaccine-Preventable Diseases. “The Pink Book.” 8th ed. 4. CDC. MMWR. 2001;50: RR-11.

7. Hepatitis C virus discovered in 1989 (Alter et al, 1999) Family Flaviviridae 1 Major disease burden Worldwide prevalence of 3%, affecting 170 million people worldwide (WHO) Considerable geographical variation in seroprevalence of anti-HCV worldwide

8. if mortality and morbidity from cirrhosis and liver cancer are grouped together, viral hepatitis would rank within the top ten causes of global mortality (Fig. 2), above that of tuberculosis and malaria. Number of deaths attributed in 2010 to HIV/AIDS, viral hepatitis, malaria and tuberculosis Lozano R, et al. Lancet 2012;380:2095–2128.

9. Sub Saharan Africa: HBV infection Chronic HBV - 62.5 million-nearly 25% of global infections Predominant mode of transmission Unsafe injections in childhood Child to child transmission Mother to child Extremely resistant; can survive when stored at –80°C for 24 months, room temperature for 6 months and at 44°C for 7 days. 50–100 times more infectious than HIV

10. Chronic HCV in Africa- 19 million infections- nearly 11% of global infections Highest prevalence in Egypt Middle Africa (Cameroon) West Africa (Burkina Faso, Gabon, Benin) Largest absolute number Nigeria- 2.5 million persons Ethiopia- 1.26 million Riou M et al, HCV seroprevalence in Africa; JVH, August 2015

11. CountryEstimated adult seroprevalence (%) Estimated number of adult carriers (thousands) Algeria2.0 (0.1-6.0)478 Egypt14.76886 Libya1.246 Mauritania Morocco1.6 (0;7.5)335 Sudan1.7 (0.1;5.5)318 Tunisia1.8 (0.1;5.9)126 CountryEstimated adult seroprevalence (%) Estimated number of adult carriers (thousands) Botswana1.113 Lesotho1.113 Namibia1.620 South africa1.1341 Zambia1.172 Zimbabwe1.6113 North AfricaSouth Africa CountryEstimated adult seroprevalence (%) Estimated number of adult carriers (thousands) Angola3.9370 Burundi3.1150 Cameroon4.9525 Chad2.354 DRC2,1647 Gabon4.941 Congo republic2.9224 Rwand3,1175 Central Africa CountryEstimated adult seroprevalence (%) Estimated number of adult carriers (thousands) Benin3.8190 Burkina faso6.1475 The Gambia2.420 Ghana3.2426 Guinea1.583 Guinea-Bissau1.815 Ivory coast2.2224 Mali1.9131 Niger2.4177 Nigeria3.12575 Senegal1.170 West Africa Riou M et al, JVH, 2015

12. Role of Unsafe injections & Iatrogenic transmission Egypt: parenteral anti-schistosomal mass treatment in the 1960s and 1970s Mass treatment campaigns against yaws, malaria, syphilis in Cameroon, Gabon, CAR and DRC Significance of unsafe injections – 8-12 billion injections are given in healthcare settings worldwide ( over 50% of these are unsafe in SSA) – Associated with 800,000 HIV infections/y – Associated with 10 million with hepatitis infection In Nigeria- native/cultural practices and scarification marks, uvulectomy, manicures, acupuncture etc

13. 250 million 36 million 150 million Overlapping Epidemics of HBV, HCV and HIV Hepatitis B virus infections Hepatitis C virus infections HIV infections Viral hepatitis has become one of the most clinically important co-morbidity among people living with HIV. (co infection with HBV and HCV occur in 15% and 7% respectively)

14. Negative impact of Hepatitis-HIV co-infections Hepatitis B co-infections Commencement of HAART accelerates progression of liver disease Enhanced risk of hepatotoxicity Chronic carriers become highly infectious (increased MTCT of HBV) HBV Vaccine failure in babies born to HBV/HIV mothers Lamivudine resistance after 12–24 months of ART (3TC) Hepatitis C co-infections Enhanced chronic immune activation in subjects with hiv co- infections Increased all cause mortality and elevated risk of of complications such as renal insufficiency More rapid progression of liver fibrosis

17. Hepatitis therapy: Unmet treatment needs HEPATITIS B Previously low treatment uptake and outcomes with interferon based therapies. High response rates with the use of tenofovir as part of HAART Disadvantage to mono-infected patients who are denied access to HIV programmes HEPATITIS C Current interferon-alfa free regimens with high anti viral potency-DAAs treatment still complex and vary according to genotype and underlying cirrhosis imposition of treatment restrictions based on fibrosis staging in many resource rich settings. high costs of HCV therapy limited medical resources

18. Sub-Saharan Africa: Regional Characteristics & Viral hepatitis control Population, total 960.1 million 2014 low income economies-60% GNI per capita, Atlas method 2013 ($1,657) Urban population 37% (2014) Chronic HBV & HCV endemic - Significant public health & economic impact Estimated 18 million cases of cirrhosis/HCC within next 20 yrs World Bank, 2015

19. 1.Lack of data-data for action, advocacy, strategic planning 2.Multiple barriers to screening and linkage to care 3.Diagnosis of liver disease & hepatitis treatment 4.Poor health infrastructure and technology 5.Sustainable funding-Cost of care & drug access 6.Human resources & personnel sub-Saharan Africa: Challenges of viral hepatitis control

20. Use of information/data at different levels of the health system

21. Lack of Data Documenting Disease Burden HIV Epidemic one of the best documented epidemics in history Large scale data collection for implementation and surveillance Accurate data 34 million infection globally Mortality 0.3m/year Research funding $2,774/PLWA Viral hepatitis Epidemic Poorly documented esp. in developing countries (silent epidemic) Mainly small scale data, specialized groups 400 million infection globally Mortality 1 m/year Research funding $20/HCV patient

22. SSA: Barriers to screening & treatment Silent epidemic of HBV/HCV: Lack of awareness and education regarding endemicity and risks Ignorance and cultural misconceptions/beliefs, communication difficulties Quality and costs of screening tests, DNA/RNA viral loads Limited access to care and drug therapy Lack of healthcare insurance Stigmatization, discrimination, job loss Leads to secrecy about hepatitis status and delayed treatment

23. Direct costs of tests & drugs Cost (US $) Government subsidy/insuran ce re- imbursement HBV serology (5 markers) 30 Nil Biochemistry/ liver enzymes (panel) 40-50Nil Ultrasound scan CT scan 30-50 200 NIL HBV DNA Viral load HCV RNA Viral load 240-450 NIL Pegylated interferon (monthly) 800-950NIL Tenofovir/monthly (Generic) 25-50NIL Financing access to care and drug therapy The availability of oral DAA have revolutionized the the treatment of HCV with cure rates over 90% even in HIV co- infected subjects

24. Viral Hepatitis control in SSA Government commitment & private sector collaboration Prioritizing Viral hepatitis Epidemic Government Legislation, viral hepatitis national policy Strengthening of government health infrastructure Reliable drug supply chain & drug registration (eg New DAAs) Partnerships (IO, Civil society etc)

25. Viral Hepatitis control in SSA Appropriate model of care to improve access Individualized or public health approach Vertical system (like HIV) vs integrative into existing program Health care financing Increased government budget Shared costs with other strategies Innovations and increased efficiencies Drug access and funding in RLS Generic versions of DAA Tiered Pricing Government funding/Donor funding Treatment subsidization as available for HIV/AIDS, malaria and TB through international donors (Global Funds, PEPFAR, AU, others)

26. summary Hepatitis is a global cause of morbidity & mortality in both HIV infected and non-infected populations Limited disease awareness and recognition Availability of effective suppressive therapy for HBV and curative therapy for HCV has converted hepatitis care into an emergency requiring urgent responses. There is need for a 360 degree response including government commitment and collaboration, strengthening African networks and collaborations, international collaborations (donors, pharmaceuticals), health insurance and HMOs), civil society, academia.

27. Thank you for your attention