On a long-overlooked health crisis: Hepatitis C

A pioneering project in Cameroon proves successful Hepatitis C treatment in Cameroon is possible
Interview with epidemiologist Prof. dr. Roel Coutinho

In most European countries, the new, highly effective curative Hepatitis C (HCV) treatment is available for all those infected and covered by health insurance. However, chronic HCV is quite rare in Europe, unlike Cameroon, where each year thousands of people die because of HCV related liver disease. Most people do not know that they are infected and if they do, they are unable to pay for the treatment. This is to the annoyance of Roel Coutinho, emeritus professor in Epidemiology and control of infectious diseases and former director of the Center for Infectious Disease control of the National Institute for Public Health and the Environment (RIVM) in the Netherlands. Together with PharmAccess, Joep Lange Institute (JLI) and a local team, he is on a mission to change this.

Roel Coutinho, together with a local and an international team, has published a research paper on a pioneering project in Cameroon, proving successful HCV treatment in Cameroon is possible.

Why did you decide to get involved in this research?

‘’In Cameroon, around 200,000 people are chronically infected with HCV and many of them suffer from the serious and life threatening consequences. The spread of HCV is a gloomy medical story — mass treatments with unsterile needles and syringes in the 60’s and 70’s for, amongst other things, endemic Syphilis and sleeping disease but also vaccinations are the reason for the spread of this virus. You can see that areas that have had most colonial involvement know the highest prevalence rates. We cannot turn our back; we are partly responsible for the spread of the virus!’’

What happens to you when you get infected with HCV?

‘’Most people, do not notice the initial infection as the symptoms are not specific and disappear spontaneously. Serious conditions appear usually much later, after many years. Approximately 20% will clear the virus by themselves, and for the remaining 80%, a chronic Hepatitis will develop. This chronic infection can cause incurable liver failure and cancer. HCV is, unlike most other viruses, well treatable. After 3 months treatment, over 95% of the patients are fully cured. This is unique — for diseases like HIV or hypertension you need to take medication your entire life.

Unfortunately, HCV treatment is very costly — in the West it runs into tens of thousands of euros.’’

Hepatitis C (HCV) has long been overlooked in the Global Health debate. The Sustainable Development Goals has contributed to pushing the disease higher on the agenda. And for a good reason: worldwide 70–150 million people are Hepatitis C positive, many more than HIV/AIDS. The disease causes liver complications leading to approximately 700,000 deaths annually.

What has the HCV project in Cameroon been about?

‘’Supported by Joep Lange Institute (JLI), PharmAccess and the Achmea Foundation we initiated a demonstration project with 161 HCV positive Cameroonians, who were eligible for treatment at a number of medical centers in Yaoundé, the countries’ capital. The doctors at the centers so far treated the patients with Interferon, which is an old, much less successful way of treating the disease, known for horrible side effects. For this project, we could use branded antivirals for 1% of the price paid in high-income countries and were able to set up and start the treatment’’.

The results of the project show similar results to Western European countries: with over 95% of the patients fully cured after treatment. Why is this so important?

‘’In a project like this it is about showing the local authorities that treatment can be successfully implemented with a high cure rate. Setting up a project in a resource-restricted setting like Cameroon means you deal with logistic challenges like searching for reliable diagnostics and the need to organize training. In addition, patients have to adhere to medication and to come back for checks.

Evidently, you need a dedicated local team and the set-up has to be adapted to the local setting. An example is that we wanted to provide the consultations, diagnostics and treatment for free, like for HIV, but the local doctors and the local Minister of Health advised against it. We were told that if the treatment is completely free, people tend to undervalue its quality. After our conversation with the Minister of Health we eventually decided to let patients contribute a small percentage of the actual costs‘’.

But if many people are not aware of carrying the virus, of how much value is a project with good treatment results?

‘’This question has been vital throughout the project. We have been looking for further opportunities to reach unaware HCV infected people: Potential blood donors are ‘low-hanging fruit’ as they are routinely tested for HCV. Those tested positive are advised to see a doctor but very few will follow-up, and often they lack the funds for treatment. We are now enrolling about 300 HCV positive patients identified through blood bank screening. If this is successful, it can be rolled out throughout the country’’.

So, your research team dealt with two challenges to increase access to the treatment— the local context and logistics as well as the process to identify patients. But what about the cost of the treatment ?

‘’With generic medicines and an easier diagnostic process, we can bring the price down to about EUR 400–500 ($450–560). Unfortunately, it would still mean it is inaccessible for most Cameroonians. Most people, like in most other African countries need to pay their health costs out-of-pocket. We investigated different financing models, as time has passed that a donor simply provides funding. HCV turns out to be well suited for the pay-for-performance model, in which the outcome payer only pays for the treatment once the patient is cured. This model is ideal as HCV patients are generally fully cured after treatment’’.

Pay-for-performance is a payment model that offers financial incentives to healthcare providers for meeting certain performance measures. In this project, upfront costs will be paid by Joep Lange Institute (JLI) and PharmAccess and repaid by Achmea Foundation, through fixed payments for each confirmed cured patient.

‘’In the ideal scenario, health insurance companies would pay for this treatment as outcome payer. Insurances do cost- benefit analyses and it shows that treating HCV infected people before they have symptoms simply pays off. It is an extra argument to advocate speeding up the rolling out of health insurances in Africa. In the meantime, the pay-for-performance model is also the most preferred one for external donors, as they can fund based on success: only for confirmed cured patients.’’

Roel Coutinho and the team are currently also working on a third HCV project in Cameroon supported by Gilead, which involves testing HIV patients for HCV infection. Both HIV and HCV positive patients will have complications at an earlier stage. Together with the local team he advocates for large-scale testing campaigns.

The research paper of the first demonstration project just appeared in The European Journal for Tropical Medicine and International Health and publicly accessible via: https://onlinelibrary.wiley.com/doi/abs/10.1111/tmi.13450

Update (July 2021): The first outcome payments for cured patients under the pay-for-performance financing model have already taken place. The second phase treats 240 patients and the program is now looking to secure additional commitments for outcome payments in order to scale and enroll 600 patients.

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