Viral hepatitis -- a liver inflammation caused by a viral infection -- is a global challenge. It is estimated by the World Health Organisation (WHO) that over 1 million deaths are caused by chronic hepatitis B and C infections per year.
But while hepatitis B virus (HBV) infection can only be suppressed and requires lifelong treatment, there is an effective cure available for hepatitis C virus (HCV). However, accessing such cure in Thailand is not easy.
With World Hepatitis Day being observed annually on July 28, the WHO this year is focusing on the theme "Bringing Hepatitis Care Closer To You", calling for simplified viral hepatitis service delivery and bringing care closer to communities. International and local efforts are now working towards eliminating viral hepatitis by 2030. To achieve this, the WHO calls on countries to reduce new infections and hepatitis-related deaths, as well as ensuring people can access diagnosis and appropriate treatment.
HCV: AN OVERVIEW
The WHO estimates that 58 million people globally have chronic HCV, with about 1.5 million new infections occurring every year. HCV is bloodborne and is mostly transmitted through reusing poorly sanitised medical equipment, receiving unscreened blood and sharing needles during drug injection. Less common transmissions can occur between an infected mother and her baby, sexual activities that may lead to exposure to blood, and poorly sanitised tattoo and piercing practices.
In Thailand, it is estimated that there are 300,000 to 800,000 people who have chronic hepatitis C, according to Dr Suchada Jiamsiri, deputy director of the Division of Aids and STIs, Department of Disease Control, Ministry of Public Health. This wide range of figures comes from several studies, which were conducted in non-overlapping areas.
HCV, in its early days of infection, is largely asymptomatic, although some persons develop acute hepatitis that may include jaundice (yellowing of the skin). Once infected, 20% of cases can spontaneously clear the virus on their own without treatment. But 80% will develop chronic hepatitis C, which can lead to cirrhosis (scarring of the liver) and liver cancer over the course of 20-30 years.
"According to statistics from the National Cancer Institute, liver cancer is among the most common cancers found in Thai people. It's the most common cancer among Thai men. So, the objective in treating hepatitis C is to decrease the chance of death and other complications from cirrhosis and cancer itself," said Dr Suchada.
Hepatitis C was considered to be untreatable in the past. But now, new antiviral medicines make it possible to cure the infection after three months of regular medications, offering cure in over 90% of people who receive treatment, with rare side effects.
Gaining access to it, however, can be difficult.
RESTRICTED ACCESS
There are restrictions associated with both the testing and the treatment of HCV infection in Thailand.
For testing, the general public will need to pay for the confirmatory testing themselves, which costs around 2,000-3,000 baht. The National Health Security Office only covers this cost for at-risk groups with high prevalence like intravenous drug users and people who are HIV positive.
Once infection is confirmed, another hurdle to cross is access to treatment. While people infected with HCV can get medicine for free through the country's universal coverage scheme and Social Security system, they must pass certain eligibility criteria. This includes having a viral load above a certain level, signs of liver damage already present, and being no more than 70 years of age. The treatment is currently limited to large hospitals, with the medicines only allowed to be prescribed by specialists. Many patients have had to wait for years and their conditions worsen before they can actually get the necessary treatment.
Additionally, the criteria makes active drug users ineligible for treatment despite possessing a higher risk of infection. This is due to the stigma associated with drug use behaviours, with arguments regarding risks of lower adherence and reinfection often used as a justification.
"These restrictions were put in place because the medicine used to be very expensive," explained Dr Suchada. "Around five to six years ago, a three-month course of medication was 150,000 baht in Thailand. Now, it's about 23,000 baht, which is more affordable although still relatively expensive compared to other medicines on the National List of Essential Medicines. But in the near future, the Government Pharmaceutical Organization aims to produce medicines to treat hepatitis C at even lower costs. We anticipate that the price of medicines will be even more affordable, hopefully making the restrictions more relaxed and the treatment more accessible."
Dr Suchada said ineligible patients can pay for their own medications, or undergo the Department of Disease Control's Test and Treat programme, which provides medications for confirmed hepatitis C patients for free, but this is only available in a few provinces. Alternatively, they can participate in research studies on hepatitis C, which are exploring ways to offer more accessible healthcare services. These studies provide testing and treatment as part of their research.
COMMUNITY-BASED CARE
The need to bring hepatitis care closer to communities is highlighted by the WHO. And in Thailand, the effectiveness of a community-based model of care is currently being explored through the C-Free research study led by the Dreamlopments Foundation, and conducted by a consortium of Thai community-based organisations (CBO), research institutes, academic experts, government officials and international partners. Targeting at-risk and marginalised populations like people who use drugs (and their partners), the study provides testing and treatment services for HCV, HBV, HIV and also sexually transmitted infections at clinics embedded within seven drop-in community centres across Thailand, which are run by Raks Thai Foundation, Ozone Foundation, Thai Drug Users Network, APASS, Care Team, Give Hope and Together.
Around 2,400 participants have already enrolled in the study since its launch in 2019, with over 1,000 patients commencing HCV therapy with Sofosbuvir/Velpatasvir medication. Among those who have already been assessed for treatment response, 92% have been confirmed to be cured of hepatitis C.
Dr Nicolas Durier, president of Dreamlopments, said these numbers illustrate both the high demand and the effectiveness of community-based, decentralised one-stop services. He views that this model of care can be implemented alongside or even as part of the national treatment programme, expanding from exclusively hospital-based services to include community-based services tailored to the needs of specific populations.
"CBO-run community centres are not only more convenient for many patients, but they also provide a friendly and safe environment for drug users, who are often discriminated against and stigmatised in other settings," said Dr Durier. "We observe that people with active substance use can have very high cure rates provided that they receive the right services. The restrictions set against them are not justified nor evidence-based."
Dr Durier hopes findings from C-Free can convince the government to remove some bottlenecks in the national treatment programme and allow any doctor in any hospital to prescribe hepatitis C treatment, as well as removing exclusion criteria on active substance use so that more patients will be able to access the treatment.
"As per WHO goals, Thailand can eliminate viral hepatitis by 2030. But to achieve this, it will take a collaborative effort between the government, health authorities and all stakeholders to raise public awareness on the issue and also remove restrictions that are preventing people from getting essential life-saving care," he said.
For more information, visit c-free.online.
