Close to 234,000 Australians live with chronic hepatitis B—one of the leading causes of liver cancer—and almost four out of ten don’t know they have the condition. It is even more alarming in South Australia, where six out of ten are not diagnosed1.
Hepatitis B diagnosis rate in Australia remains stagnant at around 63 per cent from 2015 to 2017, and our treatment rate of 8.3 per cent falls far short of the recommended 20 per cent of people with chronic hepatitis B estimated to need treatment. In this respect too, South Australia lags with a treatment uptake of only 5.7 per cent—and only 16 per cent of those with chronic hepatitis B being monitored, well below the national average of 20.2 per cent2.
Lack of Priority
While new, highly effective hepatitis C medicines have simplified strategies for tackling hepatitis C, dealing with hepatitis B remains complex, and in Australia made all the more so by the cultural diversity of communities most affected by the virus.
Despite this, there seems to be a lack of priority on the part of health authorities in supporting people with chronic hepatitis B. A new drug which have less serious long term side effects3 are still to be listed on the Pharmaceutical Benefits Scheme, even though that had been recommended by the Pharmaceutical Benefits Advisory Committee.
In that context, the recent election of eminent physician Su Wang as President of the World Hepatitis Alliance could signal a shift to focus efforts on hepatitis B. Dr Wang is an active campaigner for action on hepatitis B and is herself affected by the virus. The successful development of effective cures for hepatitis C means attention can now be turned to the challenge of finding a cure for hepatitis B.
Global Burden
The burden of hepatitis B is enormous—257 million people live with chronic hepatitis B (CHB) world-wide resulting in almost 890,000 deaths each year.
There is as yet no cure for hepatitis B because current drugs are unable to target a core part of the virus which embeds itself within host cells. That part of the virus—known as covalently closed circular DNA (cccDNA)—persists even in people who have naturally cleared the virus, and may be reactivated when their immune system is compromised, for instance, after organ transplant or through chemotherapy.
It follows that the number of people potentially at risk of hepatitis B related liver failure or death is in fact higher than the 257 million with the chronic form of the disease.
Current hepatitis B treatments aim only to suppress viral activity to achieve what is known as a functional cure, where the viral load and activity is so low as to not cause damage.
Such treatment, once begun, must generally be maintained for life. That can be a significant burden especially in developing countries where health budgets are limited and hepatitis B prevalence high.
The International Coalition to Eliminate HBV (ICE-HBV) is an international research-driven forum which aims to fast-track the discovery of a safe, effective, affordable and scalable cure to benefit all people living with chronic hepatitis B (CHB), including children and people living with hepatitis C, hepatitis D and HIV co-infection.
According to ICE-HBV, only eight per cent of people with CHB have access to treatment, so in spite of the availability of effective interventions to prevent infection and adverse outcomes in those affected, the high burden of the disease warrants a coordinated public health approach to cure CHB4.
Search for Cure
Buoyed by the success with hepatitis, and no doubt seeing opportunities in a similar success with hepatitis B, drug companies are now throwing their resources into finding a hepatitis B cure. The Hepatitis B Foundation’s Drug Watch currently lists 31 drugs on phase I or II trials and 18 pre-clinical studies5.
All stages of the life virus cycle are being targeted and a wide variety of approaches used, such as repurposing existing drugs used for other diseases or finding more effective ways of delivering treatment such as structured interruptions to allow the natural immunity to regain capacity to fight the hepatitis B virus, and achieve a functional cure. Other approaches include the use of inhibitors, and RNA silencing.
The lack of resources mean hepatitis B is not being tackled as well as it could be with current prevention and treatment options.
Even without a cure, much can be done to reduce the burden of hepatitis B using tools already available. There is a highly effective vaccine for hepatitis B that can prevent infection and new treatments can help prevent liver cancer in people with CHB.
Sadly, advocates and workers on the ground are finding few resources being allocated to hepatitis B. The lack of resources mean hepatitis B is not being tackled as well as it could be with current prevention and treatment options.
The World Health Organization (WHO) estimates that only nine per cent of people with chronic hepatitis B have been diagnosed. Of those diagnosed, only eight per cent receive treatment. In other words, of the 257 million living with chronic hepatitis B, only 22 million are diagnosed and 1.7 million receiving treatment5.
Within Australia, communities with higher prevalence of hepatitis B are those facing numerous barriers to accessing health information and services. Reaching these communities to raise awareness and facilitate testing, vaccination or monitoring requires significant time, effort and resources.
Community Education
Despite the funding of 40 very successful community education pilot projects in 2016 and the launch of the Third National Hepatitis B Strategy in 2018 by the Australian government, no additional funding has been forthcoming to further the work which was started. Hepatitis organisations around the country have had hepatitis B added to the scope of their work with no additional funding to support the new responsibilities and in some cases, there were even funding cuts.
Just as hepatitis C had for many years been the orphan of the blood borne virus sector until the “magic bullet” was found, perhaps hepatitis B has to wait for the development of a miracle cure for it to get the attention it needs.
Recommended reading – The push is on to cure hepatitis B, a long overlooked scourge of millions. By John Cohen, Science, Nov 29.
Header photo: Some of the Australian communities at greater risk of hepatitis B
Sources:
- National Surveillance for Hepatitis B Indicators – Measuring the progress towards the targets of the National Hepatitis B Strategy – Annual Report 2017
- http://ashm.org.au/about/Mapping%20Project%20Slide%20Set%202017.pdf
- http://www.infohep.org/Tenofovir-alafenamide-for-hepatitis-B-shows-improved-kidney-and-bone-safety-after-a-year/page/3414208/
- https://ice-hbv.org/hep-b-cure/hep-b-cure/
- http://www.hepb.org/treatment-and-management/drug-watch/