WORLD HEPATITIS DAY
Viral hepatitis does not wait for the effective implementation of policy
‘We can’t wait.’ That’s the World Hepatitis Alliance’s theme for this year’s World Hepatitis Day on 28 July. The theme is a fitting one. Globally, more than 350 million people are living with viral hepatitis. The disease causes more deaths around the world than HIV and malaria combined. However, effective prevention and treatment is available.
The World Health Organization aims to eliminate viral hepatitis as a public health threat by 2030. The South African government has committed to reach this goal. We have national guidelines and an action plan to guide our response.
However, little implementation has taken place in the three years since adoption. Limited public awareness and political will around this important health issue are largely responsible for the inaction.
Our liver is a vital organ. It assists us with filtration, digestion, metabolism, detoxification and protein synthesis. It also stores vitamins, minerals and energy. Viruses are one cause of liver inflammation (hepatitis).
There are five hepatitis viruses (named A through E). Hepatitis A and E are spread through the faecal-oral route and mostly cause mild illness. Hepatitis B and C are spread through blood. Hepatitis B is also spread through body fluids. Hepatitis B and C infection can be short or long term (chronic). Hepatitis D can only infect people with hepatitis B infection and is more common in the Mediterranean region.
Generally, chronic hepatitis does not cause symptoms; it is a silent disease. Chronic hepatitis damages the liver and its ability to function and increases the risk of liver cancer. The damage done and the cancer risk is increased among people living with untreated HIV infection and those with alcohol use conditions.
In South Africa, about one in 15 people live with chronic hepatitis B infection. Modelled data suggests that in 2019, 2,224 people died from hepatitis B. Most hepatitis B infections happened during childhood, before the introduction of childhood hepatitis B vaccination in 1995.
Currently, hepatitis B transmission occurs among people living with unmanaged hepatitis B infection and their non-immune household contacts. Transmission also occurs from mother to child.
Children are susceptible in the first six weeks of life before they receive their standard vaccinations. Healthcare workers are at risk from occupational exposure.
Non-immune people who inject drugs who do not have access to sterile injecting equipment, non-immune men who have sex with men who engage in condomless sex, and non-immune people in prison exposed to blood are also at increased risk for hepatitis B infection.
Hepatitis B screening is simple, and can be done using a rapid test. Additional testing is needed to assess the stage of infection and the management approach. Chronic hepatitis B infection can be treated with medication, but it cannot be cured. Hepatitis B treatment is affordable in South Africa. Treatment is usually lifelong.
The reality of hepatitis C in South Africa is very different. Less than one percent of people in the general population have chronic hepatitis C infection, compared with between a third and a half of people who inject drugs.
A lack of information, access to sterile injecting equipment, access to opioid substitution therapy (the recommended treatment of opioid dependence), access to hepatitis C treatment, stigma and discrimination and the criminalisation of drug use, contribute to the hepatitis C epidemic among the estimated 82,500 people who inject drugs in the country.
There is no vaccine to prevent hepatitis C, but it is curable using direct acting antiviral medications (DAAs).
Globally, DAAs were prohibitively expensive, but as treatment demand and access to generics have increased, the price has reduced to between $50-$100 per treatment course in many low and middle income countries.
Unfortunately, DAAs are not yet available in South Africa. Two products are registered, but have not been launched. It is unclear how much these life-saving medications will cost and who will have access to them.
South Africa has a viral hepatitis problem. We also have the tools for elimination. But, we need political will and resources to implement our scientifically informed policies.
Advocacy, which is the process of obtaining support for a cause, is key. However, our advocacy efforts — based on statistics, cost-effectiveness and national obligations to United Nations commitments — have not worked.
We need a different approach. One possibility is the use of well-crafted, evidence-based stories that reach the right people, convey core messages, shift perspectives and catalyse action.
Effective stories are relatable and establish empathy with the audience. Empathy is an important emotion that influences decision-making. Effective stories are memorable, enabling the audience to share fundamental information. Stories can provide the context for statistics.
People in South Africa need to be aware of viral hepatitis. Everyone needs to know that elimination is possible. Communities and civil society need to know that our government is not implementing their good policies.
We need to find ways to use stories to demand access to prevention of mother-to-child transmission of hepatitis B services. We need healthcare workers and families to share their stories of why hepatitis B vaccination is life-saving.
Respected champions need to help decision-makers understand how easy it should be to access nurse-led hepatitis B testing and treatment services in community settings.
People in our communities and our leaders need to hear from people who use and inject drugs about their experiences of stigma and discrimination by healthcare workers, police and community members.
Our leaders need to hear how people with heroin (nyaope/whoonga) dependency can’t access affordable opioid substitution therapy, and the desperation and hopelessness this causes for people, families and communities.
Our leaders need to understand that people are becoming infected and dying from hepatitis C while a cure exists and must be made available.
People in power and in communities need to hear the futility and harms caused by punitive responses to drugs, and the overwhelming benefits of drug decriminalisation.
I sincerely hope that in the future, we are able to tell a story about South Africa’s viral hepatitis response as a counterpoint to our delay in rolling out antiretroviral therapy for HIV in the 2000s. DM/MC
Dr Andrew Scheibe is technical adviser at TB HIV Care and researcher at the Community Oriented Primary Care Research Unit at the University of Pretoria’s Department of Family Medicine. He is a board member of the International Network on Health and Hepatitis in Substance Users.