LAUSR

As we take stock this World Hepatitis day, a mere 11 years from the World Health Organization’s (WHO) 2030 target date for global Hepatitis C Virus (HCV) elimination (a 90% reduction in new diagnoses and 65% reduction in mortality [1]), there is still a very long way to go. Only nine high-income countries (Australia, France, Iceland, Italy, Japan, South Korea, Spain, Switzerland and the United Kingdom) are on track to eliminate HCV by 2030 (Figure 1) [2]. In fact, 80% of high-income countries are not on track to meet the WHO targets, and it is estimated that at the current pace of implementation, 67% will not reach elimination targets before 2050, if ever. Although “on-track” countries include some of those with high burdens of infection such as Italy and Japan, they represent only an estimated 8.5% of the world’s 71 million people living with HCV [3]. Notably, except Georgia, no country in Eastern Europe or central Asia where HCV infection rates continue to rise unabated among people who inject drugs, is on track. In lowand middle-income countries (LMICs), there are also some exceptional leaders such as Egypt and Pakistan. However, in far too many countries, the scope of the problem is not even known, let alone efforts at elimination begun [4]. Yes, the elimination goals are ambitious. But let’s be clear. We have the tools at our disposal to eliminate HCV as a public health threat – safe, simple curative treatment, accurate diagnostics and knowledge about how transmission can be prevented. The question is, can we mobilize these tools rapidly enough and implement them widely and equitably? Slow scale-up will only serve to perpetuate the epidemic over decades and the major health gains associated with HCV treatment will be thwarted. Moreover, the momentum that has built in response to the WHO call to action will be squandered as other important health, social and environmental needs inevitably eclipse this cause. Only rapid action will yield measurable impact in the short term – modelling predicts greater benefit in prevention of new infections and reductions in decompensated cirrhosis and liver-related deaths will be realized with rapid scale-up of prevention, treatment and screening measures [5-7]. Indeed, real world evidence is beginning to confirm this modelling with tangible gains in life expectancy, reduced hospitalizations, liver transplantation and lower rates of new infections [8,9]. As a result, significant savings in health costs are projected. This is a message that policy makers need to hear. So, what can we learn from the countries that are well along the road to success? These countries uniformly have in common two things: engagement at the highest political level and well designed and executed national action plans. It is not necessary, however, to wait for a top down approach. Even in the absence of high-level political commitment, country specific strategies can be developed. An excellent example of this is Canada’s recently published “Blueprint to Inform Hepatitis C Elimination Efforts in Canada” [7]. It was developed through a consultative and inclusive process involving researchers, clinicians, policy makers, community-based organizations and people with lived experience. The Blueprint lays out specific targets, some more ambitious than those of the WHO. Most importantly, it is focused on the needs of priority populations – those who experience a disproportionate burden of HCV or who have challenges accessing HCV care and services. It offers options that can be tailored to different contexts and cultures, and is truly a model of how to advance the elimination agenda when government leadership is lacking and jurisdictional and social barriers are entrenched. But action plans are only the beginning. Digging deeper, a key feature of successful elimination programmes has been disruption in the normal way of doing business. Disruptive innovation, a business concept coined by Clayton Christensen in 1995, refers to a product that takes root initially at the bottom of a market and then relentlessly moves up, eventually displacing established competitors [10]. Generic direct-acting antivirals (DAAs), by forcing down all DAA prices, have been truly disruptive serving to catalyse elimination programmes worldwide. Indeed, the impact of generic DAAs has had much broader effects by rapidly driving down the cost of diagnostic tests. These changing market forces may ultimately have a lasting impact on all patented medications and diagnostics making health care more equitable. Rapidly falling drug prices are the result of many forces and actors and are the essential third pillar to successful Klein MB Journal of the International AIDS Society 2019, 22:e25360 http://onlinelibrary.wiley.com/doi/10.1002/jia2.25360/full | https://doi.org/10.1002/jia2.25360