Taiwan - CEVHAP hosts agenda-setting meet on hepatitis policy

While, it has taken far too long to get viral hepatitis the attention it deserves, global experts cautiously hope that with successful partnerships and learning from the HIV/AIDS experience, the Asia-Pacific region can be an example to the rest of the world in controlling viral hepatitis, reports Viveka Roychowdhury

The spread of viral hepatitis got special attention at this year's Conference of the Asia Pacific Association for the Study of the Liver (APASL) which was held in February in Taiwan. Even though viral hepatitis, especially B and C, affect approximately 340 million people across the Asia-Pacific region, most governments do not have a public health policy in place to tackle this disease. This is in sharp contrast to the efforts of HIV/AIDS advocacy, which over the last three decades, has helped to shape public health policy.

Hoping to adopt and adapt key learnings from HIV/AIDS experience, The Coalition to Eradicate Viral Hepatitis in Asia Pacific (CEVHAP), organised the 'CEVHAP Symposium: Better health through better public policies—What Viral Hepatitis can learn from the HIV experience', on the last day of APASL. The purpose of the Symposium was to identify advocacy models that might be effectively adapted within the Asia Pacific region to lobby governments to improve public health policies to cope with the threat of viral hepatitis.

Such efforts seem long overdue. In fact it was as late as May 2010, that the World Health Assembly ratified a resolution on viral hepatitis (WHA63 R18), which for the first time recognised the full scale of the challenge and finally put viral hepatitis on the global healthcare agenda, alongside HIV/AIDS, TB and malaria. The strategy provided a framework for national governments to respond to the challenge of viral hepatitis within their own borders but also as part of a cohesive approach to tackle the disease across regions. This was followed by the World Health Organization (WHO) issuing its Global Hepatitis Strategy which combines a wide range of its products to assist countries in the development of national responses to viral hepatitis.

The CEVHAP Symposium attracted leaders from the global and Asia Pacific viral hepatitis community as well as WHO regional experts. Giving the welcome address, PASL Jia-Horng Kao, President of A2012 and Professor and Director, Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine highlighted the fact that viral hepatitis is considered endemic in some parts of the Asia-Pacific region and hoped that the takeaways from the CEVHAP Symposium would assist policy makers to tackle the situation.

Prof Ding-Shinn Chen, Immediate Past Dean of the National Taiwan University College of Medicine and Chair of CEVHAP, then kicked off the Symposium, with an overview of CEVHAP's goal to be the “bridge between the medical and scientific community as well as other stakeholders.” While he admitted that the ultimate goal to eradicate hepatitis would take many years, even generations to achieve, he stressed that the short term goal is to focus on improving public health policies to reduce the health, social and economic burden of viral hepatitis in the Asia-Pacific region. He emphasised the power of collaborative partnerships, the importance of keeping patients at the centre of advocacy and ended his presentation by speculating on what would be the catalyst for mobilising a movement behind viral hepatitis.

Lessons learnt

Giving the keynote address, titled 'Learning from the Past', David L Thomas, MD, Director of the Division of Infectious Diseases, Johns Hopkins School of Medicine stressed that the viewpoint has to shift from the individual to the population. While the first lesson, is that hepatitis treatment saves lives, but unlike ARVs, this is not yet the case at the population level. Lesson two followed that improved efficacy means improved urgency, but not necessarily effectiveness. Lesson three was about reap what you sow, in terms of the impact on public health being directly in proportion to resources devoted. So while the massive resources devoted to HIV/AIDS (through PEPFAR, etc.) saw a reduction in mortality due to HIV/AIDS, the same is not the case with viral hepatitis because the political will is absent, as are the celebrities endorsing and supporting advocacy movements.

Thomas' fourth lesson is that there is more to the disease than the virus, as borne out by the fact that a study showed that there was markedly lower survival for HIV/HCV co-infected persons in Denmark during highly active anti-retroviral therapy, from 2000-2005. The fifth and final lesson is that prevention is better than treatment. He pointed out that the annual incidence of liver cancer in children in Taiwan was markedly reduced by HBV vaccination. Elimination is of course, the best form of prevention, with small pox being the best example.

Looking ahead Thomas said, controlling chronic hepatitis in the population requires more work on improving safety and efficacy of treatments, expanding testing and treatment access, educating to expand political and societal commitment. Preventing new infections, together with curing existing infections will ultimately lead to the elimination of hepatitis.

Successful collaborations

The next two speakers, Ali Sulaiman, Lecturer in Internal Medicine, Department of Medicine University of Indonesia and Benjamin Cowie, WHO Regional Reference Laboratory for Hepatitis B, VIDRL Board of Directors, Australasian Society for HIV Medicine were a classic example of the importance of leveraging partnerships and collaborations in containing diseases like HIV/AIDS in the past and now viral hepatitis. Developing countries like Sulaiman's home country Indonesia, bear the greatest disease burden and challenges due to viral hepatitis. For instance, Sulaiman said that only five per cent of hepatitis cases have access to medicine, clearly pointing to barriers that go beyond the clinic. But hopefully this will change. Sulaiman pointed out that while his government spearheaded the celebration of viral hepatitis day in the past two years, the backbone of such programmes is medicine access programmes.

Cowie spoke about translating the Australasian Society for HIV Medicine's (ASHM's) learnings from HIV to hepatitis, pointing out that while there is increasing evidence for HBV antiviral therapy as a cancer prevention strategy, antiviral effect on disease progression is reduced when resistance develops. Therefore partnerships with clinicians like ASHM's preceptorship programme, imparting primary care management of HCV for Indonesian primary care doctors and internists, are crucial. Cowie expressed the hope that maybe the Asia-Pacific region can be an example to the rest of the world in controlling viral hepatitis.

There is no doubt of the patient's role as an important stakeholder and even catalyst to policy change, hence patient advocacy groups (PAGs) have a very crucial role. Speaking about the development of PAGs in viral hepatitis, Charles Gore, President, World Hepatitis Alliance, himself a patient of hepatitis C and cirrhosis, spoke about the need to raise viral hepatitis up the agenda and the role conferences like APASL and associations like CEVHAP need to play to build up the patient voice in the Asia-Pacific region.

The WHO viral hepatitis strategy

Professor Stephen Locarnini, Head, WHO Regional Reference Laboratory for hepatitis B, Victorian Infectious Diseases Reference Laboratory, Melbourne, Australia and Joint Secretary, CEVHAP outlined the four key priorities of the WHO Viral Hepatitis Strategy. Partnership, mobilisation and communication come first, followed by collection of data to help shape for policy and action. Prevention of transmission forms the third axis followed by screening, care and treatment.

Locarnini cautioned that there were many challenges, not least the need to fully staff the WHO HQ team as well as fully fund the 2012-2013 work plan. Operationalising the global hepatitis network, translating the HQ strategy at the regional level, contributing to country strategy and technical support as well as finally producing results and actually impacting viral hepatitis are the many challenges in the path ahead.

Speaking as the co-founder of CEVHAP, he summarised its work since its inception, saying that it has established a solid base, with strong membership and a unique position. Current and planned projects can provide strong data and evidence to influence policy but will require strong follow-up on the ground. Therefore he stressed that it is imperative that CEVHAP works closely with other groups at global, regional and national levels to share data and best practices and maximise impact

The Symposium concluded with a panel discussion, chaired by Locarnini, with the panellists (Gore, Rosmawati Mohamed, University of Malaya, Kuala Lumpur, Henry Lik-Yuen Chan, The Chinese University of Hong Kong and Jack Wallace, La Trobe University, Melbourne) giving their views on what the viral hepatitis sector needed to catalyse a movement.

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