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Prevention efforts, new drugs offer hope for an end to hepatitis

A public health campaign that began in the 1960s dramatically reduced the prevalence of schistosomiasis, a parasitic disease known locally as bilharzia, which once afflicted some 40 percent of rural Egyptians. But poor infection control, especially the reuse of syringes used to administer treatment, spread a new scourge: Hepatitis C, a blood-borne virus that affects the liver and can lead to cirrhosis, cancer and liver failure.

Half a century after the bilharzia campaign began, and long after many of the original patients died, the virus remains endemic in Egypt, largely due to poor hygiene standards in the healthcare system and a lack of public knowledge about the disease and how to control it. The country currently has the highest rate of infection in the world, with an estimated 14.8 percent of the population carrying the virus and 165,000 to 200,000 new cases per year, according to government figures.

After decades of poor response from the government, there may finally be signs of relief. Renewed prevention efforts, combined with a crop of new and more effective medications, might finally allow Egypt to tackle the disease.

Together with the Center for Disease Control and the World Health Organization, Egypt is developing an action plan for hepatitis, which includes developing practical courses on infection control for students, raising awareness among both healthcare workers and the community as well as providing medical facilities with tools for disease control.

“You cannot just tell people to wear gloves. You have to give them gloves,” says Manal al-Sayed, a professor of pediatrics at Ain Shams University, supervisor of the Health Ministry’s hepatitis program and a member of the national committee for HCV. “You provide training and equipment, and then you hold them accountable.”

Starting this year, the government also plans to equip healthcare centers with “safety engineered” devices, like syringes designed to prevent re-use and needle stick injuries, while also encouraging their production by local manufacturers.

Undoing decades of neglect is a daunting task, but Sayed says that just sitting all of Egypt’s multi-sectoral healthcare system down at the same table and agreeing to standardize training and regulations is a significant step in the right direction.

Vectors of infection

There are three sources of HCV infection in Egypt, explains Wahid Doss, head of the Egyptian National Committee for Control of Viral Hepatitis. “There’s one in the healthcare system, the second is in the community—a barber shop, a circumcision. The third is intra-familial spread: the father infects his son or daughter by using shared instruments.”

A large pool of infected people, combined with a lack of training on infection control, limited resources and few regulations has created fertile ground for the disease to spread.

The state of Egypt’s healthcare system is so bad that frequent interactions with medical professionals and hospitals in and of themselves pose a major risk factor for hepatitis. Kidney dialysis and blood transfusions are particularly risky, with an estimated 60 percent of patients contracting hepatitis within a year.

Medical personnel, particularly nurses, are often poorly trained and equipped, with disastrous results. “We have the highest sharp injury rate among healthcare workers on the global level,” says Sayed.

Accidents with used needles or other sharp medical tools are a particularly effective way to spread hepatitis.

Part of the problem, Sayed says, is a fragmented healthcare system with no central oversight. The Ministries of Health and Higher Education each have their own, separate hospital systems, as do the Ministries of Defense and Interior, as well as private companies. “Each one thinks they can do things on their own,” says Sayed. “It’s been extremely difficult to get the people all in one place.”

Each system has developed its own standards, which means they are not accountable to anyone outside of their own ministry or company. Up until last month, there existed no standard regulations governing the country’s network of blood banks. A general infection control law is still in the works.

Despite the obstacles, Sayed says she feels optimistic that things may finally be changing for the better.

New treatments, but at a cost

A new generation of hepatitis drugs, which are both more effective and cause fewer side effects, have offered new hope on the treatment side.

The first of the drugs to hit the market is Sofosbuvir, known by the brand name Sovaldi. A hugely successful yet hugely controversial medication, Sovaldi made headlines both for its 90 percent cure rate and for its staggering US$84,000 price tag.

In the United States and abroad Gilead, the manufacturer of the drug, has been vilified for price gouging and taking advantage of people’s desperation for medical treatment to make a profit.

Although Gilead has maintained its sky-high pricing in the United States, arguing that the drug is still cost-effective when compared to liver transplants and years of poor-quality-of-life for patients, it has offered the drug to poorer countries at a much lower price.

“Gilead is basically playing a game of market segmentation,” says Taher Amin, co-founder of advocacy group Initiative for Medicines, Access and Knowledge. Patients from wealthy countries like the United States are locked into paying high prices, which allows the company to make huge profits while still offering lower priced drugs to low-income countries, thereby maintaining Gilead as the market leader.

The worst effects of this market segmentation hit middle-income countries like China and Mexico, which are excluded from Gilead’s cut-rate marketing program but still have millions of patients too poor to pay for the drug, explains Amin. But for countries like Egypt and India, it can actually be a rather good deal.

After intensive negotiations, Gilead agreed to supply Egypt’s public health system with a one month dose for LE2,200, around US$300. The usual treatment protocol calls for Sovaldi to be paired with a drug called Interferon, which costs the government an additional LE250 per week. This pushes the combined cost of curing a patient to around LE10,000, says Doss.

So far, the health ministry has treated around 40,000 patients with a cure rate of 90 percent. The original order of 225,000 boxes of Sovaldi should be finished at the end of this month, at which point the government will start on a second batch of the same size.

Some analysts have criticized even this reduced price, noting that studies show the drug can be produced for less than US$150 per treatment, so Gilead is still raking in a hefty profit.

Doss says he is happy with the price for the time being. “It’s definitely very cost effective to spend this amount of money to cure a patient and prevent complications. It is the best price in the world for now. I wish it was lower, but I’m sure we can’t achieve that for now.”

Egypt does have two other avenues to get the drugs. Gilead has licensed companies in India to produce their own versions of Sofosbuvir, and allowed them to sell the drug to 91 countries, including Egypt.

More interestingly, Egypt denied Gilead a patent for Sofosbuvir, opening the way for generic drugs to hit the market. Four local pharmaceutical companies have registered generic versions of Sofosbuvir with the Health Ministry’s pharmaceutical regulating body, Doss says, and drugs are beginning to hit the market.

Local manufacturers have already offered to supply the health ministry with drugs for as low as LE1,400 per dose, around 64 percent of the price Gilead charges.

“We’re going to do studies on each one of the local drugs to ensure that they are of optimum quality. The pharmaceutical companies are not happy with that, of course, but we insist on it,” says Doss.

Both Doss and Sayed say that as soon as the drugs are proven to be of equal quality and lower cost, public health authorities will shift to using local generics.

Ultimately, authorities hope the pace of treatment can outpace the rate of new infections, creating a snowball effect that further lowers the rate of disease by creating a smaller pool of infected people who might be spreading it.

Doss adds, “We hope to have treatment as a means of prevention. When you have mass treatment, you can prevent people from being infected.”

Teaching prevention

Still, progress in the healthcare system will not be enough to stem the disease without corresponding efforts in the community. To give the scale of the problem, Sayed notes that there are around 23 million unsafe injections per year in Egypt, a major infection risk partly driven by high demand from consumers of all socioeconomic levels.

“People believe in the miracles that come out of injections,” she says.

Not all of these shots are given by doctors. Injections, along with procedures like circumcisions and FGM, are often performed by pharmacists or by unlicensed practitioners with no formal medical training. Barber shops and beauty salons, where unsterilized razors, scissors and nail care equipment can spread the virus, are also an infection risk.

Intravenous drug use and unprotected sex with multiple partners — particularly anal sex — are also risk factors, with elevated risk for people already infected with HIV. However, these topics remain a major social taboo, which complicates awareness-raising efforts.

The disease is spread through families as well. The virus is passed through blood — there is little evidence for transmission via other bodily fluids like saliva, breast milk or semen — so sexual contact, breastfeeding, even childbirth don’t necessarily transmit the disease. Sharing razors, nail clippers or even toothbrushes, however, can.

The spread of the disease within communities and families is compounded by the fact that most infected Egyptians don’t know they are carrying the virus, and therefore don’t take simple precautions that could protect their loved ones.

“Only about 5 percent of Egyptians know of their status for HCV. So 95 percent don’t even know if they have or don’t have it,” says Doss.

The virus can lie dormant for decades, so most infected Egyptians only find out they have hepatitis when they develop complications such as liver cirrhosis or cancer, or when undergoing health screenings for travel or employment.

For the time being, mass screenings are out of the government’s reach, Sayed says, but the second phase of the new prevention plan does call for screenings for people at high risk: those who have received blood transfusions or dialysis, or who have other chronic conditions that require frequent contact with the healthcare system, and people whose relatives have the disease.

In the meantime, the Hepatitis committee is working to get pharmacists and barbers involved in infection control efforts, and carrying out studies to craft effective awareness raising campaigns for medical patients and the general public. Combined with the possibility offered by new drugs like Sofosbuvir, and a constitutional commitment to increase healthcare spending, practitioners hope these efforts will be enough to stem the tide of new infections and ultimately defeat the disease.

This content was produced in partnership with the Rosa Luxemburg Foundation

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