Evaluating the impact of Georgia's hepatitis C elimination plan: lessons learned for the global initiative
Authors: Yvan Hutin, Niklas Luhmann, Philippa Easterbrook
Journal: The Lancet Global Health (2019)

In 2015, Georgia was faced with one of the highest prevalence levels of hepatitis C virus (HCV) infection worldwide (5·4%, with 150 000 adults infected).1Gvinjilia L Nasrullah M Sergeenko D et al.National progress toward hepatitis C elimination—Georgia, 2015–2016.MMWR Morb Mortal Wkly Rep. 2016; 65: 1132-1135Crossref PubMed Scopus (53) Google Scholar An injection drug use epidemic along with unsafe health-care practices led to large-scale transmission in the 1990s. In 2015, Georgia adopted a plan to eliminate HCV by 2020 (ie, reduce the prevalence of HCV infection by 90% by 2020).2Mitruka K Tsertsvadze T Butsashvili M et al.Launch of a nationwide hepatitis C elimination program—Georgia, April 2015.MMWR Morb Mortal Wkly Rep. 2015; 64: 753-757Crossref PubMed Scopus (64) Google Scholar, 3Tsertsvadze T Gamkrelidze A Chkhartishvili N et al.Three years of progress towards achieving hepatitis C elimination in the country of Georgia, April 2015–March 2018.Clin Infect Dis. 2019; (published online Sept 29.)DOI:10.1093/cid/ciz956Crossref Scopus (17) Google Scholar Between May, 2015, and February, 2019, there has been progressive scale-up of testing and 54 313 patients have been treated.4Walker JG Kuchuloria T Sergeenko D et al.Interim effect evaluation of the hepatitis C elimination programme in Georgia: a modelling study.Lancet Glob Health. 2019; (published online Dec 18)https://doi.org/10.1016/S2214-109X(19)30483-8Summary Full Text Full Text PDF Scopus (14) Google Scholar In The Lancet Global Health, Josephine Walker and collaborators report on a dynamic transmission compartmental model that used Georgian data from the national biomarker survey and two biobehavioural surveys among people who inject drugs.4Walker JG Kuchuloria T Sergeenko D et al.Interim effect evaluation of the hepatitis C elimination programme in Georgia: a modelling study.Lancet Glob Health. 2019; (published online Dec 18)https://doi.org/10.1016/S2214-109X(19)30483-8Summary Full Text Full Text PDF Scopus (14) Google Scholar They projected the effect of diagnosis and treatment activities on incidence, prevalence, and mortality and calculated the treatment rates required to reach the 90% prevalence reduction target. The model suggests that compared with 2015, both incidence and prevalence had fallen by 37% and that mortality was reduced by 14%. It also suggests that if Georgia aims to reach its 90% prevalence reduction target by 2020, the treatment initiation rate should be increased from 1000 to 4000 individuals initiating treatment per month. Alternatively, the duration of the programme could be prolonged to 2026. Two observations from this work are particularly relevant to other HCV elimination programmes. First, from a programmatic standpoint, it informs how a programme can adjust its treatment targets to make sure it reaches its impact target. In the case of Georgia, more patients need to be treated and cured. This objective implies increasing case-finding activities and improving linkage to care and treatment. As in Georgia, several other countries have experienced an initial phase of rapid treatment scale-up as preidentified patients with advanced disease received direct-acting antivirals. However, at a later stage, cost-effective testing approaches are needed to identify more individuals infected. These approaches require awareness-raising and simplified service delivery to achieve optimal linkage to treatment and cure. Second, from a strategic information perspective, this work is a good example of the use of mathematical models that predict the effect of testing and treatment on the epidemic ahead of actual epidemiological measurement. Other countries engaged in elimination efforts could also make use of similar methods. However, ultimately, the results of the output of this and other modelled projections will need to be validated through comparison with data collected empirically to guide further policy.4Walker JG Kuchuloria T Sergeenko D et al.Interim effect evaluation of the hepatitis C elimination programme in Georgia: a modelling study.Lancet Glob Health. 2019; (published online Dec 18)https://doi.org/10.1016/S2214-109X(19)30483-8Summary Full Text Full Text PDF Scopus (14) Google Scholar, 5Estes C Abdel-Kareem M Abdel-Razek W et al.Economic burden of hepatitis C in Egypt: the future impact of highly effective therapies.Aliment Pharmacol Ther. 2015; 42: 696-706Crossref PubMed Scopus (52) Google Scholar, 6Delva W Wilson DP Abu-Raddad L et al.HIV treatment as prevention: principles of good HIV epidemiology modelling for public health decision-making in all modes of prevention and evaluation.PLoS Med. 2012; 9e1001239Crossref PubMed Scopus (29) Google Scholar In 2016, WHO defined "elimination of hepatitis as a public health threat" as a reduction of incidence (90% decrease) and mortality (65% decrease). Measuring incidence requires a combination of data sources (eg, re-testing of individuals who initially tested negative).7Shiha G Soliman R Mikhail NN Easterbrook P Educate, Test and Treat Model towards elimination of hepatitis C infection in Egypt: Feasibility and effectiveness in 73 villages.J Hepatol. 2019; (published online Nov 14.)DOI:10.1016/j.jhep.2019.11.004Summary Full Text Full Text PDF Scopus (19) Google Scholar Measuring mortality requires death registration data on cirrhosis and hepatocellular carcinoma along with information on the fraction of these events that are attributable to HBV, HCV, and other causes. The effect of treatment on mortality depends on the population-based distribution of various stages of fibrosis when a programme is initiated. There are recent epidemics, as in Georgia, in which a lot of individuals were infected in the past 20–30 years.1Gvinjilia L Nasrullah M Sergeenko D et al.National progress toward hepatitis C elimination—Georgia, 2015–2016.MMWR Morb Mortal Wkly Rep. 2016; 65: 1132-1135Crossref PubMed Scopus (53) Google Scholar In such settings, more people have earlier stages of fibrosis. The future mortality reduction is likely to be large, but delayed in time. There are more established epidemics, as in Egypt, where people were infected many decades ago.8Frank C Mohamed MK Strickland GT et al.The role of parenteral antischistosomal therapy in the spread of hepatitis C virus in Egypt.Lancet. 2000; 355: 887-891Summary Full Text Full Text PDF PubMed Scopus (849) Google Scholar In such settings, more people have advanced fibrosis. Mortality reduction might take place faster,9de Martel C Maucort-Boulch D Plummer M Franceschi S World-wide relative contribution of hepatitis B and C viruses in hepatocellular carcinoma.Hepatology. 2015; 62: 1190-1200Crossref PubMed Scopus (321) Google Scholar but some individuals might be treated too late to prevent evolution towards hepatocellular carcinoma. In the near future, WHO will initiate work to determine how achievement of elimination will be validated. An evaluation of effect on incidence and mortality will be key. Prevention and treatment coverage will also be considered to assess sustainability. The absence of progress on harm reduction, for example, could lead to persistence or recrudescence of HCV transmission.10Zibbell JE Iqbal K Patel RC et al.Increases in hepatitis C virus infection related to injection drug use among persons aged ≤30 years—Kentucky, Tennessee, Virginia, and West Virginia, 2006–2012.MMWR Morb Mortal Wkly Rep. 2015; 64: 453-458PubMed Google Scholar The experience from validated models will be key given the extended period between infection and progression to advanced disease and mortality. These models will help to understand how service coverage relates to effect in terms of incidence and mortality, so that the validation process can be relevant, efficient, and accurate. They will also allow a more efficient use of empirically collected data and projections of future mortality reductions in the case of recent epidemics for which the effect of interventions could be delayed in the future. We declare no competing interests. Interim effect evaluation of the hepatitis C elimination programme in Georgia: a modelling studyGeorgia's hepatitis C elimination programme has achieved substantial treatment scale-up, which has reduced the burden of chronic hepatitis C. However, the country is unlikely to meet its 2020 elimination target unless treatment scales up considerably. Full-Text PDF Open Access