Introduction to Hepatitis C in Egypt

Globally, 58 million people live with chronic hepatitis C virus (HCV) infection. Although no vaccine exists, affordable, safe, and highly effective short-course treatments with direct acting antivirals (DAAs) can cure the disease. However, 80% of those infected worldwide are unaware of their condition. Without treatment, HCV infection can lead to severe liver disease and cancer.

In 2015, Egypt had the highest prevalence of HCV in the world. When the WHO released their 2030 global viral hepatitis elimination targets, Egypt launched a national test-and-treat programme following the increased availability of DAAs. Egypt diagnosed 87% of its hepatitis C cases and treated 93%, surpassing WHO gold-tier targets of 80% diagnosis and 70% treatment. This achievement transitioned Egypt’s HCV prevalence from one of the highest rates at 10% to one of the lowest at 0.38%.

To achieve complete elimination of HCV in Egypt, the national test-and-treat programme must include pregnant women and children under 12 years, who are currently excluded. This paper recently published in BMJ Public Health evaluates the cost-effectiveness of various HCV screening and treatment strategies for these groups.

Screening and Treatment Strategies

Using a decision analysis model, the study assessed the long-term clinical impact and cost-effectiveness of 18 different HCV screening and treatment strategies for pregnant women and their infants. These strategies combined three components: antenatal screening, treatment of HCV-RNA positive pregnant women, and treatment of HCV-RNA positive children. HCV-RNA testing is a well-established method that determines the presence of active HCV in the bloodstream and chronic HCV infection.

Current practice involves targeted antenatal screening with deferred treatment for both mother and child. The researchers also explored prophylactic treatment for infants born to HCV-infected mothers. The goal was to compare these strategies against current practices to determine their effectiveness and cost-efficiency.

Figure 1. Model structure. The antenatal model provides the postdelivery distribution of mothers and their infants regarding their HCV status. Postdelivery maternal and paediatric models allow assessment of lifetime costs and life expectancies based on the postdelivery cascade of care. DAA, direct acting antiviral; HCV, hepatitis C virus.

Antenatal HCV Screening

Antenatal screening options included current practice, WHO-recommended targeted screening, and universal screening of all pregnant women. Researchers found that universal screening during pregnancy is more comprehensive, potentially identifying more cases of HCV. This approach could lead to earlier interventions and better health outcomes for both mothers and infants.

Treatment of HCV-RNA Positive Pregnant Women

Treatment options for HCV-RNA positive pregnant women included deferred treatment until after delivery and breastfeeding cessation, targeted early treatment during pregnancy, and universal early treatment. Early treatment during pregnancy, especially for women with high risk factors, showed promise in reducing vertical transmission of HCV. This strategy could improve life expectancy and reduce disability-adjusted life years (DALYs) for both mothers and children.

Treatment of HCV-RNA Positive Children

For children, treatment options included starting at 12 years old, or as early as 3 years old for those children born to mothers who were HCV-RNA positive. The researchers found that early treatment from 3 years old, as recommended by WHO, is more effective in managing HCV. This approach could lead to better long-term health outcomes and lower lifetime healthcare costs.

Cost-Effectiveness Analysis of Screening and Treatment Strategies

The study used incremental cost-effectiveness ratios (ICERs) to compare the strategies, where strategies with lower costs and higher benefits were considered cost-effective. Current practices resulted in the highest costs (US$ 314.0), lowest life expectancy (46.3 years), and highest DALYs per mother-child pair (0.0512 years). In contrast, universal screening and treatment during pregnancy proved to be cost-saving (US$ 219.3) with higher life expectancy (46.4 years), and lower DALYs (0.0359 years). Prophylactic treatment at birth was also cost-saving (US$ 218.6), with a similar life expectancy and DALYs as the universal approach, even with 15% treatment uptake. This study demonstrated that universal screening and treatment of pregnant women with HCV during pregnancy leads to the highest diagnosis and cure rates by delivery, reducing infant infection rates by 50% compared to current practices.

Conclusion

The study highlights the importance of including pregnant women and their children in national HCV elimination goals. Implementing universal screening and early treatment offer a cost-effective approach to managing HCV, benefiting both mothers and infants. By adopting these methods, healthcare systems can enhance patient outcomes, reduce healthcare costs, and successfully eliminate HCV in Egypt.