With a relatively high proportion of the population infected with hepatitis C virus, the government is taking up an MSF programme to treat patients. Sharmila Devi reports.
A project using generic drugs to treat hepatitis C in Ukraine, run by Médecins Sans Frontières (MSF), was transferred to local authorities earlier this month amid hopes that it will be implemented across the country, as Ukraine continues to reform its health system.
An estimated 3·5% of Ukrainians live with hepatitis C, much higher than the European average of 1·5%. The causes include a large number of people who inject drugs, which has also led to high HIV rates, Karan Kamble, MSF's medical activity manager for the Ukraine project, told The Lancet.
“There is a large vulnerable group of drugs users and a high prevalence of HIV, which has a direct correlation with hepatitis C”, he said. “Also, the health structure of any post-Soviet country needs time to reform and grow its health-care system.” However, it was uncertain if Ukraine would continue the Mykolaiv project after the drugs donated by MSF ran out in late 2021, he said.
The MSF project started 3 years ago in the Mykolaiv region on the Black Sea coast in southern Ukraine. Under a model developed with the Ukrainian Ministry of Health, generic drugs were used for the first time to treat hepatitis C for free, and MSF provided tests, laboratory equipment, and supplies. Previously, patients would have had to pay for treatment themselves, which vulnerable groups would have found extremely difficult, said Kamble.
On offer was the WHO-recommended combination of daclatasvir and sofosbuvir, which is effective for treating all types of hepatitis C after 12–24 weeks, and has fewer side-effects than pegylated interferon. The new treatment regimen has had a cure rate of almost 94% in Mykolaiv.
MSF and other groups continue to campaign for generic versions of sofosbuvir, which has been estimated to cost about US$5 to make, whereas brand-name regimens cost thousands of dollars in the USA.
“After MSF came, generic versions were registered in Ukraine and [their] use has been adopted by the ministry of health, but there are many health and other challenges in the country”, said Kamble. “For example, the HIV budget has been cut to $55 per patient. In India, first-line drugs cost a minimum of $80 per patient and second-line drugs around $400.”
Ukraine could reach the WHO aim of eliminating viral hepatitis as a public threat by 2030 if there was concerted action, said Antons Mozalevskis, medical officer for the joint tuberculosis, HIV, and viral hepatitis programme at the WHO Regional Office for Europe. “Ukraine has the potential to reach those targets due to improved access to low-cost quality medicines, strong collaboration between the government and civil society sector, and political commitment”, he told The Lancet.
1163 patients have been treated for hepatitis C in Mykolaiv and just under 300 are awaiting testing, which has been delayed because of COVID-19. Patients living with HIV or undergoing opioid substitution therapy were also offered psychosocial support. Medicines have been delivered by post and support given by telephone during the pandemic.
Among the challenges in efforts, such as MSF's, to scale up treatments was knowing exactly how many people were infected with hepatitis C, said Mozalevskis. “The figure of 3·5% is our best guess in the absence of a proper serology survey as has happened in Georgia, for example”, he said.
Combating hepatitis was firmly on the Ukrainian Government's agenda, but health reforms had taken many years and were not yet complete, he said. WHO conducted a hepatitis response assessment mission in 2017, at the request of the government. Its report said there was “increasing awareness and commitment to responding to viral hepatitis by the majority of government and non-government stakeholders. Still, at the national level hepatitis response is currently fragmented.”
Planning for health needs in Ukraine has been difficult because of decentralisation in the large country, which has a population of around 42 million. “Compared with Georgia and the republics of Moldova and Belarus, Ukraine is big and this is why it's difficult to coordinate and decentralise treatment programmes and planning to the regions”, said Mozalevskis.
“Presently, the regions send requests for medicines to the central level, the ministry of health, and public health centre. This could be improved with, for example, a national registry to implement hepatitis C treatment projects.” To this end, WHO has been working with all partners, including the government and civil society, to improve outcomes, he said.