WHO´s response to HIV/AIDS and viral hepatitis in the European region

6 October 2014 – BARCELONA - Gottfried Hirnschall speaks at the HepHIV2014 conference representing the WHO Regional Director for Europe, Zsuzsanna Jakab. In his speech, he highlights the need for increased testing, overall "public health approach" for equitable access, and measurable targets used in HIV response as valuable lessons that should be applied in the response to viral hepatitis. There are estimated 2.2 million people living with HIV and some 28 million adults living with hepatitis B and C in Europe.

Dear ladies and gentlemen, dear colleagues and friends.

I am very delighted to be with you here today, personally, and also to convey the greetings of WHO’s Regional Director for Europe, Zsuszanna Jakab.

You may be aware that in WHO at global level, the Global Hepatitis Programme has just at the beginning of this year moved together with the HIV Department; this is also the case in most regional offices including EURO. The idea behind this move is clear: there are important lessons learnt that can be shared. Specifically when it comes to the impressive treatment scale we have seen for antiretroviral treatment (ART) globally, much can be learnt to build and inform a similar movement for the scale up of hepatitis B and C programmes, including treatment, which is so much needed. I am sharing this structural change in WHO, as I believe it has relevance for the central theme and focus of this conference: sharing experiences across programmes, HIV and hepatitis, looking at commonalities and opportunities for alignment, for addressing major gaps, and to capitalize on exciting new opportunities, specifically for HCV.

So let me start by sharing some observations on HIV and viral hepatitis in the European Region. Here in the Region, HIV and viral hepatitis share similarities: first, and most unfortunately, both are increasing; both disproportionately affecting key populations with similar vulnerabilities (particularly persons who inject drugs and men who have sex with men), both are more prevalent in the east (three quarters of new HIV cases in the Region are reported from eastern Europe - and two thirds of the people with hepatitis B and C live in central Asia and eastern Europe); and there is a large pool of persons being co-infected. Last, both continue to present major public health challenges.

Important amongst these challenges is the large number of people who are unaware of their infections. Obviously, undiagnosed persons cannot take advantage of the great advances in treatment. Untreated persons will sicken and die. The transmission risk is also greater. Another related challenge is that many of those diagnosed are diagnosed late – sometimes too late to get the full benefit of treatment, this holds for both HIV and hepatitis. A third challenge is that universal access to treatment cannot be achieved without lowering costs, and through greater efficiency by adopting a public health approach which addresses the full range of needs of the patient.

WHO has been responding to both HIV and viral hepatitis at the global and European levels, for HIV since the early days of the epidemic and for viral hepatitis much more recently.

A major WHO emphasis and contribution in HIV has been the formulation of a public health approach – specifically through guidance to optimise and standardize treatment across the continuum of care, from testing, to treatment, to patient monitoring, adherence support, and sustained viral suppression.

In HIV, this approach clearly shows positive results – dramatically in some regions, and particularly in the region most affected, sub-Saharan Africa.

Yet it has become apparent that global and European gains in HIV prevention and treatment are unevenly distributed. In western Europe, the number of people receiving ART is high and most countries had achieved or were expected to achieve the 80% ART coverage target by 2015.

In eastern Europe, by contrast, the HIV response remains, overall insufficient. Even though the absolute number of people on ART increased over recent years, treatment coverage remains low, at 35% in 2012. As a result, the numbers of AIDS cases and deaths have increased by 47% and 13%, respectively, since 2010. In 2012, more than 130 000 new HIV cases were reported in the European Region, the highest annual number since reporting began. The Russian Federation and Ukraine accounted for 92% of new cases.

Many infections are undiagnosed and treatment is arriving too late for many persons in the EURO Region. In 2012, it was estimated that although more than 50 million tests were performed, people, in some countries in eastern Europe and central Asia, up to 65% of PLHIV are undiagnosed. And about half of people with newly diagnosed HIV infection present for testing at a late stage (CD4 cell count < 350 per ml blood).

Hence, one of the top priorities of the Regional Office is to support efforts of Member States to expand access to HIV testing and counselling, to increase early uptake of HIV testing, and to respond to the particular needs of vulnerable populations.

This support includes publishing a policy framework for testing in the European Region (2010), supporting the European Union initiative “European HIV testing week” (2013), and of course our engagement with the pan-European “HIV in Europe” initiative including our participation in the organising committee of this conference.

In providing technical assistance directly to Member States we encourage each country to consider its treatment cascade. The data from the cascades (some of which will be presented by Professor Kazatchkine in this conference) show that not only do many people living with HIV remain undiagnosed but also that those diagnosed are “lost” at each stage of the cascade – resulting in fewer than 20% of persons living with HIV achieving viral suppression.

For hepatitis after many years of neglect the situation is finally changing, in large part, this is triggered by the exciting prospect of a simple, tolerable, and effective cure for hepatitis C. And of course it has to become affordable. It is really noticeable that countries are starting to explore how best to respond.

The gain in global momentum is reflected also in the World Health Assembly resolution which was endorsed earlier this year by all Member States of WHO.

This resolution presents an opportunity to accelerate the pace of action on hepatitis prevention and treatment at global, regional and country levels. The resolution does call for enhanced action to improve equitable access to hepatitis prevention, diagnosis and treatment and asks countries to develop comprehensive national hepatitis strategies. Elements of the resolution concern improving hepatitis B birth-dose coverage and expanding harm reduction programmes for persons who inject drugs, and improving the quality of strategic information on hepatitis. It also asks WHO to take a global convening role to explore the feasibility of the elimination of hep B and C and to consult towards setting global targets in this regard. As you will be aware, currently no global targets for hepatitis exist, unlike for many other health priorities, including HIV. This is a significant mandate and responsibility for WHO, and I assure you we are not taking it lightly. We are taking comprehensive action in various aspects and I will share some of the most important areas of action with you.

In the area of normative guidance, WHO released hepatitis C guidelines earlier this year, and hepatitis B treatment guidelines will be ready for launch very soon. We have also started to develop consolidated hepatitis guidelines for B and C that will also provide recommendations on screening, management of end-stage liver disease, diagnostics, and service delivery aspects.

New hepatitis medicines, and as you know, there is a robust pipeline, will be assessed for inclusion in the WHO Model List of Essential Medicines. Expression of interest letters will be issued for prequalification of hepatitis medicines, as a mechanism to ensure safety and quality of generic drugs as they will become available. A patent landscape for hepatitis C drugs has been finalized as part of a broader effort to make the currently very expensive hepatitis medicines more affordable and accessible. This information will list relevant patents and countries where the products are patent protected and will be useful to governments as well civil-society organizations in considering a range of strategies to improve access. For greater transparency, price information on hepatitis drugs is also now being included in our global price reporting mechanism that exists for HIV drugs.

Currently, there is limited attention and resources for hepatitis in the work and focus of the HIV and also the broader health-focused organizations, and in general the high price of the newer HCV drugs is cited as reason for not embracing and engaging in hepatitis treatment scale.

WHO started to create a global partner platform and held the first global Partners meeting for hepatitis in Geneva in March 2014. We are also proactively advocating for the inclusion of hepatitis in the work and also funding of partners, such as UNITAID (who has embraced co-infection in its new strategy) and of the Global Fund, where discussions are happening as we speak.

Our EURO Regional Office contributed to global strategic information including European Region data to the Global policy report on the prevention and control of viral hepatitis in WHO Member States. The Regional Office has strengthened collaborative relationships with the World Hepatitis Alliance and other international NGOs and advocates for treatment and prevention of hepatitis particularly for key populations. A WHO Collaborating Centre on HIV and Viral Hepatitis was established at the University of Copenhagen in September 2013, led by Profressor Jens Lundgren. WHO and partners have published estimates of the burden of, and policy responses to, hepatitis B and C in the European Region.

One last, but important recent piece of work is our support to countries in developing and strengthening national plans for viral hepatitis.

Looking into the future, it will be essential to place both HIV and hepatitis visibly and firmly in the post-2015 Sustainable Development agenda. In that context, we started the development of two global strategies: the Global health sector strategy on HIV for 2016-2021, and the Global strategy on viral hepatitis for 2016-2021. The latter will include global targets as mentioned. There will be significant overlaps and cross-referencing in these two strategies. The process will require broad consultation with countries, relevant constituencies and partners, and linkages with other key health and development strategies.

Let me close by saying that we look forward to continue, and in some instances, to strengthen our work and engagement with many of you here in a range of important work areas that lie ahead in the development of global strategies, of access approaches, country plans, and normative guidance.

Overall, our collective responsibility will be to take full advantage of an exciting window of opportunity to re-dress the poor global attention and commitment to hepatitis to date, and to inform and concretize the vision on elimination of hepatitis B and C. With the tools we now and will soon have at hand, there is no excuse not to have this aspiration. At the same time, we will also have to find ways of sustaining and scaling up the HIV response in places and countries where it remains inadequate. Please do count on WHO as a committed and enthusiastic partner in this effort at this critical juncture.