Egyptian HCV carriers will soon have cost-effective alternatives to interferon therapy. Credit: Cam McGrath/IPS.

By Cam McGrath
CAIRO, Apr 9 2014 (IPS)

Mohamed Ibrahim first learned he had hepatitis C when he tried to donate blood. Weeks later he received a letter from the blood clinic telling him he carried antibodies of the hepatitis C virus (HCV). He most likely acquired the disease from a blood transfusion he received during surgery when he was a child.

“I needed a lot of blood, and this was at a time before they screened it,” Ibrahim recalls.Even with new drugs showing promise in reversing cirrhosis, it may already be too late for late-stage HCV patients.

Now, at 24, Ibrahim is living with the blood-borne virus, knowing it is slowly eroding his liver. Unless treated, by the time he reaches his forties the disease will likely advance to cirrhosis or liver cancer.

While Ibrahim has been undergoing treatment since he first learned of his infection, the medication is costly and yet ineffective.

“Nothing has worked, and the side effects of the medicine are as bad as the disease,” he says. “I can’t work in [other places such as) Dubai or Saudi Arabia, because they require a clean blood test before issuing a work permit.”

Ibrahim is one of an estimated eight to 10 million Egyptians living with hepatitis C.

Egypt is said officially to have the highest prevalence of hepatitis C in the world, with 10 to 14 percent of its 85 million people infected, and about two million in dire need of treatment. HCV-related liver failure is one of the country’s leading causes of death, taking over 40,000 lives a year.

But Egyptians infected with HCV now have fresh hope in novel treatments.

The Egyptian government recently struck a deal with U.S. pharmaceutical firm Gilead Sciences to purchase its new hepatitis C pill Sovaldi at a fraction of its American price.

Under the agreement, Gilead will supply a 12-week regimen of Sovaldi to Egypt for 900 dollars, instead of the 84,000 dollars the medicine costs in the United States. Egypt’s health ministry is expected to make the drug available at specialised government clinics in the second half of 2014, once local drug registration procedures are completed.

Studies have shown that Sovaldi is up to 97 percent effective in curing HCV type-4, the most common strain of hepatitis C among Egyptians. The pill is seen as a significant improvement over the traditional HCV treatment in Egypt, which is a 48-week course of the anti-viral drug interferon taken in combination with ribavirin tablets.

The existing treatment costs up to 7,000 dollars using pegylated interferon supplied by multinational pharmaceutical firms Roche and Merck, and is only about 60 percent effective. Many patients also report severe side effects such as anaemia and chronic depression.

Interferon is available without a prescription at pharmacies in Egypt, but at 150 dollars per weekly injection, the 48-week regimen is well beyond the reach of most Egyptians. Reiferon Retard, a locally manufactured interferon, costs a third of that price, but critics claim it is less than 50 percent effective.

Since 2006, the Egyptian government has treated more than 250,000 HCV patients at specialised units affiliated to the National Committee for the Control of Viral Hepatitis, a government body formed to tackle the disease. Interferon injections are provided at reduced cost or free to uninsured Egyptians, but as many as half of the patients treated suffer a relapse within six months.

A 2010 study by the U.S.-based National Academy of Sciences estimates that more than 500,000 new cases of HCV infection occur in Egypt each year. Researchers attributed the spread of the disease to the high background prevalence of HCV in Egypt – about 20 times higher than the global average – and to poor medical hygiene practices, including the use of unsterilised medical equipment and unscreened blood.

Egypt’s government claims the figures are highly exaggerated, and that the high prevalence is the clinical outcome of infections decades earlier.

Many HCV carriers were infected during a national campaign in the 1960s and 1970s to stamp out the water-borne disease schistosomiasis, also known as bilharzia. Health authorities administered repeated injections of the bilharzia treatment to Egyptians in rural areas using unsterilised needles, inadvertently spreading hepatitis C among the population.

“Doctors at that time were unaware of HCV, which was only identified in 1987, and were using glass syringes instead of the plastic disposable syringes that is current practice,” explains Dr. Refaat Kamel, a surgeon and specialist in tropical diseases. “Once a needle got infected, the disease spread quickly.”

Kamel says a better understanding of the structure and reproductive mechanism of HCV has allowed scientists to devise more effective treatments.

Gilead’s Sovaldi received the approval of the U.S. Food and Drug Administration (FDA) in December 2013 after clinical trials demonstrated its effectiveness in curing HCV without significant adverse effects. The drug, one of a new line of direct-acting antiviral agents, combats the disease by targeting infected liver cells and inhibiting the enzymes that allow the virus to replicate.

The FDA has also approved Janssen Therapeutics’ Olysio, a direct-acting antiviral agent that is about 25 percent cheaper than Gilead’s pill. Pharmaceutical firms AbbVie, Bristol-Myers Squibb, Merck and others are all hustling to develop their own oral therapies.

Sovaldi’s effectiveness on HCV type-4 is proven only when used with interferon and ribavirin. Further testing will establish whether the drug can be taken without weekly interferon injections, or as a combined therapy with other direct-acting antiviral agents.

“Trials here of six months of Sovaldi without interferon but with ribavirin showed similar success rates, higher than 96 percent (cured),” says Dr. Mohamed Abdel Hamid, director of the government-run Viral Hepatitis Research Lab (VHRL). “The drug might also be effective taken for three months without interferon. We just don’t know yet.”

He says that apart from the reduced cost and greater efficacy of Sovaldi, oral medication could reduce the manifold problems associated with long-term intravenous interferon therapy.

“Obviously, over 48 weeks there is a lot more that can go wrong,” Abdel Hamid tells IPS. “Adherence is a problem as patients must visit the treatment centre at the same time every week to receive the injection. There are also problems keeping the interferon cold, and the medication has many side effects.”

But he cautions that even with new drugs showing promise in reversing cirrhosis, it may already be too late for late-stage HCV patients. With a limited healthcare budget, Egypt is expected to prioritise treatment for those in whom the disease has not yet manifested.

Lack of awareness among youth on risks of HIV infections needs to be addressed quickly to stem the disease from spreading, the National HIV Strategic Plan Sri Lanka 2013–2017 has warned. Credit: Amantha Perera/IPS.

By Amantha Perera
COLOMBO, Feb 2 2014 (IPS)

Four thousand HIV infections in a population of 20 million should not be a difficult figure to manage. But experts in Sri Lanka say social customs and strict laws are hindering them from carrying out prevention and awareness campaigns among high-risk groups.

Despite impressively low national infection rates, there are signs that the spread of HIV – which can lead to AIDS – has increased among these groups, most of which face ostracism, they say.

Sri Lanka, an Indian Ocean island nation, is considered a low HIV prevalence country, according to official statistics. Going by the latest data of the National AIDS Prevention Programme, there are little over 1,800 HIV infected in the country, of which the majority is male, at 1,080.For Sri Lanka’s high-risk groups, time is ticking away.

Even if undetected cases were to be factored in, the overall case load is estimated to be around 4,000, Susantha Liyanage, director of the programme, told IPS.

Liyanage, however, warned that these low figures could be hiding a much more explosive and complex situation – the risk of an epidemic within high-risk groups. “There is a very real chance that there are higher infection rates among high risk groups. We are already seeing such a trend,” he told IPS.

A similar warning came in the Sri Lanka National HIV Strategic Plan 2013-2017 released last year. “Certain socio-economic and behavioural factors noticed in the country may ignite an epidemic in the future,” it said.

Among the risk groups identified in the plan were men who have sex with men, youth aged between 15 and 25, intravenous drug users and the offspring of HIV positive parents.

Experts say while HIV awareness has grown in Sri Lanka, fighting the spread of the disease within high-risk groups is being stymied by legal and social strictures.

“Under Sri Lankan law, homosexuality and drug use are criminal offences, making it extremely difficult to work openly with these groups,” Milinda Rajapaksha, working director at National Youth Services Council, told IPS.

Liyanage said the situation is similar for commercial sex workers, identified as yet another high-risk group.

“With all of these groups we have to be discreet and use intermediary organisations to conduct awareness and prevention programmes,” he said.

Of the known infections, 80 percent are due to unprotected sexual activity and 4.4 percent due to parent to child transmission.

Liyanage said despite the presence of a free island-wide prenatal care service carried out by the Ministry of Health, HIV screening of pregnant mothers was still very poor.

The National HIV Strategic Plan said in 2011 only three percent of all pregnant women had been tested for HIV, even though over 95 percent of pregnancies in the country had access to prenatal care.

Another astonishing detail is, of the known infections, 20 percent is in the age group of 15 to 25. A little over five years back, this age group made up less than six percent of known infections.

Liyanage said the increase in infections among the youth was a grave concern. “It indicates that awareness programmes are not effective among the youth.”

Last November a new intra-ministerial committee was formed, with Liyanage at its head, to draft new recommendations to slow down the spread of the disease among youth.

Sri Lanka also lacks sex education at the secondary school level.

Rajapaksha from the National Youth Council said lack of awareness was becoming a serious problem as more and more youth became sexually active. The official said Sri Lanka’s health policy was yet to recognise youth as a special category, making it difficult to target health risks within the group.

A new National Youth Policy scheduled for release in February recommends that this anomaly be rectified.

Rajapaksha said homosexual men were particularly at risk since social conventions stigmatised them severely. He said in urban areas, especially in the Western Province, activists and groups were helping gay groups but such work was extremely difficult in rural areas.

“On top of this there is hardly any chance of conducting large-scale public awareness campaigns aimed at these groups – the public backlash will be too much,” he said.

Asela, a gay man who works with homosexual groups, said all meetings conducted by his group were limited to a very closed group and there were hardly any public programmes.

“If you are in the network, help is readily available. But we do not carry out any programmes aimed at the general public whereby gay men or women unknown to us can reach us,” he said.

According to research, there are between 30,000 and 40,000 men having sex with men in Sri Lanka. HIV infections within the group have shown a steady increase in the last five years. In 2009, a year after surveillance of the group began, infections were 0.48 percent of overall cases. The rate was 0.9 percent in 2011 and it is currently 12.3 percent.

The group also showed a high number of sexual partners and at least a quarter indicated they had sexual liaisons with women as well.

For Sri Lanka’s high-risk groups, time is ticking away.