Hepatitis C Virus in Children: Trying to Overcome the Domestic and Global Challenges of Cases and Cost.

Over the last decade, Hepatitis C virus has persisted and evolved as a domestic and global health challenge for adults and children. The challenges involve both increased cases in the United States and cost of treatment both in the US and globally.

Hepatitis C virus elimination in Indonesia: Epidemiological, cost and cost-effectiveness modelling to advance advocacy and strategic planning.

BACKGROUNDS & AIMS: In Indonesia 1.9 million people are chronically infected with hepatitis C virus (HCV), but a national strategic plan for elimination has not yet been developed, despite the availability of low-cost treatments which could save many lives. We used epidemiological and cost modelling to estimate targets and resource requirements of a national elimination program and explore the potential impact and cost-effectiveness. METHODS: To model the HCV epidemic, we used a dynamic model, parameterised with Indonesia-specific data, accounting for disease progression, injecting drug use and demographics. Future scale-up scenarios were designed for 2018-2050 to capture possible policy choices. Costs of an initial 5-year national strategy and of long-term elimination were estimated for the most feasible scenario, as agreed with government and local partners. Cost savings from reduced drug and diagnostics prices were also estimated. The cost-effectiveness of baseline predictions and those with drug price reductions were compared to the no treatment scenario. RESULTS: Elimination by 2045, considered the most feasible path to scale-up, would prevent 739 000 new infections and avert 158 000 HCV-related deaths. The costs would be $5.6 billion (USD) using baseline prices but could fall to $2.7 billion if price reductions for HCV drugs and diagnostics are secured. With these price reductions, the incremental cost-effectiveness ratio for a 2045 elimination program would be cost-effective at $300 (USD) per year of life saved vs the no treatment scenario. CONCLUSIONS: This study has underpinned advocacy efforts to secure Indonesian government commitment to HCV elimination, and provides further inputs for HCV strategic planning efforts.

Leave no one behind: response to new evidence and guidelines for the management of cryptococcal meningitis in low-income and middle-income countries.

In 2018, WHO issued guidelines for the diagnosis, prevention, and management of HIV-related cryptococcal disease. Two strategies are recommended to reduce the high mortality associated with HIV-related cryptococcal meningitis in low-income and middle-income countries (LMICs): optimised combination therapies for confirmed meningitis cases and cryptococcal antigen screening programmes for ambulatory people living with HIV who access care. WHO's preferred therapy for the treatment of HIV-related cryptococcal meningitis in LMICs is 1 week of amphotericin B plus flucytosine, and the alternative therapy is 2 weeks of fluconazole plus flucytosine. In the ACTA trial, 1-week (short course) amphotericin B plus flucytosine resulted in a 10-week mortality of 24% (95% CI -16 to 32) and 2 weeks of fluconazole and flucytosine resulted in a 10-week mortality of 35% (95% CI -29 to 41). However, with widely used fluconazole monotherapy, mortality because of HIV-related cryptococcal meningitis is approximately 70% in many African LMIC settings. Therefore, the potential to transform the management of HIV-related cryptococcal meningitis in resource-limited settings is substantial. Sustainable access to essential medicines, including flucytosine and amphotericin B, in LMICs is paramount and the focus of this Personal View.