title: HCV management in resource-constrained countries.
abstract: With the arrival of all-oral directly acting antiviral (DAA) therapy with high cure rates, the promise of hepatitis C virus (HCV) eradication is within closer reach. The availability of generic DAAs has improved access to countries with constrained resources. However, therapy is only one component of the HCV care continuum, which is the framework for HCV management from identifying patients to cure. The large number of undiagnosed HCV cases is the biggest concern, and strategies to address this are needed, as risk factor screening is suboptimal, detecting <20% of known cases. Improvements in HCV confirmation through either reflex HCV RNA screening or ideally a sensitive point of care test are needed. HCV notification (e.g., Australia) may improve diagnosis (proportion of HCV diagnosed is 75%) and may lead to benefits by increasing linkage to care, therapy and cure. Evaluations for cirrhosis using non-invasive markers are best done with a biological panel, but they are only moderately accurate. In resource-constrained settings, only generic HCV medications are available, and a combination of sofosbuvir, ribavirin, ledipasvir or daclatasvir provides sufficient efficacy for all genotypes, but this is likely to be replaced with pangenetypic regimens such as sofosbuvir/velpatasvir and glecaprevir/pibrentaasvir. In conclusion, HCV management in resource-constrained settings is challenging on multiple fronts because of the lack of infrastructure, facilities, trained manpower and equipment. However, it is still possible to make a significant impact towards HCV eradication through a concerted effort by individuals and national organisations with domain expertise in this area.
authors.affiliation: Division of Gastroenterology and Hepatology, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore. mdclimsg@nus.edu.sg.|Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore. mdclimsg@nus.edu.sg.
authors.forename: Seng Gee
authors.identifier: http://orcid.org/0000-0003-0994-4932
authors.initials: SG
authors.lastname: Lim
mesh_terms: D000621:Aminoisobutyric Acids; D000998:Antiviral Agents / Q000191:economics* / Q000627:therapeutic use; D001315:Australia / Q000453:epidemiology; D001562:Benzimidazoles / Q000627:therapeutic use; D002219:Carbamates / Q000627:therapeutic use; D003266:Continuity of Patient Care / Q000592:standards*; D003521:Cyclopropanes; D004338:Drug Combinations; D004359:Drug Therapy, Combination / Q000379:methods; D016568:Drugs, Generic; D005449:Fluorenes / Q000627:therapeutic use; D005838:Genotype; D016174:Hepacivirus / Q000187:drug effects / Q000235:genetics*; D006526:Hepatitis C / Q000175:diagnosis / Q000188:drug therapy* / Q000191:economics* / Q000453:epidemiology; D006576:Heterocyclic Compounds, 4 or More Rings / Q000627:therapeutic use; D006801:Humans; D007093:Imidazoles / Q000627:therapeutic use; D047029:Lactams, Macrocyclic; D007930:Leucine / Q000031:analogs & derivatives; D008103:Liver Cirrhosis / Q000175:diagnosis / Q000378:metabolism; D011392:Proline / Q000031:analogs & derivatives; D011759:Pyrrolidines; D011810:Quinoxalines / Q000627:therapeutic use; D012254:Ribavirin / Q000627:therapeutic use; D012307:Risk Factors; D000069474:Sofosbuvir / Q000627:therapeutic use; D013449:Sulfonamides / Q000627:therapeutic use; D014633:Valine / Q000031:analogs & derivatives
chemical_list: D000621:Aminoisobutyric Acids; D000998:Antiviral Agents; D001562:Benzimidazoles; D002219:Carbamates; D003521:Cyclopropanes; D004338:Drug Combinations; D016568:Drugs, Generic; D005449:Fluorenes; D006576:Heterocyclic Compounds, 4 or More Rings; D007093:Imidazoles; D047029:Lactams, Macrocyclic; D011759:Pyrrolidines; D011810:Quinoxalines; D013449:Sulfonamides; C000611331:sofosbuvir-velpatasvir drug combination; C586541:ledipasvir; C000622691:pibrentasvir; D012254:Ribavirin; D011392:Proline; D007930:Leucine; D014633:Valine; C000612853:glecaprevir; C549273:daclatasvir; D000069474:Sofosbuvir
keywords: Birth cohort screening; Direct-acting antiviral agents; HCV care continuum; HCV therapy; Linkage to care; Screening