An interview with William Haseltine about the following article is also available here: https://www.nejm.org/doi/full/10.1056/NEJMp1915818
Thirty years ago, chronic conditions such as diabetes, heart disease, and obesity accounted for less than 45% of the global disease burden. Today, they are the leading causes of death and disability worldwide, having surpassed infectious diseases such as HIV/AIDS and malaria.
Although we are now able to treat many chronic and infectious conditions, few countries — rich or poor — have systematically tested and treated their people for the diseases that threaten them most. Now, however, the Egyptian government has provided an example of how routine testing and treatment for infectious and chronic diseases for an entire country can be achieved. In 2018, Egypt embarked on a vast disease screening and treatment campaign for hepatitis C, hypertension, diabetes, and obesity, called the 100 Million Healthy Lives program. The country’s success shows that dramatic improvements in public health are possible.
Egypt has the highest rate of hepatitis C infection in the world. Ten years ago, it was estimated that nearly 15% of Egyptians were infected. Many of them were infected during the country’s decades-long fight against schistosomiasis, a disease that children often acquired from swimming in the Nile River.1 In the 1950s, the Ministry of Health and Population promoted tartar-emetic injections to treat schistosomiasis. For nearly 30 years, doctors working in overcrowded rural clinics routinely reused unsterile needles dozens of times, unknowingly infecting people with hepatitis C.
In 2006, faced with evidence of rampant infection, Egypt’s health ministry created the National Committee for the Control of Viral Hepatitis and appointed Dr. Wahid Doss to run it. The U.S. Agency for International Development provided much of the funding for the program, and the World Health Organization (WHO) provided support.
Over the past year, I have visited Doss several times and discussed the screening program and its history with him.2When he was appointed, the best available treatment option for viremia was the combination of interferon and ribavirin, which acts by stimulating the immune system instead of directly inhibiting virus replication. The cost of treatment in the private market was about $4,000 (in U.S. dollars) per patient, which was prohibitive for a population-based treatment program. Doss, as he put it, “became an expert in how to reduce the price of medications.”
To assuage the fears of manufacturers such as Roche and Schering-Plough that Egypt would become a source of cheap black-market interferon, he agreed that doctors would administer treatments only in specialized centers. “That way,” Doss said, “we control the distribution of the drug.”
By 2013, Doss’s group had established 25 hepatitis C treatment centers. Physicians gave weekly injections, paid for by the Egyptian government, to 50,000 patients per year. The success rate of the treatments was only 40%, however.
That same year, Doss got word of a new treatment: direct-acting antivirals. Gilead Sciences revealed in December 2013 that a 12-week course of treatment with Sovaldi (sofosbuvir) would cost $84,000 per patient. The medication is highly effective and has fewer side effects than traditional treatments. Doss negotiated a lower price by promising that the Egyptian government would buy the drug in bulk and keep tight controls on its use. To reduce the possibility of fraud, each person receiving treatment would be identified with a unique number and patients’ information would be tracked in a single database.
Gilead agreed to supply Sovaldi at about $900 per treatment course — the rate generally reserved for developing countries. Free testing and treatment were offered in public clinics to anyone older than 18 years of age.
News of free and effective treatment traveled fast. To make it easy for people to sign up for screening, Doss’s group built a website that required only a name, national identification number, and mother’s maiden name. The centers opened registration on September 14, 2014, and 100,000 people signed up in the first minute. By 2017, the centers had treated 1.6 million people. The cure rate with a two-drug combination was between 96% and 98%.
The treatment centers began using other drugs such as simeprevir, ledipasvir, and daclatasvir in later years. Even given negotiated drug prices well below market rates, Egypt would not have been able to cover the cost of treating the millions of people who screened positive for hepatitis C infection. The government was granted an exemption under the World Trade Organization Agreement on Trade-Related Aspects of Intellectual Property Rights that allowed manufacturing and use of direct-acting antivirals free of patent restrictions. Twenty Egyptian companies now formulate seven generic direct-acting antivirals. The active pharmaceutical agents for these drugs are produced in India in collaboration with Chinese manufacturers. The cost to the Egyptian government is about $45 per 3-month treatment. Patients electing to receive treatment at a private clinic pay $75.
In 2018, the World Bank offered Egypt a $530 million loan. About half of the loan was to be used to expand hepatitis C screening and treatment. The remainder was for strengthening of the health system. The World Bank encouraged Egypt to broaden its program to include screening for other chronic diseases.
On October 1, 2018, Egypt launched the 100 Million Healthy Lives program. The goal was to screen all Egyptians 12 years of age or older for active hepatitis C virus replication, hypertension, diabetes, and obesity. Free treatment would be offered in government clinics for people who tested positive for hepatitis C, hypertension, or diabetes, and free counseling would be available for those considered obese.
In addition to the funds provided by the World Bank, 5000 electronic tablets were provided by the WHO for data collection. Each person’s height, weight, blood pressure, and blood sugar levels are recorded as part of the screening process. All data are uploaded in real time to a single information network to permit ongoing updates regarding treatment and follow-up.
The program initially launched in 11 districts. By June 2019, screening was taking place throughout the country, and there are now 116 affiliated screening and treatment centers linked to the network. The program has become a permanent part of the Egyptian health system.
Egypt has now screened 60 million people older than 18 years of age and 8 million people between the ages of 12 and 18. More than 4% of them had antibodies to hepatitis C, of whom nearly 75% had active viremia; 21% screened positive for hypertension; and about 5% screened positive for diabetes. Counseling is under way for the 40% of the screened population that is considered obese by WHO standards.
Virtually all people identified as having active virus replication have been effectively treated. Egypt may soon be the first country to eliminate hepatitis C. The success of this program suggests that other countries could effectively pursue other chronic and infectious diseases by using similar strategies. It may be hard work to get there, but Egypt has proven that universal screening for a range of diseases is not impossible. Drug-pricing challenges can be overcome. Treatments can be made available for all.