Welcome to the Viral Hepatitis Elimination session entitled, Are We Any Closer? I'm Nora Turow from the University of Southern California, and I'm joined by my co-chair, Harry Jensen from the Toronto Centre for Liver Diseases. We're excited to bring you this program. As you're all very aware, all countries are striving to meet the WHO goals of viral hepatitis elimination. And so we felt it was important to bring together hepatologists to share the lessons learned, including those that have resulted from the response to the COVID-19 pandemic, with a view that this may help us to advance progress towards hepatitis elimination. So our very specific goals for this session are to enumerate the global progress and to highlight the strategies globally that have yielded the greatest impact, to discuss and differentiate the unique diagnostic linkage to care and treatment challenges for hepatitis B versus hepatitis C, and then of course, to also think about how COVID-19 associated changes in delivery of care can be leveraged to aid in the viral hepatitis elimination. We have an outstanding faculty for this session. Let me introduce them briefly. The global update on elimination will be given by Mark Sokowski from John Hopkins University. The challenges and successes related to hepatitis B by Maud Lumon from the Imperial College of London. Challenges and successes with hepatitis C by Margaret Hellerd from the Burnett Institute in Melbourne. And leveraging COVID-19 to accelerate progress on elimination by John Ward, who's from the Task Force for Global Health. During the session, you will be able to post questions to the presenters using the online chat feature on the right-hand side of your screen in real time. And we have a dedicated question and answer period where we'll be covering as many of those questions as possible. So we look forward to your participation. Thank you very much for joining us today. Hello, I'm Professor Mark Sokowski. From Johns Hopkins University in Baltimore, Maryland. I'm thrilled to be part of this important session and to present an update on global hepatitis elimination. My disclosures are outlined on this slide. Well, let's jump right into it. This audience is familiar and well aware of the global burden of viral hepatitis. In 2019-2020, WHO estimated there were 58 million persons living with chronic hepatitis C, of whom 1.4 million were persons who inject drugs and 2.3 million were co-infected with HIV. New infections were identified in more than 1.5 million people with deaths in the range of 0.3 million. The burden of hepatitis B was even greater with 296 million people estimated to be living with chronic hepatitis B. Two-thirds of these people were living in Africa or the Western Pacific region and 2.7 million were co-infected with HIV. Importantly, the prevalence among children aged five or under was less than 1%, but well above the targets that we'll discuss. New infections, 1.5 million, deaths, 0.8 million. Indeed, more than 500,000 people had hepatocellular carcinoma as a direct result of chronic viral hepatitis, which is preventable with vaccination and treatment. If we look at the figure to the right, this comes from a seminal paper from David Thomas at Johns Hopkins, and it shows the mortality or deaths due to malaria, HIV, TB, and viral hepatitis. You'll see that due to public health efforts, there is a decline in these other three pathogens, but at the current pace, it is anticipated that morbidity and mortality from viral hepatitis C and B will continue to increase if we don't begin to apply the tools that we have developed for treatment and prevention. Indeed, the Nobel Prize Committee has selected advances in viral hepatitis first in 1976 and more recently in 2020. In 1976, Dr. Bloomberg was recognized for the discovery of the Australia antigen and his work, which led to vaccination. More recently, Drs. Alter, Halton, and Rice were recognized for their contributions in discovering hepatitis C and basic biologic mechanisms that led to direct acting antiviral therapy. Indeed, the Nobel Committee said, for the first time in history, the disease can now be cured, raising hope of eradication. Now, the goal at this point is elimination. In 2016, WHO released its proposal to eliminate viral hepatitis as a public health threat by 2030 compared to 2015 baselines. The organization envisioned a world where transmission is halted and people living with hepatitis have access to effective care and treatment services. In other words, the care continuum is vastly improved. If we could do that, the anticipation is we'd reduce new infections by 90% and we'd reduce mortality by 65%. Along the bottom of the figure are estimates of what that would mean in terms of human lives with new cases and number of deaths. This is certainly a very important goal. When we have the tools, it's simply a matter of applying those, which is, of course, very difficult. So, where are we starting from? Well, this shows the global care continuum in 2015 along with the WHO elimination targets. So, if we can improve diagnosis, treatment, and delivery of care leading to viral cure for C and viral suppression for B, we can reach the goals of decreased incidence and mortality. But you see, for both viruses, we are far from diagnosing the appropriate number of individuals and we are far from linking those individuals to treatment and even further from virologic outcomes. We have a lot of work to do. Now, there has been progress. In November of 2019, hepatology societies globally led to a call for better hepatitis C testing, treatment access, and really simplified the treatment paradigm. This is essential. We have safe, tolerable therapies and they gave us a roadmap for simplification of diagnosis and treatment algorithms for decentralization of care and task sharing, getting specialists out of the picture and moving to frontline and community health workers. Now, I note along the bottom that similar work is being done to focus on clinical strategies for achieving hepatitis B elimination, but simplification is important when we translate to a public health forum. Now, in 2021, WHO also set targets for demonstration elimination. I'd like to start with hepatitis C. And what this slide outlines from the interim guidance for country validation of viral hepatitis elimination in June 2021, we see the targets of 2030 relative reduction compared to 2015, reducing the incidence of hepatitis C by 80%, mortality by 65%. What is helpful is HCV-specific targets for an absolute annual incidence. Now, it's interesting that the annual incidence rate can be higher among persons who inject drugs, two per 100, and that's to be expected. As we'll talk about, this population is critical in achieving reduction in transmission and reduction of incidence, the anti-mortality rate of less than two per 100,000. They also set programmatic targets for testing and treatment. More than 90% of people with hepatitis C diagnosed, and of those diagnosed, more than 80% of people treated. But let's not forget prevention. While there is no available vaccination for hepatitis C, we can prevent by reducing unsafe medical injections, still a major role of transmission around the world, making the blood supply 100% safe, and a critical point, providing needles, syringes, and injection kits to persons who inject drugs. The estimates are about 300 kits per person who injects drugs per year, and as we'll see, this is a major driver of new infections, particularly in the United States. Well, how are we doing? Well, I'd like to thank Homer Rezavi for his work, and that of his colleagues at the CDA Foundation in the Polaris Observatory. This slide shows progress towards elimination targets using 2020 data. Now, if we look at 90% diagnosed, 80% treated, absolute mortality, absolute incidence, it's pretty clear that globally, we are not on target to achieve these programmatic goals. Now, this is not a surprise, and it's also showing us the entire world. What if we drill down and look at specific countries? Well, here we see that 15 countries are on track to eliminate hepatitis C as a public health threat by 2030. The countries are listed in the green table to the left of this slide. Now, if we pay attention to the map, we see that there are other countries in yellow that are working towards this goal, and then countries in red that are not on track. I want to highlight the United States, where we have made considerable progress with respect to mortality. However, due to the ongoing opioid epidemic and limited access to injection kits and harm reduction programs, we continue to see rising acute hepatitis C or new cases, and are missing the mark on the target of reducing new infections. But let's look a little bit deeper at some of the countries on the left in the table and look at successes. I want to highlight Iceland, where the Trap Hep C program was a nationwide program, which included testing and access to services free of charge. What I want to focus on for this particular effort was that prisoners and people who inject drugs, those with recent injection drug use, were targeted. This is the key population and driving the epidemic of hepatitis C in Iceland. They also allowed for prompt retreatment of those with reinfection, used outreach, going to where people are, and incorporated a scale-up of harm reduction services and point-of-care testing. Along the bottom, we see the WHO target, and we see the outcomes published in the Lancet gastroenterology hepatology in 2021 for a Trap Hep C. 94.7% diagnosed, 91.2% of those diagnosed treated. They've met these programmatic targets. Now on a much larger scale is the program in Egypt, which is equally successful. The Ministry of Health determined a plan to screen everyone in Egypt 80 years or older with a target of 62.5 million, and then provide treatment to all those with active infection at no cost. The Table 1 taken from the New England Journal of Medicine paper demonstrates that screening took place in more than 49 million people, that is about 80%. Of those, more than 2.2 million were found to be Hep C antibody positive. And by September 2019, 91% of 1.15 million people with chronic infection started treatment. If we look at the figure to the right, again provided by the CDA Foundation, to the left is 2015, and these are the countries ranked by the total viremic infections. And you can see that Egypt was number five. If we look to the right of this slide, we now look at 2020, and we see that Egypt have dropped to 18. This is a dramatic and remarkable shift. The other top five or seven countries listed here have not changed their positions. Indeed, the number of people with active infection remains similar in 2020, and really quite remarkable in terms of the progress. So this needs to be replicated in other settings. But let's turn our attention to Hepatitis B. Here we see the target is a 95% reduction in incidence, a 65% reduction in mortality, with the targets of reduction particularly of Hepatitis B source antigen positivity in children less than or equal to five years old and a reduction in mother-child transmission. So unlike C, it's the application of universal Hepatitis B vaccine at birth and for the three-shot series. And in addition, in countries where they're already enrolled in targeting HPV vaccination to look at improved testing of mothers during pregnancy, antenatal testing, and delivery of antiviral therapy, if eligible based on recent recommendations. Similarly to Hepatitis C, the goal is to diagnose more than 90% of people with Hep B and treat more than 80% of those. But the element of prevention with vaccine is a critical part of Hepatitis B elimination as a public health threat. If we focus on mother-child transmission, birth dose vaccine coverage in 2019-2020 was 43%, with considerable gaps in the WHO African region. In a modeling study from 2016, there was an observation that scale for birth dosing would prevent 18.7 million infections, so getting to that 90% goal. And the addition of antivirals during the third trimester could prevent another 1.4 million. So in July 2020, the WHO issued this revised guidance. The foundation of this pyramid is vaccine, with maternal antiviral prophylaxis being added as a new tool in the armamentaria to prevent mother-child transmission. So how are we doing? Well, similar to Hepatitis C, the Polaris observity suggests that we are not on target for the diagnosis, treatment targets, or absolute mortality and prevalence in children less than five. So we've got work to do. And here again, the picture is a bit mixed. But if we look at prevalence in children less than or equal to five years old, below 0.1%, there's actually 84 countries on target to achieve this by 2030. And we can see countries in yellow working towards this goal, and then in red, I mentioned earlier that the birth dose vaccine was low in the WHO African region, and this is a clear point of emphasis as we move forward with elimination. But what about mortality targets? Well, screening and treatment programs, only one country, the Netherlands, are expected to achieve the mortality targets by 2030. A lot are red on this map, indicating we have a lot of work to do that can be aided by simplification of the testing, diagnosis, and treatment algorithms. Now unfortunately, as I provided an update, we have to talk about COVID-19. We're all well aware that in January 2020, the COVID-19 pandemic surged across the world and continues to surge and disrupt health care services for every condition, including hepatitis C and D. John Ward will talk a bit later about how we can leverage these. But in the immediate term, there is no question that it has impacted dramatically the elimination pathway. If we look to the left in Louisiana, in the second quarter of 2019, they launched an innovative program called Hepatitis C Free Louisiana, tremendous increase in treatment, and you can see the decline that's beginning to come back through the pandemic. And then the modeling site to the right, the estimation was a one-year delay in programming for hepatitis C could lead to an additional 72,000 deaths and really get us off track for elimination. So in summary, viral hepatitis elimination is more or less on track, although we are clearly taking a step backwards because of the COVID-19 pandemic. When I said it was on track, what I mean by that is we have WHO guidance for validation of targets, and we have the tools. The seminal work of our Nobel Prize scientists have given us the tools in vaccine and treatment and diagnosis to achieve these outcomes. We do need simplified approaches. We have those hepatitis C, but we need a vaccine. Hepatitis B, we have the tools of vaccine. We need to deliver it, particularly in the African region, and we urgently need a simplified approach. And finally, efforts to control SARS-CoV-2 or COVID-19 will help the hepatitis C pandemic. And if we look here, I want to thank Homi Razavi, John Ward, and the Johns Hopkins Rheumatitis team, and thank you for joining me. Good morning, good afternoon, good evening, depending on where you are. My name is Maud Lamon, I'm Professor of Hepatology at St. Mary's Hospital in Royal College London, and I'm leading a viral hepatitis research program in Sub-Saharan Africa. It's my great pleasure to be part of this exciting project on viral hepatitis elimination, and I will discuss with you today the successes and challenges to achieve HPV elimination. So as you all know, HPV is responsible for a high global burden of disease with 296 million people chronically infected, 820,000 annual deaths due to HPV mainly from cirrhosis and HCC, and in 2019, according to the most recent WHO Global Progress Report, 1.5 million people were newly infected with HPV. The burden of disease is, however, quite different according to the WHO regions, and as you can see, the WHO African region is clearly the most affected region in the world, with 80 million people infected, 4.3 million children, and two-thirds of the new HPV cases are observed in the African region. HPV is also responsible for 80,000 deaths per year in the region. This high burden of disease is observed despite low cost and highly effective interventions, and this is one of the big successes achieved over the last decades. We have now highly effective HPV vaccines available at low cost, less than $1. We have also AcuRate HPV antigen healthy point-of-care tests available also at low cost, and we have also highly effective drugs available at generic cost in most countries, including African countries. So despite this preventive and treatment intervention available, and despite the high disease burden, the level of intervention is not good. Except the HPV vaccine coverage of three diseases in infants, you can see here that is one of the big successes achieved over the last decades, with the coverage estimated at 85% globally, so close to the 2030 target set up by the WHO. However, the HPV first-dose vaccine coverage remains very low, and I will come back to that point, and we are also very far to achieve the elimination targets for HPV diagnosis and treatment coverage. So the first one, the first big success is, as I've just told you, the HPV vaccination coverage of three diseases in children. It is estimated currently at 85%, and this has induced a major reduction in the prevalence of HIV infection amongst children younger than five years, with the prevalence estimated at 0.9%, below the 1% set up as a target by WHO. However, as you can see here, there are, again, disparities in terms of vaccine coverage. And Africa is the only region where the HPV three-dose coverage is below 80%, estimated at 73% in 2019. So as a result, Sub-Saharan Africa carries the highest HPV prevalence in children below five years, estimated at 2.5% in 2019. According to the WHO report from 2021, 4.3 million babies are infected with HPV in Africa. And a systematic review estimated that every year in Sub-Saharan Africa, there are 370,000 newborns infected with HPV, which is twice the number of babies infected with HIV at birth. However, even if HPV vaccination is critical, we know that it is not sufficient to achieve HPV immunization, and I would like to refer to this nice work conducted by my colleagues at Imperial College London, as you can see here, to achieve HPV immunization. It is critical to increase prevention of HPV model to child transmission, but also scale up diagnosis and treatment coverage to 90%. And I think that these are the two major challenges for the next years. First, we have to improve prevention of HPV model to child transmission, which combines infant hepatitis B birth dose vaccination and maternal screening and treatment of highly variant pregnant women. We also have to scale up diagnosis and treatment coverage in people with chronic hepatitis B. So let's start with hepatitis B birth dose coverage. This has been a major challenge and is still a major challenge, especially in Africa. The global coverage is estimated at only 43% in 2019. The coverage is even low in America and Europe. But again, in Africa, it's even worse, with only 6% of newborns receiving the first dose of hepatitis B vaccine at birth within the 24 hours after life. Only 14 countries out of 47 have adopted policies for HPV birth dose implementation in Africa. And even in the Gambia, which is a country where the birth dose was first implemented in Africa in the 90s, the coverage is estimated around 1%. So there are multiple barriers to explain HPV birth dose vaccination coverage. So first, the low maternal education level has been identified as a factor associated with poor HPV birth dose coverage. The rural settings, the long distance between home and maternity centers, births during the weekends because the staff do not want to open the vials for the birth dose. The cold chain system is also a barrier. And I invite you to read this very nice systematic review from the team of Margaret Bellao, which has shown that actually the use of controlled temperature change could help overcoming this problem of the cold chain system. And obviously, poor awareness of the mothers and the healthcare workers is a major explanation for poor HPV birth dose coverage. So prevention of HPV mother-to-child transmission is a major challenge, especially in resource-limited countries. Also, because behind the poor birth dose coverage, maternal-antenatal HPV screening is not systematically performed. Secondly, access to HPV viral load remains very limited. The level of knowledge and perception amongst pregnant women is poor. And there is a lack of simplified and integrated strategies. And we can discuss about this later. I mean, pregnant women are screened for HIV during their pregnancy, but they are not screened systematically for HPV, as an example. So the prevention of HPV mother-to-child transmission is a major challenge, and not only in resource-limited countries. And I invite you to read this nice paper. In Hong Kong, for example, this study showed that only 18% of HPV-infected pregnant women had sufficient knowledge on prevention of HPV mother-to-child transmission. And only half of the women were reluctant to receive antiviral therapy for diverse reasons. In the US as well, this retrospective analysis conducted in almost 400 HPV-infected pregnant women showed that first, only 85% had an HPV viral load assessment. And among those who had a viral load requiring antiviral therapy, only 68% received antiviral therapy. So let's move to the HPV continuum of care. Improving HPV cascade of care is, I think, one of the other big challenges for the next years. This is data from the 2021 WHO report on progress on HIV, varicotitis, and STI. And as you can see here, we estimate today that this is 2019 estimate. Only 10% of people infected with HPV have been diagnosed, and 2% of them received treatment in 2019. So we are very far from the 2030 elimination target. And again, the region where the most affected by these gaps is the African region, where only 2% of people are diagnosed and about 0.1% of people treated. This is in line with what we found in Senegal. As an example, we assessed the continuum of care in real life. And we found that, actually, only half of patients were screened outside the hospitals for a full clinical staging, and 2% of patients when in the hospital could have a full clinical staging. So this implies that, clearly, it will be difficult to achieve the 2030 elimination target. But again, this is not only a challenge in resource-limited countries. And I found this paper very interesting, recently published in J. Petal. It's a retrospective analysis in the US assessing the continuum of care of more than 12,000 patients with varicotitis. And the study found that only 52% did not have a complete clinical assessment, and only 60% received antiviral therapy among patients who were eligible for treatment. And this is roughly quite in line with what we found in Senegal, actually. So why is this continuum of care full of gaps? Probably, it's because the current guidelines on the management of chronic hepatitis B are complex. They are not always in agreement. And they require repeated clinical appointments based on expensive tests, which are hardly accessible in a routine and resource-limited country. So probably, the current guidelines are not adaptive to resource-limited settings, but also difficult to reach population. And the population infected with hepatitis B in rich countries are also difficult to reach population, or difficult population, difficult to retain, to care. So of course, success has been made in simplification of tests. And we have to acknowledge this. And as an example, the HPV DNA GeneXpert system has been a major progress. But I believe there are still many challenges. For example, the accessibility of the GeneXpert, even if it's really good in most countries, it remains complicated in remote areas. The cost remains high. The other examples, the HPE antigen point-of-care test that we could use, for example, to stratify the risk of HPV model to transmission, the accuracy of these tests remains debated. And there are plenty of other tests, including, for example, ALT point-of-care tests, which are still in development. So clearly, and that has been mentioned by the 2021 WHO Global Progress Report, a huge simplification of hepatitis diagnosis and treatment is requested to achieve the target of reduced mortality by 2030. So we need simplified diagnosing and monitoring algorithm, but we need to address a lot of questions. I have listed a few questions, which I believe are important challenges to questions to address over the next years. Can we reduce the number of visits and tests to improve retention to care? Can we use alternative to expensive and complex HPV viral load assessment to the FibroScan as well, which is not available everywhere? Can we also use models of care, which are free of HPV DNA and liver fibrosis measurement? Or should we even treat all HBS, antigen-positive carriers, irrespective of their liver disease severity? So I think these are important questions to address. And I also believe that this question will benefit the Western countries, where first, as I've told you, people infected with viral hepatitis are mainly population, which are difficult to reach and difficult to retain to care. And also, even in rich countries, health resources are not infinite and increasingly limited. So what else do we need? Public awareness and political will. I think major progress has been made. As an example, whilst in 2012, we had only seven countries with national hepatitis plan, we have now 124 countries which have developed national hepatitis strategy plans. There is also an increasing number of extremely dedicated civil society initiatives, and this should be clearly acknowledged. Funding, probably it's urgently needed to collect good quality data, but also to assess innovative strategies to improve hepatitis-diverse coverage, treatment of pregnant women, and as I've just told you, to simplify the HPV diagnosis and monitoring. We also, of course, need support from professional societies, and I think actually ASLD, with this meeting, illustrates the great support we can have to achieve viral hepatitis. So to conclude, clearly major progresses have been made. Vaccination, in terms of vaccinations, screening tools, which are now available at low cost, but we need more diagnostic tools. We have also effective drugs, which are now available at generic price, and there has been massive mobilizations since 2014, when the World Health Assembly, for the first time, recognized viral hepatitis as a health threat. However, there are still major gaps and challenges if we want to achieve viral hepatitis. Probably major efforts need to be made to develop innovative and simplified strategies adapted to the local setting and resources, with two priorities, prevention of HPV in order to track transmission and scale-up of diagnosis and treatment for the million of people who are infected with hepatitis B. Access to viral hepatitis services actually remains slow and based on a complex algorithm, and on top of this, these viral hepatitis services have been disrupted by the COVID-19 pandemic. But I will let John cover this topic. I would like to thank you for your attention and to thank the organizers and ICLD for this great meeting. And of course, I take the opportunity to thank all my colleagues from Sub-Saharan Africa, but also outside Africa, because without them, I wouldn't be able to think and discuss this exciting topic with you today. Thank you very much. Good morning, good afternoon, good evening. I'd like to thank the conference organizers for the opportunity to present today on hepatitis C elimination challenges and successes. Prior to starting, I'd like to acknowledge the traditional owners of the land on which I'm doing this presentation, on the land of the Gadamart people. I pay my respect to their elders, past and present. I'd also like to acknowledge the other contributors to this work and share my declarations of interest. Hepatitis C remains a major global health challenge, with approximately 58 million people currently infected with hepatitis C globally and an estimated 1.5 million new infections annually. As well, it causes nearly 400 million deaths every year. Compared with other diseases, viral hepatitis-related deaths have been increasing over the years. As well as deaths, it's important to think about the broader impact of hepatitis C. It reduces health and well-being and quality of life in individuals and their families, liver cirrhosis, liver cancer and comorbidities. As well, people with hepatitis C infection have internalized and enacted stigma and there's discrimination which impacts on their lives. They have reduced social and workforce participation, reduced workforce productivity and personal financial insecurity. It impacts on all aspects of their life. An acknowledgement of the issues impacting or leading due to hepatitis C was acknowledged in the Sustainable Development Goals. Goal three was to ensure healthy lives and promote well-being for all at all ages and acknowledge the importance of combating hepatitis C. Also talks Sustainable Development Goals talk about achieving universal health coverage. I think this is essentially incredibly important when one thinks about hepatitis C and access to affordable and essential healthcare. In acknowledgement that hepatitis C could be eliminated globally, WHO set targets for reducing infections and to stop deaths. These initial targets also looked at ways to prevent, diagnose and also impact targets in terms of trying to reduce 90% of new infections, but it was 80% for hepatitis C and 65% reduction in deaths. These targets have been recently updated where there's as well some direct targets to eliminate hepatitis C in terms of looking at absolute prevalence of incidents and mortality. Critically important for some countries who might be doing great things in terms of achieving elimination to better look at this along the way. Why is hepatitis C elimination achievable? Essentially because direct acting antiviral medications were game changing. We have curative therapies available where people could take a single tablet a day for eight to 12 weeks and be cured of their infection. It's extraordinary what these tablets can do. But despite the setting of targets and the game changes that make it possible to achieve elimination globally, we are not tracking well, with really only a dozen or so countries on track to achieve elimination. And as well, those that are on track are constantly changing and you might have a few or lose a few, but the barricades essentially are not being stormed. When you think about all the countries in the world, we're not achieving the elimination targets. The major challenge in my view is the massive lack of funding for viral hepatitis response. Despite the high numbers of infections and the rising deaths, despite the WHO targets and despite the disease having a cure, hepatitis C does not receive major funding for any of the big global initiatives, such as Global Fund Gates, the World Bank Global Financing Facility. And this is unlikely to change soon. There have been some important admirable exceptions in terms of Unitaid providing support and as well some leftover funds, I should acknowledge from Global Fund, but overall very little has been done in terms of global investment in hepatitis C. And why is this the case? In my view, it's in part a non-virtuous cycle. Global health funding priorities have been developed over the years by a number of reports and programs. The key driver though, is whether the disease in question is likely to have a significant economic and development impact on a country and its individuals. Words and phrases that are important and need to be kept in mind when thinking about hepatitis C or any disease elimination is the Sustainable Development Goals, universal health coverage, disease control priorities and country specific health benefit packages. The 2030 Sustainable Development Goals and essentially the United Nation member states agreed to work towards universal health coverage. And UHC aims to provide healthcare and financial protection to all people of particular country or region by providing a specific package of benefits, the country specific health benefits packages. And the end goal is providing risk protection, improve health services and broadly help the country. And diseases that are included in the country specific health benefits packages are identified through disease control priorities as well as other priorities more generally. So particularly in countries where hepatitis C has a considerable impact, you need to show the extent of this impact of hepatitis C on the country on health, so it's recognised as a priority disease. But here's the rub, to be included in a country specific health benefit package you need to show that the disease is having a significant impact in the country. And how do you do this? You need data, the disease prevalence, incidence, morbidity, mortality, broader impact. Funding is needed to collect that data. You need to model the data to show impact. Funding is needed to make that model. Treatment and testing costs are falling, so you need to show that it's cost effective because once it was $1,000 a pill and now it's $50 treatment. Do you need data and modelling to show this? And funding is needed to do that. Community awareness and agitation, community engagement is critically important to raise the profile, to engage with politicians and bureaucrats about the impact of hepatitis C on community. And funding is needed to raise that awareness. So as you can see, we've got this terribly non-virtuous cycle going on of funding being needed to show the case of the impact of a disease. We're not going to get there. And the reality is there's a lack of awareness about hepatitis C and there's a lack of awareness about cure. People don't even know it exists. And part of the issue as well was that there were initially the prices of these drugs were terrifically expensive. But they have fallen markedly over the first five or so years, or five to eight years now, of their availability. So that you can really get a cure for treatment at less than $50, although diagnostics can still be slightly expensive. So what to do about the slow progress despite having the tools to achieve elimination? We need commitment and leadership. And we need to help countries to address some of the issues around funding and the lack of investment. Part of this work and work done by WHO was the WISH report, which is the Eliminating Viral Hepatitis and Investment Case. And what this was about was establishing a framework to say, how could countries begin to think about investing in hepatitis C? What do they do about this? How do we get things going? And what this clearly showed in terms of the cost effectiveness and the cost of it was that countries would begin to save money very quickly in terms of if they embarked upon an elimination effort. And it's also important to have champions and to show successes, either in the evidence gathering and planning, or implementation or integration. And some examples of what I'll call some successes despite the challenges is Georgia. And partly, if you think about what happened with Georgia, is the first country in WHO European region to set a clear hepatitis C elimination goals, developed a national plan, and as well, you had tremendous buy-in from government with great success. South Africa is also progressing, and they developed an investment case. Scotland has been really hot on collecting accurate data and investing in testing and many other things. Egypt has been extraordinary in their efforts. And essentially, they did testing, linkage to care and treatment, but also had massive buy-in, again, and political leadership from the government. And Australia has taken a multi-pronged approach, had a long history of partnership approach with community as strong advocates to try and convince government to get on board, a long history of harm reduction, and DAAs developed an interesting risk-sharing agreement with the originator pharmaceutical countries, and great progress has been made. So how do we finance viral hepatitis elimination efforts? We need to think about domestic funding is required to strengthen health systems and finance hepatitis-specific activities. Health system costs, we need to think about it, not just for hepatitis C alone, but for improving injection and blood safety, harm reduction programs and services, strengthening surveillance systems, technology to link patients to care. We need to be innovative. There's also some hepatitis-specific costs, such as the treatment for hepatitis C. We need to think about innovative financing, including blended financing, pool financing, technical assistance, results-based financing, social and development impact bonds, and a dedicated hepatitis fund. There's many different ways that we could approach this, but overall investment needs to increase. We need to improve the affordability of hepatitis C elimination in individual countries and regions. So this is the reduction in treatment costs, which, as I said, have come down, but still some people pay well over what is needed. So we need to look at licensed generics. We need to look at innovative new treatments and the like. We need to maximize the effectiveness of the public health spend. So we need to make sure we're helping with local investment cases and supporting local investment cases. Looking at sharing costs with other strategies, with a TB elimination program, HIV or the like, hepatitis B. We need to piggyback onto existing infrastructure and we need innovations and efficiencies over time. Also, we do need international donor investment. Even if we just, to help support the investment case within a country, we need some donors to help with that, particularly in resource-limited countries. There are other critical, important barriers that can be addressed. Healthcare workers, many have a lack of awareness. Guidance systems are complex, we need to simplify them. They also can lack support and have competing priorities with service delivery barriers. And also chronic disease management is never simple, but these can be overcome with supports and education. We also need really to work on increasing community support to increase community awareness. In my view, simplifying testing, getting rid of multiple visits can be helpful. We need to simplify guidelines. We need to really be mindful that in high-income countries, that what we may be able to afford or might be affordable is not at all appropriate in lower middle-income countries. We need to simplify all of our guidelines. Should we treat all? Of course we should, at least in those people that want to be treated. We need to move care into the community with hub-and-spoke approaches to link people with significant liver specialists. In many low- and middle-income countries, there can be less than 20 specialists providing care. So we need to make sure that the vast majority of the care can occur in the community with specialists only seeing those with really hepatic decompensation. So in my view, hepatitis C elimination is technically possible. And there have been some great successes, but we need countries and global funders to invest. Countries need to have strategic plans. We need to recognise how the Sustainable Development Goals, universal health coverage and disease control packages are working. We can't be naive about the system, and we need to help countries do this. We need to start to show considerable impact of these diseases on community, so it's made a priority disease in countries. Where possible, we need to integrate the response within countries, UHC's approaches to save dollars and get it included within the funding mechanism, but also it will help improve the country's health systems. We need to show how hepatitis C elimination can have a broader impact on country well-being. Georgia is a really good example of how this has been done in terms of surveillance systems, strengthening and strengthening of blood supply and the like. We need to make viral hepatitis, in my view, an exemplar disease in terms of the efforts. Make it clear to politicians and policymakers that there will be great progress in a few years if governments invest, and that they'll have a win in terms of UHC. At the same time, we should never forget we are talking about individuals and their families and friends, and that health systems need to work for all people. In my view, we need to acknowledge as well the absolute impact of stigma and discrimination on our progress towards hepatitis C elimination, that the war on drugs impacting on many people who inject drugs has been a real failure, and we need to rethink what that looks like to remove this stigma in our efforts. I'd like to acknowledge many people in terms of the WISH team and others, and let's go for elimination. Thank you. Good day. It's my privilege to be part of this session today and give you some information and perspectives regarding the opportunities to advance progress toward hepatitis elimination coming from the response to the COVID-19 pandemic. This is a little information about myself. These are my disclosures, and this is the agenda for the next few moments. We'll be looking at the impact of the COVID-19 response on our efforts to provide prevention, care, and treatment services for persons at risk for living with viral hepatitis, and then explore opportunities coming from the COVID-19 response to building capacity to eliminate hepatitis in the areas shown here, the role of hepatitis elimination programs in the COVID-19 response, and then bring that information together to look ahead to see how this should influence our planning for the work ahead. We're in the midst of a large pandemic, as shown by the numbers here, and this complicates our efforts to deliver the services needed to eliminate hepatitis, which was already a challenge, as shown in this bar graph from WHO for persons with living with hepatitis C. Most have yet to be diagnosed and linked to care, despite the availability of reliable tests and curative treatments. Now, the response to the COVID-19 complicated that even further because of the social distancing measures needed and the redirection of resources that were for health care, both in terms of clinical space and staffing, really reduced access to a test and treatment. Here in the United States, as shown by the line graph from the trends in hepatitis C testing, as reported by CDC on the left, and the number of persons being treated, as shown in the line graph on the right. This was also revealed in a global survey that the coalition conducted in the last months of last year with clinicians, program managers from 44 countries reporting large declines in inpatient visits and in testing treatment for hepatitis, with the green bars representing, on a hopeful note, that those declines lessened over the time period, but still remained lower than pre-COVID levels of the number of persons being tested and treated. On a hopeful note, those same providers did acknowledge some improvements in access to testing, networks linking primary care with specialists, and recognizing the role that hepatitis clinics were playing in the COVID-19 response. So this is really revealing a long-standing interest in ours, is what are these opportunities coming from this large response to this COVID-19 pandemic? And we hosted a site event at the United Nations General Assembly to explore this in detail, and some of the information I'll be presenting was shared at that site event, and it is available on our website at globalhep.org. When we think about options of scaling up testing as a result of the COVID-19 response, some of that's coming from the build-up in the virologic testing capacity, there are opportunities to integrate hepatitis testing with COVID-19 testing, and then we need to recognize the role of hepatitis testing programs in the COVID-19 response. As an example, capacity building is in Africa. Pre-pandemic, only two countries had the capacity to detect viral infections by testing in the central laboratory. With the assistance of the Africa CDC, by August of last year, every country had that capacity with the right equipment and the right training of the workforce to provide that testing. This is part of large global efforts such as WHO and a variety of partners that are bringing together large amounts of financial resources to apply to the COVID-19 response, including the scale-up of diagnostics as shown here, both in RNA testing platforms as well as point-of-care core antigen, seeking to improve laboratory quality in 70 low- and middle-income countries, and to seek to do that, integrating that testing within the existing health system rather than a siloed program. There's also a development component of that to improve test quality, and that has byproducts in improving testing, test development for hepatitis C when we think of a new point-of- care testing to detect current HCV infection. So it's really important to always recall that this virologic testing capacity, particularly the PCR capacity, when it's scaled up for COVID-19, can be applied to hepatitis testing. I provide two examples, one from Pakistan on the left of a large national laboratory that at the onset of the pandemic only had manual PCR capacity available. With the emergence of the pandemic and greater resources, they could move toward an automated high-throughput testing. In addition, Pakistan scaled up point-of-care testing for RNA for SARS-CoV-2. All of that can be applied to the National Hepatitis Elimination Program launched by the Prime Minister. In Ethiopia, for the very first time, they had automated PCR machines as a result of the response to COVID-19, opening the possibility of applying that testing for hepatitis in the future and having that testing done in the country for the very first time. There are also studies looking at how to integrate hepatitis testing with COVID-19 testing. In the case of Italy, they showed that the testing was fairly well accepted. They found that the proportion that had evidence of exposure to HCV was greater than the national average and that about half of the infections detected were in persons who were previously unaware of their infection. There are other studies ongoing, such as the one in Spain, of bringing together hepatitis testing with COVID-19 vaccination programs as people have to wait a few moments after vaccination to detect adverse events, provides an opportunity to provide hepatitis testing. Conversely, hepatitis testing programs, such as the ones in Egypt, are examples of how hepatitis elimination can help in pandemic preparedness. As most of you all know, there's been, Egypt put in place a highly effective hepatitis elimination programs with large-scale hepatitis testing, including PCR testing, through a well-established laboratory network. With the emergence of COVID-19 and the new challenge of rapid scale up of testing, they redeployed that hepatitis C testing capacity through PCR to test over 1 million persons for SARS-CoV-2 infection. Also, in Georgia, they also scaled up the hepatitis C elimination program, beginning to develop a laboratory network, starting with the central laboratory in 2017, then branching that out into other laboratories throughout the country, and then decentralizing testing for a variety of different clinical settings, resulting in large volumes of persons being tested for evidence of HCV infection with antibody positivity, followed by PCR testing the current infection. Again, with the emergence of COVID-19, they were able to quickly apply that PCR network to COVID-19 testing, resulting in 1.2 million SARS-CoV-2 tests in the first 10 months of the pandemic. Looking ahead, how can the COVID-19 response improve care? There have been innovations coming from the COVID-19 response. One example is among a group of clinicians outside of London, recognizing the move to temporarily house previously homeless persons, provided an opportunity to implement a testing program, which they did, revealing a very high prevalence of hepatitis C infection. They then implemented a treatment program, showing that high cure rates could be achieved for this previously marginalized population, a strategy that I hope will continue even after the COVID-19 pandemic wanes. There has been great expansion in telehealth, as shown here in this line graph, in the United States, but also a variety of other countries. This pre-pandemic, only about 35 states allowed some type of telehealth to be conducted. With the declaration of a public health emergency for the COVID-19 epidemic in the United States, the U.S. government began to provide equal reimbursement for telemedicine and in-person visits for the Medicare program, waiving or reducing patient co-pays, and relaxing health IT standards to allow a variety of non-public communication channels to be used to connect clinicians with their patients. This resulted in large scale up in telemedicine use, including among gastroenterologists, and in a number of states, either improving their telemedicine coverage or implementing it for the very first time. Going forward, we need to see how we can sustain the support for telemedicine as a routine service rather than an emergent one, recognizing disparities in access to telemedicine and see how to overcome those with financial and technical assistance, and turn our operational research beyond just the process evaluations, which have demonstrated clinical feasibility and patient acceptability, to really understand what are the outcomes that are achieved for certain patient populations or certain disease states so that that can inform our recommendations for clinical and public health practice. There are benefits for the COVID-19 response to prevention. I'll just give you one example. For harm reduction, we continue to see increases in hepatitis C infection fueled by the opioid epidemic in the United States. Syringe exchange programs have always been in short supply. They were further challenged by the response to COVID-19, and those program managers put in place a variety of innovative strategies to overcome these limitations as shown here. It's also important to note that for the very first time, the U.S. government provided money to pay for naloxone and sterile syringes to be provided to people who inject drugs. This was previously prohibited. A powerful new resource to expand access to this vital prevention service, and we really all need to advocate to move this from an emergency response to routine annual funding. So with all of those interrelationships in mind, we need to recognize that the world's moving from a pandemic response to pandemic recovery, recognizing the disparities revealed by the COVID-19 pandemic, and then seeing how health systems can be made more resilient to respond to public health emergencies without compromising the delivery of essential health services needed for their communities. And there are a variety of different broad concepts being put in place as guiding principles, sustained pandemic investments for the long term, engage multiple partners to strengthen health systems rather than just relying on health systems on their own, recognizing the innovative models coming from the COVID-19 response and seek to adapt those for the long term, recognizing these health disparities, and extending the health protections and other provisions that sought to reduce those disparities for COVID-19 and apply them for the long term. Importantly, the recovery planning in progress is underway for a variety of disease states, and I think this needs to happen for viral hepatitis elimination and probably for liver disease care overall. So looking ahead, I think we need to continue to monitor and raise awareness of the limitations in hepatitis prevention, care, and treatment as a result of the COVID-19 pandemic, but we also need to recognize that in this recovery phase offers some real opportunity for us to prioritize the interventions needed to eliminate hepatitis. So we really need to be at the table to form the concepts for resilient health systems and plan coverage for these essential services, initiate advocacy, conduct the operational research to develop the policies to promote these innovations for the long term. And to really formalize that, I think as we develop our plans for the future, we need to recognize these opportunities from the COVID-19 response, capitalize them on them, and incorporate them into our planning so that we can become more efficient and more effective in our efforts to achieve goals for hepatitis elimination. Thank you. Thank you very much, John. Thanks very much to all the other speakers. Great talks, really. There's still a lot of work to do in the field of hepatitis. Obviously, it's clear that the 2030 goals are there, but are difficult, very difficult to reach. It's a bit like the climate crisis that we get together, we try to get things done, but then in individual countries, it's not always done. It's very often not done. And it is indeed very difficult for such a disease where there's 30 years between the time point of infection and the moment of death, basically, which is three, four cabinet terms at least, with people on the lowest steps of the social ladder. And the question is really how to get more funding and how to get into those groups of malaria, tuberculosis and HIV. I'm sorry, my voice is a bit bad. I still hope that people can hear me. I don't have COVID, I just had to flee. And if it's very bad, Nora, you should really take over. What I kind of missed, just to get the first question done, is the word cancer, because a lot of patients really develop cancer after these 30 years of infection. And many of them die silently, where mortality statistics are basically not correct. And very few people actually understand and know that they're dying from viral hepatitis instead of cancer. So to what extent could we also, in the setting of vaccination for hepatitis B, use liver cancer, which is the big killer obviously in these diseases, more effectively to advocate for this disease? Maybe I'll start with Margaret and then the rest of the team, and then I'll just take a sip of tea and hopefully I'm back in a second. Harry, I think that's a super important comment and question. In fact, some work I've been doing in Australia to do with hepatitis B in culturally and linguistically diverse communities, because as Maud indicated, this is the group in high-income countries invariably who have hepatitis B. We actually presented that as a question or tried to explore this issue. Do we talk to you about a risk of cancer or do we talk to you about a risk of infection? I suspect it makes for the actual individual not as much difference as we might think. I think we just have to really think about what are the barriers to the person with infection accessing care by explaining simply risks and the like. So I think as Maud alluded to, and I think in my talk I sort of talked about, I think all the speakers did, the simplification of systems. In terms of working with government, I do think we need to get that story across better that these diseases cause cancer, big causes of cancer, liver transplants and those kinds of things. I think Maud will speak far more effectively than me about, to me, the unrecognised cancer, particularly in Africa. I think it's just an absolute tragedy with hepatitis B and elsewhere in the world. And to me, the sooner we can think of ways to measure this simply to help countries say, this is really impactful, this is causing a big problem, like they were able to do in Egypt, because that's where Egypt got the funding from World Bank and the low cost loans. So I'll let Maud speak to that more, but to me, until we can better do that in countries, and I think we can, I gave some examples how, I think that's where the tragedy is that there's estimation of the impact of these diseases, cancer, liver failure, impacts on families. But over to you, Maud, for your thoughts on Africa, I suspect. Maybe Maud, if you can, let me ask the crowd, please send in questions as well, because it would be very good to get input from people attending. Go ahead, Maud. Actually, I can, yeah, I can comment on this and also address one question about testing women earlier before pregnancy when they are in age of childbearing. I think it's an excellent comment you've made about cancer. We don't explain enough. And it's interesting, for example, Bill Gates is actually supporting quite strongly the screening of papillomavirus in Africa, so HPV. And I think we should actually combine HPV and HPV. But I had some discussion, and actually, I think a lot of people understand that papillomavirus induce cervical cancer, which is very, very, it's a big burden in Africa, but they do not realize that hepatitis B is also a major cause of cancer in Africa. So, yes, I fully agree with this. And just to go back to the question of funding, I think we should really get on board the Global Fund, Bill Gates and other big agencies which target other disease like HIV, TB, et cetera, and maybe aim for combined elimination. And in the field of pregnancy and pregnant women to prevent mother-to-child transmission now, there is a big change about the fact that we want to eliminate HIV, syphilis, HPV, HCV, so it's triple, quadruple elimination. So, and just to address the question that was asked from the audience about this screening of women, I think screening women when they are in age of childbearing, vaccinating women when they are in age of childbearing, it's already too late. Just to remind everyone that in endemic areas, hepatitis B is transmitted early in life when we are, when during, yeah, it's very early during childhood. So, if we vaccinate women when they are in age of childbearing, it's already too late. But it's a very good comment because I think when we screen women when they are pregnant, maybe it's already too late as well. And maybe we should screen young women when they are teenagers before they get pregnant. Okay, Nora, go ahead. Well, can I just maybe step back? I do want to come back to this sort of how do you piggyback, you know, onto other programs. But can I just ask something, maybe Mark, you can start with this. You know, we do these global report cards, and John, you're also facilitating countries developing these report cards. And, you know, we see ourselves as either being red or green. But there's different aspects to elimination, right? So, in some countries, they're doing very well in terms of seeing the mortality rates improve, but it's the epidemic of new infection that's really sort of driving the bad report card, as it were. And I guess my question for you is, should we have more granularity around these report cards to better understand where we should be doing our interventions? An intervention to prevent new infections might be quite different than ones where we're trying to prevent liver cancer, where it's more around diagnosing individuals with a chronic infection, making sure we're getting access to treatment, that sort of thing. So maybe I could just ask you to comment on the report cards and sort of what we take from them in terms of next steps. Sure, I think that's a great point. I think there is always an issue when you simplify things. You know, in the United States, we gave each state Medicaid program a A, B, C, D, or F criteria, and it oversimplifies the challenges. And I do think your point about incidence and mortality are incredibly important because they really target different ends of the spectrum of hepatitis C. As you allude to, in the United States, we are failing miserably by any report card to be an F on incident hepatitis C. And we're missing the opportunity to link our efforts to reduce overdose death with reduction of transmission through evidence-based programs to treat opioid use disorder. And as John mentioned during COVID, making needles insurance exchange programs federally funded or readily available. So I do think there's different aspects of each part of this. And at least in the U.S., we haven't talked enough about the linkage of hepatitis C incidence to the injection drug use epidemic, which has worsened during COVID-19. So I think there is need for granularity and to look at each region specifically to see what makes the most sense and how we allocate our resources. Yeah. Regarding these report cards, Nora, we've gone a little bit more in a granular direction, recognizing that just showing you're not on track may just turn governments off that weren't that interested to begin with. It's hardly very motivating just to say you're way behind. So what we've done with these, we're calling them profiles, is that obviously we show the data as the data are regarding the burden in their status and progress toward targets. But we also recognize what's the status of their policies, their programs, their plans, encourage them to highlight some achievements. And to your point, it's not all zero progress in every country. Indeed, there could be some innovations coming from some countries that you were not aware of, to outline some challenges and collectively see what are some feasible next steps. And then importantly, what do you do with that information? Number one, who can you work with to bring the information together? Civil society, expert clinicians, ministries of health, et cetera. So everybody gets more on the same page about what is the problem, what's the status of our programs and capabilities for interventions, feasible next steps, and then help them then use that information to engage more stakeholders in the country, including politicians. And through those feasible next steps, really get them on the track rather than just giving you them a A, B, C, D, or F, A, B, C, or D, or F, yes. Actually really make it more engaging and really sort of showing them the way toward elimination rather than just giving them a numerical score. Right. Or the A, B, C, the Fs, you're right, I think it discourages individuals at some level. So I think the profiles and sort of lessons learned and successes really helped, again, sort of motivate, whether it's a city, a state, or a country really to be thinking that way. Well, I think also incredibly important within that is also pathways forward, which I think is what John and others at WHO are trying to do. Because to me, one of the biggest issues is often we have also why, and I sort of to one of the questions in the chat, why things don't happen is an absolute lack of data in some countries, as I alluded to in my talk for both C and B, to help them even begin to think what's the pathway forward. But it's also why places like the Gates Foundation, the structure of the system is such that they go, World Bank, Gates, Global Fund, look at things that will take people, and that's what the whole UHC stuff is, or Sustainable Development Goals, is get countries out of poverty. It's an economic driver of things as well. And if you don't have the data to show that this actually has impact, the countries do not get that funding. And so we can talk about Gates coming on board and giving money, but Gates looked at this a number of years ago, a couple of years ago, there was in-house discussions in Gates, from what I understand, where they clearly made a decision not to, because the decision was the economic impact of viral hepatitis was not sufficient on countries' development to make it that that would be what they would invest in. If you don't have good data in countries to say, actually, this does impact on my economic development, as was able to be shown in Egypt, as can be shown in Pakistan, we get into this really difficult circle of things. And so in Africa, in parts of Asia, there's a lack of information, credible information to say, actually, this is impacting on our economic development. This is causing a generation of people to be dying of cancer, such that they're not looking after the grandchildren whilst the parents are working, depending on the structures of systems in low and middle income countries. We will continue to have the same problem. So I think we have to be really thoughtful about the report cards, the data, the approach, but also understand the forces at work of where money sits, and how you get money, big money. Okay, I think I got my voice a little bit back, Nora, so maybe I can get a question from the chat box. One for John, COVID has helped to break program silos and increase program networking. How do we maintain this post COVID to ensure programs are able to leverage on existing resources in a sustainable way? So how can we get the COVID momentum to move on in a post COVID new normalcy, so to say? No, that's a great question. And that kind of silo breaking is really a big part of these discussions regarding building resilient health systems to prepare for the next pandemic, recognizing the limitations of the response to the current one. And indeed, when we had our UN General Assembly side event, the African CDC really pledged itself to breaking down those silos, because we all know how deleterious those silos have been for us, where you have a point of care machine for TB in the very next clinic over that can't be used for hepatitis C because of administration or workflow issues, etc. So we really need to break down those silos. And it does provide an opportunity for this. And we just have to see how strong the impact of COVID-19 is in really making those kind of programmatic changes possible and long lasting. And I guess one of my points of the talk was just for us to get into a COVID-19 mindset, and really beginning to advocate for changes in health systems that are being recognized as important for pandemic preparedness, we need to be calling them out to be important for hepatitis elimination. And then as we go by country by country, as we work to really see, really see what's, you know, what's possible. And then globally, as these, you know, larger concepts that drive funding from Global Fund or the World Banks, Development Banks, regarding these building resilient health systems, you know, I want hepatitis at the table as an exemplar disease, as was mentioned earlier, of how how this, these changes can be implied and applied in dementia. And in so doing, prepare that health system for the emerging threat to come later. Okay, any other comments on this COVID? If not, then I have a kind of playing the devil's advocate here. And I've done it before. And it created a lot of antibodies. But is there any way that we can reallocate money from the big, from the big four, whatever it is from HIV, tuberculosis, malaria, to viral hepatitis? I mean, Margaret has already told us this cycle, which is continuing, basically. So is it just the data? Or is it famous patients that we need? Is it? What can we really do to get to that step other than getting better data? Because that's, I would really think that is the way to get to our 2030 elimination goals. If we don't get more money, it will be very, very difficult, in my view. But Carrie, I think having some famous people is always handy. So I'm not going to dispute that. But the, the showing that it, you've got to say, where's the big money, the cheap loans for countries. And I think, to me, I've decided that whenever I hear that a country is having to redo its disease control priorities, that there should be a SWAT team of volunteer groups that are ready to go in there and help those countries that we think have actually high burdens of disease. And we, to go and say, how can we help you prepare your submission so that hepatitis B, if it's appropriate, or hepatitis C, if it's appropriate, gets onto those, into those DCPs. Because we've been able to show very quickly that there is a significant amount of disease and that the impact and the burden of that disease. So yes, you can have your famous people, but in behind it, we did some work in Pakistan, because of look at what happened in Egypt. I think there's other groups looking at that, that kind of work as well. And I think groups of us need to get together and be ready as a cohesive kind of SWAT team to get in there and do that hard work as well, which might take three months, might be no money in it for you, but it gets the countries over the line. More and more of them have that these, that hepatitis B in Africa, particular C in Asia, or a bit of both. That's my view of it as well as famous people. Can I ask you a quick question? They commented today that Rwanda has moved, you know, made great strides. So what was, what was the, what was the secret there? Maybe that's a helpful example. Yeah. For those very reasons. Okay. Combination of those reasons. They had data, they responded, they got funding. They got the SWAT team. And they are the very supportive governments. Okay. Yeah, exactly. Because it's very often that the government, there's someone either in the government or someone who gets the ball rolling. And then even without good data, much more is possible than we sometimes think, right? Yeah. So it is that. And Georgia was the same. I mean, John can tell you the story of Georgia. Strong government, same with Egypt. Yeah. Yeah. I think for all three of those examples, there was some external catalytic funding that sort of helped to ignite the whole effort. I mean, Georgia was a public-private partnership. In Egypt, it was the World Bank. In Rwanda, they used the Global Fund and the HIV clinical infrastructure to, to build their program on. So I think that then after that, they began to use national resources for the programs. And that really seems to be the model that can be, that could be replicated. Also, I have to say quickly, you know, I've been learning that these development banks, people have been, most recently have said, we will, we have no problems funding hepatitis activities. Countries just have to ask for them. So I think getting back to Margaret's point, how do we get that data together? So our health ministry and, you know, related stakeholders can make the case to the Ministry of Finance, and then the political leaders accept that among their priorities that there's, you know, they're placing in front of these development banks seems to be the, you know, a big effort here. Regarding the Global Fund, it's highly unlikely they're going to move beyond HIV, TB, and malaria. They may help us eliminate hepatitis C among people with HIV, which I really hope they'll make as a goal, because it really should be a quality indicator. If someone's in care for HIV, they should not be dying of hepatitis C. But how far they go beyond that seems to be unlikely. And I'll be interested to hear from Margaret or others if they have more recent information. I think the big problem with viral hepatitis as well, it's very silent diseases. So it's extremely difficult to get people on board. And honestly, I've tried to engage very well known people. So maybe I'm not well known enough. But I sent emails and email I reached via the agents of I mean, we have very famous footballers who are even died from HIV related HCC. But it's interesting that sometimes I have no response. And sometimes I got like, Oh, sorry, we are already given funding for HIV for tuberculosis, because people feel for these people, children die from malaria, etc. So I think we suffer from the silence, the invisibility of it. Yeah, the invisibility, the fact that, yeah, that a lot of patients are on the lower social steps of the ladder. And, and, and stigma, basically, a lot of I've also approached a lot of, like a lot, some famous patients, and they wanted to advocate for HCC or for liver transplant, but never for the viral hepatitis, which is which is really, yeah, and maybe we have to start by the beginning, we have to, to really explain better to the population. So increase awareness, education, and even communication. In some countries, we can even not communicate about a disease we would like to eliminate. So it's just like absurd, as we would say in French. So we, there are some in some languages, we cannot name cirrhosis, liver cancer, etc. Or we don't have the right tools just to explain and communicate about the disease. And this is something very simple. Okay. I think we're at the end of this session, really. And I really would like to thank the speakers for these excellent talks. I'd like to thank the audience for attending. There's still a lot of work to do. I hope we'll get to 2030. It's it will be very, very big challenge. But that's at least a good start. We didn't have anything by 2015. We have at least a plan forward and a goal. And let's try to achieve this together. Thank you very much for your attention. And we hope to see you tomorrow again at the next ASL BBK. Bye. Thanks very much.

viral hepatitis

elimination

COVID-19

progress

challenges

strategies

therapy advancements

funding

political commitment

diagnosis simplification

innovative financing

treatment access

healthcare systems integration