investments to support countries with greatest burden of viral hepatitis All heavily burdened countries to have fully funded elimination plans by 2019 Recognition of need to focus on high burden countries and support for national policy development (All) Funding for national elimination plans Creation of fiscal space for new programmes with costed investment programmes Adopt domestic innovative finance tools where appropriate Support national policy makers in their activity (WHO, UNITAID, NGOs) Provide international support for financing measures (UNITAID, GFATM, bilaterial donors) Prevention Ensure all WHO elimination targets addressed in plans Address operational challenges in delivery of birth dose HBV vaccine Ensure provision of harm reduction services and engage with marginalised group (e.g. prisoners, PWIDs). Ensure clear public health messages to encourage testing and treatment Support countries to decriminalise injecting drug use and ensure equitable access to services for all (NGOs, WHO, civil society) Ensure appropriate funding for HBV vaccine, including birth dose (GAVI, WHO) Support R&D into HCV vaccine development (Research funders and pharma) Testing and Models of Care Focus on substantially scaling up testing for HBV and HCV Create and evaluate simplified care pathways relevant to local setting, integrating with existing services. Promote task sharing and decentralisation of care through capacity building, training and removal of Support operational research into simplified pathways (Research funders, UNITAID) requirements for specialised prescribing Diagnostics Ensure testing is integrated into the wider healthcare system, rather than centralised facilties Ensure access to quality diagnostics through Essential Diagnostic List and prequalification (WHO, funders) Support implementation science for models of care and R&D into novel diagnostics suitable for decentralised settings. (Research funders, FIND, industry) Access to treatment Ensure all Essential Medicines for viral hepatitis are included in national programmes, with an emphasis on pan-genotypic regimens Apply comprehensive policy approach to promoting access, including compulsory licensing Ensure all essential medicines are pre-qualified and either available through voluntary licensing or Medicines Patent Pool (WHO, NGOs, civil society, funders) Support shared procurement mechanisms for treatment (PAHO) Monitor Progress National plans need clearly defined, measurable objectives Develop new indices of national progress Progress of individual countries needs to be closely monitored towards elimination goals (Polaris, WHO, Creation of Elimination Index) Develop greater capacity for advocacy in high burden regions (all) Viral hepatitis is one of the leading causes of death in the world. 96% of those deaths are due to hepatitis B and C, which are the focus of this commission. Unlike many other major diseases, the tools exist to eliminate viral hepatitis. A highly effective vaccine is available to prevent hepatitis B, and a revolution in HCV treat...
IntroductionThe 16 countries of the Eastern Europe and Central Asia (EECA) region are home to 6.6 million people in need of treatment for chronic hepatitis C virus (HCV) infection. Because of transformational change in HCV treatment, global efforts to address HCV are accelerating. Given its large regional burden, the EECA needs to ensure its inclusion in and benefit from any new developments.MethodsOur 2015–16 survey aimed to collect and report on epidemiology, treatment access (including drug registration and prices, national HCV guidelines and treatment program coverage) and pertinent civil society organization (CSO) activities in 11 countries in the EECA.ResultsMajor gaps in epidemiological data exist; reported anti-HCV prevalence ranged from 1.5 to 7.5% for the general population, 22.7 to 70–95% for people who inject drugs (PWID) and 18 to 80% for people living with HIV (PLHIV). Ten countries (91% of the sample) have registered one or more of the second-generation, direct-acting antiviral medications (DAA) for potential interferon-free treatment. However, intellectual property issues and prices limit access to these drugs. In 2014, HCV programs in the surveyed countries covered only 0.15% of the total number of people in need of treatment. CSO-driven, international donor-funded programs are starting to fulfill needs of PWID and PLHIV.ConclusionsAs feasible curative HCV treatment is now available, and given the significant regional disease burden, EECA countries need to ensure HCV surveillance and DAA availability at affordable prices in order to expand treatment and prevent the onward transmission of the infection. EECA CSOs have demonstrated their capacity to play a crucial role in advancing HCV issues, and they should continue leveraging these issues for the benefit of individual patients and public health in general.
Running Title: Boston DeclarationWord Count: 689 (not including the table) 2 Nearly three out of every four deaths globally in 2017 were caused by non-communicable diseases (NCDs). 1 Many countries have made progress reducing NCD risk factors such as tobacco use, hyperlipidemia, and hypertension, but no countries have successfully reversed the increasing trends in diabetes prevalence and mortality from diabetes is increasing. 1 This represents a massive global health failure considering the fact that type 2 diabetes is largely preventable with lifestyle modification and that cost-effective treatments exist for both type 2 and type 1 diabetes. 2 Specific concern is needed for type 1 diabetes, which without insulin, it is fatal.In parallel, forced migration has reached a record high with 68.5 million people displaced from their homes around the world, 85% being hosted in low or middle-income countries such as, Uganda, Lebanon, and Pakistan, and 65% occurring in protracted refugee situations. 3 In addition, there are over 100 million conflict-affected non-displaced people and 175 million people who are affected by natural disasters annually. 4 These individuals are particularly vulnerable in crises due to disrupted health services and unpredictable-and often unhealthy-food supplies, which may exacerbate their condition and lead to complications.To date, diabetes and other NCDs have largely been underserved in humanitarian settings. 5,6,7 The true scope of the problem has not been established and it is not known which interventions are efficacious, feasible, and cost-effective in these contexts. With respect to type 1 diabetes, arguably the most immediately life-threatening NCD, the supply and cost of insulin, blood glucose monitoring and diagnostic tools are barriers for both humanitarian responders and their host countries, as well as patient adherence, life expectancy, quality of life, follow-up and provider training in diabetes care.In order to begin to address these major gaps, on 4-5 April 2019, Harvard University convened a meeting of humanitarian and other actors in global health to discuss the immediate needs and barriers to tackling diabetes in humanitarian crises, and to adopt a unified, action-oriented agenda to address this pressing global health issue (http://globalendocrinology.bwh.harvard.edu/symposium). Whilst it was recognised that there are substantial gaps in care for diabetes in all low-resource settings, 8 not just humanitarian crises, and that many other NCDs (e.g., cardiovascular disease, chronic obstructive pulmonary disease and asthma) are also prevalent globally and inadequately addressed in humanitarian settings, 9 we chose to prioritize efforts on diabetes in humanitarian crises, for the following reasons:First, because people with type 1 diabetes who cannot access insulin and continuity of care in a crisis are at acute risk of death. The principles of the Humanitarian Charter and United Nations Universal Declaration of Human Rights include the right to life with dignity. 10 The human rig...
Primary biliary cirrhosis (PBC) is a chronic cholestatic liver disease, which predominantly affects women. It is characterised histologically by necroinflammation of small intrahepatic bile ducts and biochemically by elevated serum alkaline phosphatase, levels of which at diagnosis predict survival. Ursodeoxycholic acid (UDCA) is the only treatment shown to improve liver biochemistry and survival. We report two patients with PBC who show a fall in serum alkaline phosphates levels whilst receiving tamoxifen therapy. Tamoxifen may exert this effect, which warrants further study, either via cholangiocyte estrogen receptors, inhibiting cholangiocyte proliferation and inducing apoptosis or by activating pregnane X receptor, analogous to the mode of action of UDCA.
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