While it has been known that Hepatitis C is a widespread disease in Pakistan, the full extent of liver infection burden in Pakistan was previously unclear. A recent paper published in the Journal of Viral Hepatitis in April of this year sought to use modeling to better characterise the extent of Hepatitis C in Pakistan. They then used this information to propose what an evidence-based path towards Hepatitis C elimination would entail.

This project was an international collaboration consisting of 24 authors representing twelve different organisations – including the Center for Disease Analysis Foundation (US), the Ministry of National Health Services in Islamabad, representatives from all provincial hepatitis control programmes, in collaboration with liver experts from both private and public sector.

The unique approach that this team used to start with provincial data to extrapolate the national prevalence of Hepatitis C. Based on their calculations, they estimated that 9.7 million patients in Pakistan are currently infected with Hepatitis C.

We contacted one of the contributors to the paper Professor Aamir Ghafoor Khan from the Lady Reading Hospital in Peshawar regarding these findings. He shared context that there are many common practices that risk spreading Hepatitis C. “Mainly people use the reusable syringe, they should use disposable sealed syringes, barber should use clean blades, roadside dentist and ataais [who do medical treatment without having certification] in villages for delivery should be avoided, because they have infected instruments.”

The paper provided insights into what next steps may look like for Pakistan, and what solutions are available to decrease Hepatitis C. Specifically, in order to reach the World Health Organization elimination targets for Hepatitis C, they estimated that Pakistan would need to establish processing for 18.8 million annual screens, 1.1 million treatments, and prevent 46,700 new infections each year. This could ultimately save 152, 000 lives by 2030.

We discussed the feasibility of such a plan with Dr Huma Qureshi, another co-author of this paper and prior national lead on hepatitis management in Pakistan with the Ministry of National Health Services. Dr Qureshi commented via email, “The cost of this is estimated to be PKR 70 billion. Currently, the 4 provinces are supporting hepatitis testing and treatment through their own budget but their budget is not enough to cater for all the population.”

Dr Qureshi emphasized, “We, therefore, requested the Prime Minister to support hepatitis C elimination as a national health emergency, to which the PM agreed,” explaining that “There would be no cash transfer, the federal government shall buy commodities ie rapid screening tests, PCR and treatment and give to the provinces on their need and performance basis. An electronic medical record system has been developed for the registration of the people who undergo screening, testing, and treatment. This system shall have unique identifiers to avoid duplication and monitor the progress.”

She also explained additional interventions that can be pursued to limit the spread of the virus. She specified that “to prevent new infections, the injections have to be made safe by introducing the auto-disposable syringes (cannot be used once used), infection control in the health care settings shall be ensured through the infection control committees of the hospitals and the overall supervision of the provincial healthcare commissions, safe blood shall be ensured through the blood transfusion authorities of the provinces. Compliance from these stakeholders shall be taken regularly to ensure adherence and proper coverage.”

Such interventions have been successfully conducted in low and middle-income countries. Dr Qureshi gives the example of Egypt.

“In the past decade, Egypt had the highest Hepatitis C disease burden in the world but they were able to eliminate the disease using a similar approach. A great awareness campaign was undertaken to inform the people about the disease and where to go for testing. All testing and treatment was done in the public sector with the shortest waiting time.”

Dr Qureshi emphasized that while this may seem ambitious, she is hopeful it is possible, adding that “In 2023, Egypt was declared free of hepatitis C by the WHO. Egypt is the 1st country in the world to achieve this gold medal and we think that Pakistan would be the 2nd country to eliminate this disease.”