This article is part of a series on hepatitis C (HCV) elimination in Pakistan and other high-risk countries around the world. Other articles in this series cover the Pakistani provinces of Sindh and KPK. Scroll to the bottom of the article for the full list.

With around 24,000 HCV-related deaths every year, Pakistan has one of the world’s highest rates of HCV infection. Punjab, one of the country’s largest provinces, is an area of particularly high HCV prevalence. According to 2018 screening figures, roughly 9% of the province’s 28 million people were afflicted with the disease, compared to 5.4% for the total population.

To discuss strategies for improving the situation, the Lab Insights team spoke with two leading experts on HCV in Punjab:

• Professor Ghias Un Nabi Tayyab, Dean of the Faculty of Gastroenterology at the College of Physicians and Surgeons in Karachi, President Pakistan Society of Gastroenterology & GI endoscopy, Ex Principal Post Graduate Medical Institute/Ameer Ud Din Medical College, Lahore, Professor and Dean of Medicine, Lahore General Hospital, Lahore, Member of steering committee for Prime Minister Hepatitis Control Program and Chief Executive of the Provincial Working Group on Hepatitis for the government of Punjab
• Professor Muhammad Umar, Vice Chancellor and CEO, and Chairman and Professor of Medicine at the Rawalpindi Medical University Hospital, and Chief of the Gastroenterology and Hepatology section of the Holy Family Hospital in Rawalpindi, Punjab

As active participants in both provincial and national HCV programmes in Pakistan, Prof Tayyab and Prof Umar share their perspectives on Punjab’s HCV eradication efforts and solutions for local challenges.

Punjab’s HCV eradication efforts

Like other provinces, HCV screening and prevention programmes have been underway for many years in Punjab. Local authorities have also rolled out hepatitis B vaccinations to help reduce the burden of liver disease.

Looking ahead, the province is undertaking many efforts to improve the situation. Prof Tayyab, for example, is involved in a regional initiative to remodel hepatitis clinics, develop GI & endoscopy units, and a transplant hospital for kidney and liver diseases has been commissioned.

“Three centres of excellence in Punjab have been earmarked for providing high-end care to population of the province,” he explains. “Diagnostics and POC testing will be carried out at 152 hepatitis clinics attached to various public hospitals across the province.” GI units and hepatitis clinics in collaboration with College of Physicians & Surgeons, Karachi and various university programmes shall train doctors, nurses and paramedics for the future needs of the discipline and strengthen the human resources needed for ‘HCV elimination programme’.

Punjab province is also using software to better track and engage patients. “The majority of patients that have HCV are financially constrained and healthcare providers find it difficult to closely follow up with such patients,” says Prof Tayyab. “Once patients are confirmed as HCV positive, they are informed via their cell phone and their healthcare providers are able to communicate with them and provide them with details of a treatment plan,” he continued.

Prof Tayyab notes that the 152 hepatitis clinics attached to various public hospitals are using a common software for data sharing, logistical monitoring and assessing the outcomes, and there are plans to roll out the software to departmental hospitals, sister organisations, NGOs and family physicians. Prof Umar also believes that this sort of tool could act as a central monitoring database to track the number of patients that have been tested and to ensure they are getting the treatment they need.

Overcoming the challenges

Despite legislation from the Punjab Hepatitis Act (2018) and Safe Blood Transfusion Act (2017), and requirements for mandatory registration of healthcare and ancillary services with the healthcare commission, both experts note that Punjab faces many of the same challenges as other provinces, such as poor sterilisation practices within clinics, dental practices and blood transfusion centres.

For various reasons, patients testing positive for HCV fail to report for treatment initiation or do not comply with the treatment duration. Liver transplant remains a difficult task associated with high costs, donor availability and patient management. Few centres in the province provide liver transplant service, and it often still takes too much time for patients to get the care they need.

The pandemic has also led to a shift of focus towards managing COVID-19 patients. “We are struggling with a backlog on the HCV front, particularly at testing sites,” observes Prof Tayyab. “On the one hand, we are trying to control a disease with a limited outlook, and on the other, a disease with longer term implications. These are two different ball games.”

One approach to overcoming these challenges, and also helping to reduce the costs of community outreach, is to enlist community leaders in HCV eradication efforts. “We need the support of MPs, religious leaders and teachers to educate people and raise awareness about the risks and associated complications of HCV,” explains Prof Umer.

Prof Umar also sees a need to improve outreach to family care physicians and integrate their practices with clinics and hospitals. For screening, it may also help to target members of the local community that come into contact with many people daily, such as hairdressers, beauticians and non-traditional doctors, such as by handing out pamphlets and putting out adverts on trains and buses.

As for the COVID challenge, a hybrid model to tackle both HCV and COVID simultaneously is possible, but mainly for bigger cities with shorter travel time to clinics and hospitals. For rural areas, rapid point-of-care (POC) testing could be performed, but cost remains a barrier in low-resource settings.

With so many challenges, comprehensive planning is needed that combines the ‘test, educate and treat’ model, integration of macro & micro elimination efforts, and strong advocacy groups to eradicate HCV in Pakistan. “It is important to set up models and carefully plan for the goal of HCV elimination by 2030,” says Prof Umer. “A road map needs to be defined, as well as timelines, milestones, and regular review and monitoring of all aspects – the funds, resource, training, outcomes and target.”

To learn more about the growing burden of HCV in Pakistan and the Asia Pacific, check out these other case studies on Lab Insights:

• HCV screening in Egypt: key elements of a successful national screening programme
• HCV elimination in Pakistan: the national perspective from Dr Zaigham Abbas
• HCV elimination in Northern Pakistan: Prof Aamir Khan on treating patients in KPK province and the Afghan borderlands 
• HCV elimination in Sindh province: insights from Prof Muhammad Sadik Memon and Dr Zaigham Abbas
• Pakistan’s national HCV elimination programme: insights from Dr Huma Qureshi

To learn more about the broader challenges posed by liver disease in Asia Pacific, check out this video Q&A with Prof Pierce Chow of the National Cancer Centre Singapore.