From vision to execution: how Balochistan is advancing Pakistan’s HCV elimination roadmap

Pakistan carries one of the highest burdens of hepatitis C virus (HCV) in the world. With a national prevalence rate of 4.3%, it is estimated that over 10 million people are living with HCV across the country.

However, the burden is unevenly spread. Punjab and Sindh bear the brunt, with prevalence rates of 6.7% and 6.9% respectively, while Balochistan and Khyber Pakhtunkhwa see considerably lower rates. Anti-HCV prevalence hovers around 1.5% and 1.1%, and HBsAg prevalence around 4.3% and 1.3%, respectively. Yet the numbers, even when smaller, are not negligible. In Balochistan alone, around 70,000 to 80,000 people live with the virus, as noted by Dr Shoaib Aziz Kurd – the current Project Coordinator for the Prime Minister’s HCV Elimination Programme in Balochistan.

Recognising the urgency of this challenge, the Government of Pakistan has recommitted to its national HCV elimination programme, in line with the World Health Organisation’s (WHO) target of HCV elimination by 2030.

Learning from international experience: the case of Egypt

Pakistan’s efforts align with global HCV elimination campaigns, drawing particular inspiration from Egypt, a country that successfully implemented a large-scale test-and-treat strategy. In 2018, Egypt launched the world’s largest national HCV screening initiative, demonstrating that such an approach is both feasible and effective in high-burden settings.

The campaign aimed to screen all individuals over the age of 18 within one year, deploying 5800–8000 mobile screening teams across urban and rural areas.

Key features of Egypt’s programme included:

• • • Immediate referral of seropositive individuals to treatment centres for confirmatory testing and fibrosis assessment.
    • Use of digital tools that allowed patients to register via mobile phones and receive results and treatment reminders.
    • Coordination through a central database that connected treatment centres, improving patient flow and follow-up.

In the first seven months, nearly 50 million people were screened, and 2.2 million individuals were referred for further care. The programme is widely regarded as a benchmark for national HCV elimination strategies and has provided valuable operational insights for countries with similar epidemiological and economic profiles.

The national response and renewed efforts

This is not Pakistan’s first attempt at tackling HCV. The Balochistan Provincial Control Programme, launched in 2007, was among the earliest province-led efforts. While these early efforts helped raise awareness and establish treatment protocols, they faced challenges related to scale, coordination, and consistent diagnostic coverage.

Then came a federal reset.

In 2019, a more comprehensive approach was launched through the Prime Minister’s HCV Elimination Initiative. Although delayed by the COVID-19 pandemic, the programme was reactivated in 2024 with stronger federal-provincial coordination. Key features of this renewed effort include:

• • • A federal commitment to screen 69 million people and treat 9.8 million by 2030.
    • Shared funding responsibilities between federal and provincial governments.
    • Use of locally manufactured direct-acting antivirals (DAAs)
    • A strategy to integrate screening with primary care services and to expand diagnostic laboratory infrastructure to efficiently handle high sample volumes
    • Active and passive mass screening, including door-to-door outreach
    • A centralised Electronic Medical Record (EMR) for end-to-end patient tracking

Spotlight on Balochistan

While the 2007 Hepatitis Provincial Control Programme focused on diagnosis, treatment, and prevention efforts, the newly launched Prime Minister’s Hepatitis Elimination Programme will function as an independent initiative with a primary emphasis on screening, followed by diagnosis and treatment. In its first phase, the programme aims to cover 18 districts in Balochistan, targeting the screening of 5 million people over a three-year period. Based on a 2.4% estimated prevalence, around 70,000 to 75,000 individuals are expected to require treatment.

One of the key figures helping bridge the past and present efforts in Balochistan is Dr Kurd. Dr Kurd’s career journey reflects a deep commitment to Pakistan’s public health systems. Although he originally trained as a dentist, he transitioned into public health after completing a master’s degree in primary healthcare management. His early roles included serving as a Monitoring & Evaluation Officer for a tuberculosis (TB) control programme and then as a Project Manager for the Global Fund malaria control programme. These experiences provided him with a systems-level perspective on disease elimination – working closely with international donors, coordinating multi-site operations, and managing disease surveillance and follow-up.

In 2020, Dr Kurd became the Provincial Coordinator for HCV control in Balochistan under the older programme. This positioned him to witness firsthand the challenges of limited tracking, rural access barriers, and fragmented diagnostics. His leadership in that role made him a natural choice to lead the Balochistan rollout of the new Prime Minister’s HCV initiative. In his current role, Dr Kurd is helping shape the programme’s strategic and operational contours.

Expanding access: building a smarter, scalable HCV testing network

The Prime Minister’s HCV Elimination Programme aims to scale both passive and active screening methods, with a strong emphasis on reaching underserved populations. As Dr Kurd explains, “We want to go beyond passive screening and also employ active screening – where we go door to door to test patients.”

In Balochistan, the programme will target individuals aged 12 years and above, using a two-step diagnostic approach:

• • • Initial screening will be conducted using Rapid Diagnostic Test (RDT) kits.
    • Individuals with reactive RDT results will then undergo confirmatory PCR testing.

To enable this workflow at scale, blood samples will be collected on-site – either at screening centres or during field visits – and transported to district headquarters for centrifugation. From there, samples will be sent to provincial headquarters for PCR confirmation.

Ensuring quality through WHO-prequalified diagnostics

The programme’s diagnostic backbone is built on WHO Prequalification (PQ) in vitro diagnostics (IVDs), a global standard that ensures tests meet rigorous benchmarks in safety, performance, and quality. For countries like Pakistan, the use of WHO-prequalified tests is particularly critical to ensure:

• • • Accurate detection of HCV antibodies
    • Reliable confirmatory testing
    • Trust in the diagnostic process across varied healthcare settings

Integration with treatment and digital monitoring

Patients who test positive via PCR will be initiated on treatment at designated dispensaries within each district. These treatment records will be maintained through an EMR system, enabling improved tracking of patient outcomes and enhanced coordination between provincial and federal health authorities.

Tackling roadblocks: potential challenges and mitigation strategies

While the foundation for Balochistan’s HCV elimination pilot is firmly in place, several operational challenges remain. Dr Kurd outlines both anticipated barriers and early strategies being put in place to address them.

“Funding has always been a challenge everywhere, and it took nearly two years for the federal and provincial governments to mobilise the required resources. Thankfully, in Balochistan, we now have the funding in place. The federal government is aiming to allocate around 70 billion rupees this year,” he says. Nevertheless international funding would be of great support to accelerate the efforts and achieve the targets timely.

Environmental and logistical constraints

Two major implementation hurdles have been flagged at the outset:

1. 1. Extreme weather conditions with summer temperatures often exceeding 45–50°C, field teams will face considerable physical strain during outdoor screening efforts.
   2. Sample transportation logistics especially in remote areas, ensuring a reliable flow of blood samples from community sites to district labs and onward to the provincial reference lab poses logistical and quality control concerns.

Alternative transport and infrastructure use

To manage transportation gaps, plasma separation cards (PSCs) can be used as an alternative to traditional blood collection tubes. These offer better stability for sample handling and can be particularly helpful in areas where cold chain logistics are difficult to maintain.

“Courier services are not consistently available in Balochistan,” notes Dr Kurd. “We are exploring whether the PCR vendor might be responsible for transportation. Alternatively, local transport networks, such as those used in the TB programme, could be adapted for intra-district sample movement.”

He also highlighted the importance of integrating with existing infrastructure from Global Fund-supported programmes, particularly in facilities already handling human immunodeficiency virus (HIV), TB, and malaria. These sites have trained staff and existing sample transport systems, providing a ready platform for expansion.

Ensuring data integration and patient follow-up

A common challenge in earlier provincial programmes was the inability to track patients once screened or treated. To address this, the new programme will make use of a centralised EMR system to record:

• • • Patient history
    • Diagnostic outcomes
    • Treatment milestones
    • Follow-up reminders

“The EMR will serve as a unifying system to bring together data from different screening and lab points,” explains Dr Kurd. “We are also recording patients’ self-reported history of prior diagnosis or treatment, so we can avoid duplication and better track outcomes.”

To minimise loss to follow-up, the programme will provide a two-month initial treatment supply, prompting patients to return for the third month. For those who do not return on schedule, home visits will be conducted to encourage continuation of care.

Engaging the private sector: opportunities ahead

The role of the private sector in HCV elimination remains an area of ongoing development. While public-private partnerships have been implemented in other communicable disease programmes, such as malaria and TB, similar collaborations for HCV in Balochistan are still in early discussion.

“Some private partners have expressed interest – especially in offering infrastructure and staffing support – but formal lab partnerships are yet to be established,” says Dr Kurd.

There is growing interest in engaging private laboratories, which could help expand diagnostic capacity, reduce turnaround times, and strengthen the programme’s reach in urban areas. The Ministry of Health is currently exploring opportunities to align private sector capabilities with public health goals under a shared governance framework.

Launching the pilot: Balochistan’s first field test

The Balochistan pilot programme began in July 2025, marking the first on-ground implementation of the Prime Minister’s HCV Elimination Programme in the province. Two districts – one relatively well-resourced, the other more remote – have been selected to test and refine the operational model.

According to Dr Kurd, screening will be conducted for 4,000 individuals at each site, with a combined target of 8,000 people over a span of just six days. This timeline is informed by previous public health campaign experience in the region and is intended to simulate the pace and scalability of mass screening when the full programme rolls out.

Planning for impact: timeline, phasing, and programme goals

The national HCV elimination programme is designed with a six-year horizon, aiming to meet WHO’s elimination targets by 2030. While mass screening is expected to conclude within the first year, the PCR testing and treatment rollout will occur over a longer period, due to phased budget allocations.

Dr Kurd explained that the federal government will supply RDT kits, part of the PCR kits, and a portion of the treatment, while provincial governments will fund and procure the remaining PCR and treatment resources, along with managing operational costs. The procurement process is currently underway. Once concluded, provincial rollouts will proceed simultaneously across the country.

Staged PCR testing: a practical necessity, a strategic risk

One critical issue under discussion is the staging of PCR testing. Under current plans, only initial screening using RDT will be performed during the first year’s screening drives, and PCR confirmatory testing may be spread out over the next two to three years, depending on budget release schedules.

While this approach allows the programme to initiate action rapidly, it brings potential risks. Delays in PCR testing could lead to:

• • • Loss to follow-up, particularly in remote or mobile populations
    • Delayed initiation of treatment, undermining public trust and programme efficiency

Dr Kurd acknowledged these concerns, adding that the final protocol is still being evaluated to ensure feasibility without compromising patient outcomes.

From metrics to milestones

Success will ultimately be measured not only by the number of people screened or treated, but by the reduction in population-level viremia, an indicator of real progress toward elimination.

“Our endpoint is clear,” says Dr Kurd. “We are working toward the WHO-defined criteria for declaring a country hepatitis-free. Reduced viremia rates are a step in that direction, but our target is full elimination by 2030.”

With pilot efforts in Balochistan set to inform national scale-up, Pakistan now stands at a pivotal moment. The groundwork has been laid: local funding secured, diagnostics streamlined, and operational teams mobilised. What lies ahead is consistent execution, patient engagement, and a commitment to long-term monitoring.

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

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