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 Punjab, KPK and Sindh. Scroll to the bottom of the article for the full list.

In 2019, Pakistan announced a countrywide programme to scale up HCV prevention, testing and treatment. With the direct support of the country’s Prime Minister, this programme aimed to bolster the provincial-level efforts that have been in place for years, but which have had limited impact in reducing the country’s HCV infection challenges.

One of the key figures in this national programme is Dr Huma Qureshi, a prominent gastroenterologist and researcher who helped introduce direct-acting antivirals (DAA) to the country. She also contributed to Pakistan’s HCV testing and treatment guidelines, and helped forge its National Hepatitis Strategic Framework. In this interview with Lab Insights, she shares her thoughts on best practices for screening and elimination across the region.

Motivations for a national-level HCV elimination effort

The Prime Minister’s programme for eliminating HCV is a 10-year initiative that was initially planned to run from 2020 to 2030. Structured as a two-phase programme, it aims to screen the entire population over five years of age for HCV and provide treatment for HCV-positive individuals.

“The main reason for focusing on the general population, and not just the high-risk population, is that the major risk factors of HCV in Pakistan—blood transfusion without proper screening, unsafe therapeutic injections, and improperly sterilised medical devices—are not commonly observed in other parts of the world,” says Dr Qureshi. “HCV is a silent killer, so by and large, the majority of people who are infected do not know they are infected.”

While ambitious in its scale, the Prime Minister’s programme is not the first attempt to get HCV under control in the country. For decades, provincial-level programmes helped establish sentinel sites with diagnostic and treatment facilities, but the impact was limited due to numerous challenges.

One of those challenges was access to treatment options for HCV-positive patients. “DAAs were unavailable in the country and only interferons could be obtained to treat HCV patients,” reflects Dr Qureshi. “Treatment with interferons had low response rates, adverse effects, and issues with adequate storage space in fridges and freezers.” Other challenges included limited funding and workforce constraints.

By 2008, Pakistan had the second-highest prevalence of viral hepatitis in the world. “This really opened the eyes of the decision makers and they realised they needed to take action,” recalls Dr Qureshi. Modelling results, including some proposed by the World Health Organization (WHO), suggested that HCV elimination efforts were a good investment.

Then, in 2010, Pakistan’s provinces became autonomous, leading to fragmentation of HCV elimination efforts and spurring the government to develop a long-term, national-level programme. The goal was to help support these provincial efforts, in part by achieving economies of scale in important matters such as the bulk procurement of diagnostic tools and treatments.

Ensuring the programme’s success

Even as COVID-19 delayed the launch of the national programme, and continues to dominate the headlines and steal attention from Pakistan’s health policy makers, progress is happening. Continued momentum of the programme will require a commitment to funding, monitoring, and evaluation, according to Dr Qureshi.

“Often as things evolve, deviations from the original plan start happening and things can get off track,” she says. “These obstacles could hinder progress and therefore require regular monitoring and evaluation.”

Dr Qureshi believes multi-stakeholder alignment is necessary to stay on course. “We are engaging corporate sectors, partners, NGOs and CSOs to help us create awareness and behaviour changes,” she notes.

NGO and public sector engagement will be necessary to reach patients in underserved and marginalised communities. In KPK province, for example, hospitals in Peshawar will often receive patients from across the border in Afghanistan. While such patients are unlikely to be turned away, more planning may be needed to address their needs.

For ordinary Pakistanis, Dr Qureshi believes that the private sector engagement may be particularly crucial. “The majority of the population will seek private healthcare,” she says. “So there is a strong need to engage the private sector as they will play an important role in disseminating information and raising awareness.”

For those patients that receive diagnosis and are funneled into treatment programmes, she is less concerned about compliance with DAA treatments, which are cost effective and efficient. “If there are issues with compliance, they are generally with people who have advanced disease with complications,” she says. “But I would expect around 85% – 95% adherence for the general population.”

“With a successful programme roll out, and widespread screening and DAA treatment, Pakistan will make strides in HCV elimination,” Dr Qureshi concluded.

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: 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

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.