The cost of eliminating hepatitis C in Pakistan
Authors: Zaigham Abbas, Minaam Abbas
Journal: The Lancet Global Health (2020)

In 2016, the World Health Assembly pledged to eliminate hepatitis C virus, a major public health threat, by 2030.1WHOGlobal hepatitis report 2017.www.who.int/hepatitis/publications/global-hepatitis-report2017/en/Date: 2017Date accessed: January 20, 2020Google Scholar To achieve this ambitious goal, 90% of all patients with hepatitis C must be diagnosed in a timely fashion and about 80% of all eligible patients must be treated with direct-acting antivirals. Pakistan has the second-largest burden of hepatitis C globally, with a nationwide prevalence of 4·8%.2Qureshi H Bile KM Jooma R Alam SE Afridi HU Prevalence of hepatitis B and C viral infections in Pakistan: findings of a national survey appealing for effective prevention and control measures.East Mediterr Health J. 2010; 16: S15-S23Crossref PubMed Google Scholar Despite the availability of generic direct-acting antivirals in Pakistan and an accompanying reduced cost of treatment, the prevalence of hepatitis C remains persistent, with no evidence of decline.3Mahmud S Al Kanaani Z Abu-Raddad LJ Characterization of the hepatitis C virus epidemic in Pakistan.BMC Infect Dis. 2019; 19: 809Crossref PubMed Scopus (8) Google Scholar One of the reasons for this persistence is the absence of a comprehensive, population-wide screening programme that can identify the missing millions of people who require treatment. To set diagnosis and treatment targets for hepatitis C elimination in Pakistan, Aaron G Lim and colleagues4Lim AG Walker JG Mafirakureva N et al.Effects and costs of different strategies to eliminate hepatitis C virus transmission in Pakistan: a modelling analysis.Lancet Glob Health. 2020; 8: e440-e450Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar present in The Lancet Global Health projections from a revamped deterministic model of the spread and control of hepatitis C. The new, dynamic model incorporates important new parameters, such as the cascade of care and local cost data. The study compared four possible strategies to the status quo. Modelling showed that if the status quo was to be maintained, hepatitis C prevalence and incidence would remain unchanged, whereas a comprehensive, one-time screening programme for 90% of the 2018–30 population (14 million per annum) with an 80% referral rate to treatment (350 000 patients) would decrease incidence by 26·5%. The numbers, while astounding, are not new. The same group previously suggested that large-scale screening coupled with the treatment of 880 000 patients per annum was needed to attain WHO's 2030 target.5Lim AG Qureshi H Mahmood H Hamid S et al.Curbing the hepatitis C virus epidemic in Pakistan: the impact of scaling up treatment and prevention for achieving elimination.Int J Epidemiol. 2018; 47: 550-560Crossref PubMed Google Scholar Alternative modelling by Chhatwal and colleagues6Chhatwal J Chen Q Wang X et al.Assessment of the feasibility and cost of hepatitis C elimination in Pakistan.JAMA Netw Open. 2019; 2e193613Crossref PubMed Scopus (10) Google Scholar suggests that the number needing screening might be even higher at 25 million per annum to diagnose 900 000 cases and treat 700 000 patients per year. The novel message of the study by Lim and colleagues is that by prioritising the aforementioned comprehensive screening to higher prevalence groups (people who inject drugs and adults aged ≥30 years), increasing the rates of referral (with minimal loss to follow-up), and introducing rescreening for high-risk groups (which in turn would increase the total number screened per annum), WHO's targets for decreasing the incidence of new hepatitis C infections by 80% can be met. However, even the most aggressive strategy cannot tackle the lofty goal of a decrease in hepatitis C-related mortality by 65% by 2030. Although the findings are illuminating, the numbers needed to screen and treat might be far larger in reality; the model does not consider that the most at-risk groups in the country are paradoxically those receiving treatment in medical centres. Indeed, unsafe therapeutic injections and nosocomial transmission are bigger risk factors for hepatitis C transmission than intravenous drug use.7Trickey A May MT Davies C et al.Importance and contribution of community, social, and healthcare risk factors for hepatitis C infection in Pakistan.Am J Trop Med Hyg. 2017; 97: 1920-1928Crossref PubMed Scopus (12) Google Scholar, 8Wait S Kell E Hamid S et al.Hepatitis B and hepatitis C in southeast and southern Asia: challenges for governments.Lancet Gastroenterol Hepatol. 2016; 1: 248-255Summary Full Text Full Text PDF PubMed Scopus (35) Google Scholar An example of this trend was the 2019 outbreak of HIV amongst children in Larkana, Pakistan that was traced back to negligent practices at the health-care centres.9Mir F Mahmood F Siddiqui AR et al.HIV infection predominantly affecting children in Sindh, Pakistan, 2019: a cross-sectional study of an outbreak.Lancet Infect Dis. 2019; (published online Dec 19.)https://doi.org/10.1016/S1473-3099(19)30743-1Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar This example also challenges the underlying assumption that the largest at-risk group consists of adults older than 30 years. Lim and colleagues also did financial modelling in their analysis and show that it would cost the national exchequer about US$8 billion. The best-cost scenario, incorporating a discount from the use of future cheaper direct-acting antivirals and diagnostics alongside savings from implementing a simplified treatment pathway, would still require an investment of 9% of Pakistan's health expenditure for the 2017–18 fiscal year. However, as the authors acknowledge, this projected figure ignores the additional costs associated with the establishment of the appropriate infrastructure, training, and transport facilities. In a resource-limited setting, the allocation of the projected figures coupled with overheads appears highly challenging. Perhaps some of this cost may be offset by a public information campaign that discourages high-risk behaviour. The impact of such a strategy is not addressed by this model and might best be captured by agent-based modelling. Such modelling could help researchers and policy makers to understand the network effects that must be leveraged to facilitate the participation of targeted high-risk groups, alongside the broader public, in the prevention, diagnosis, and treatment of hepatitis C. In Pakistan, the control of hepatitis has so far remained a low political priority, with poor implementation of health-related policies and government-sponsored treatment programmes by the devolved provincial health ministries. There is an urgent need for a central decision body to set guidelines and recommendations that can simplify the treatment pathway and, with the education and recruitment of non-specialists, facilitate the mass screening and treatment effort proposed by Lim and colleagues. Inspiration for such a paradigm shift could be drawn from the hugely successful hepatitis C control programme in Egypt.10El-Akel W El-Sayed MH El Kassas M et al.National treatment programme of hepatitis C in Egypt: Hepatitis C virus model of care.J Viral Hepat. 2017; 24: 262-267Crossref PubMed Scopus (91) Google Scholar Such a body must also be empowered to federally negotiate discounted procurements for the programme in an accountable and transparent manner. Despite the barriers to an effective strategy, there are grounds for optimism. The establishment of the National Blood Transfusion Authority in Pakistan has been a major development that addresses one of the biggest sources of infection in the country: contaminated blood units. Injection safety, another major concern for transmission, is also being addressed with the introduction of auto-disable syringes. Together with the newly announced Prime Minister's hepatitis C control programme, all of these steps serve as important groundwork for the challenging work ahead. We declare no competing interests. Effects and cost of different strategies to eliminate hepatitis C virus transmission in Pakistan: a modelling analysisPakistan will need to invest about 9·0% of its yearly health expenditure to enable sufficient scale up in screening and treatment to achieve the WHO hepatitis C elimination target of an 80% reduction in incidence by 2030. Full-Text PDF Open Access