Curbing the hepatitis C virus epidemic in Pakistan: the impact of scaling up treatment and prevention for achieving elimination

Abstract

BackgroundThe World Health Organization (WHO) has developed a global health strategy to eliminate viral hepatitis. We project the treatment and prevention requirements to achieve the WHO HCV elimination target of reducing HCV incidence by 80% and HCV-related mortality by 65% by 2030 in Pakistan, which has the second largest HCV burden worldwide.MethodsWe developed an HCV transmission model for Pakistan, and calibrated it to epidemiological data from a national survey (2007), surveys among people who inject drugs (PWID), and blood donor data. Current treatment coverage data came from expert opinion and published reports. The model projected the HCV burden, including incidence, prevalence and deaths through 2030, and estimated the impact of varying prevention and direct-acting antiviral (DAA) treatment interventions necessary for achieving the WHO HCV elimination targets.ResultsWith no further treatment (currently ∼150 000 treated annually) during 2016–30, chronic HCV prevalence will increase from 3.9% to 5.1%, estimated annual incident infections will increase from 700 000 to 1 100 000, and 1 400 000 HCV-associated deaths will occur. To reach the WHO HCV elimination targets by 2030, 880 000 annual DAA treatments are required if prevention is not scaled up and no treatment prioritization occurs. By targeting treatment toward persons with cirrhosis (80% treated annually) and PWIDs (double the treatment rate of non-PWIDs), the required annual treatment number decreases to 750 000. If prevention activities also halve transmission risk, this treatment number reduces to 525 000 annually.ConclusionsSubstantial HCV prevention and treatment interventions are required to reach the WHO HCV elimination targets in Pakistan, without which Pakistan’s HCV burden will increase markedly.

The cost of eliminating hepatitis C in Pakistan

“…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. 5 Alternative modelling by Chhatwal and colleagues 6 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.…”

We know DAAs work, so now what? Simplifying models of care to enhance the hepatitis C cascade

“…A second study made comparable projections for other European countries, but also found that some countries would need to scale‐up opioid substitution therapy (OST) and needle and syringe exchange programmes (NSP) interventions to reduce chronic HCV prevalence . Yet in most countries of the world, particularly low‐ and middle‐income countries, access to DAAs and harm reduction services remains extremely limited , and achieving the WHO targets will require major expansion of both forms of access . That is because besides DAA therapy, which enables a sustained virologic response (SVR), the most effective form of HCV prevention for PWID is harm reduction, including OST, NSPs, and supervised injecting centres.…”

Interim impact evaluation of the hepatitis C virus elimination program in Georgia

“…In the United States an opioid epidemic is growing and leading to a growing number of HCV cases in young people. In Pakistan, a growing population and increasing HCV prevalence will require an enormous scale up in treatment to reduce the burden of HCV 30 . In contrast, evidence suggests that the overall HCV epidemic as well as the contribution of PWID to HCV in Georgia is declining.…”

“…Sero-prevalence estimates from IBBS surveys were converted to chronic prevalence based on the ratio of chronic to antibody prevalence in the National Serosurvey (72%). The National Serosurvey provided gender-specific HCV prevalences in the general population, grouped into three age categories (18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46)(47)(48)(49), and 50+), while the IBBS provided year specific HCV prevalence estimates for all PWID, young PWID (18)(19)(20)(21)(22)(23)(24) and older PWID (25+). The HCV prevalence estimates used to calibrate the model are given in Table 3, with specific prevalence ratios being used to calibrate the model to ensure it captures increases in HCV prevalence amongst all PWID (16% relative increase over [2006][2007][2008][2009][2010][2011][2012][2013]…”