Pakistan, a country where more than 15 million people are living with hepatitis B or C, is estimated to invest 3 billion dollars in efforts to eliminate the hepatitis C virus (HCV) and hepatitis B virus (HBV) by 2030. With the increasing number of tests and screenings of the disease, the cost is expected to go upwards over the next 10 years.
The number of patients suffering from HCV and HBV in Pakistan is the second highest in the world, according to a report by The Economist Intelligence Report.
To tackle this challenge, the Pakistan government, on the World Hepatitis Day in July 2019, announced an ambitious screening and treatment programme to eliminate HCV and HBV by 2030.
This programme aimed at scaling up prevention, testing and treatment efforts in the four provincial-level hepatitis programmes, supplementing the existing National Hepatitis Strategic Framework 2017-2021.
The findings of another regional survey combined with a provincial infection scandal have created a greater sense of urgency among policymakers. According to one study, tackling HCV effectively will save more than 320,000 lives and 2.6 billion USD in direct costs between 2015 and 2030.
The aim of the programme is to test and treat 70 percent of the population by 2023. Based on modeling supported by University of Bristol and the Centers for Disease Control and Prevention (CDC), initial estimates indicate that around 140 million people will need to be screened.
Of these, 14 million may be positive for HCV and will require more sophisticated testing while approximately 10 million are likely to require treatment. Testing and treatment will be offered to the public absolutely free of charge. The government's healthcare budget has earmarked funds for HCV treatment but this will not cover the cost of testing and treatment across the country.
Dr Saeed Hamid, professor of gastroenterology at Aga Khan University, a co-organiser of this year's World Hepatitis Day, informed that the government estimates that there is some confidence that funding can be found from various sources.
To raise this amount, funds are expected from the Asian Development Bank and the World Bank. Governance of these funds must be strengthened, as there are concerns over improper use and corruption, according to interviewees. The plan is for the federal government to procure tests and medication and distribute them to provinces.
The announced programme focuses almost entirely on HCV. Policies for HBV will be revisited after a couple of years by which time they hope to have the HCV epidemic under control, says Dr Huma Qureshi, former executive director, Pakistan Health Research Council.
Based on the survey conducted in Punjab, by the World Health Organisation (WHO) with 250,000 cases being reported every year in Pakistan, the rates of HCV increased sharply from to 6.7% in 2008 to 17% in 2017. But crafting the appropriate policy response requires a deep understanding of the underlying causes of current viral hepatitis rates in the country alongside its existing prevention and control policies.
Meanwhile, stable or declining infection rates of the hepatitis B virus (HBV) in many regions suggest Pakistan's vaccination programme is currently holding this virus strain at bay. Based on the survey conducted in Punjab, the prevalence of HBV, on the other hand, decreased slightly to 2.2% from 2.4% over the same period. This was attributed to the introduction of an HBV vaccination programme for infants at six weeks of age.
On crafting policies around HBV, Dr Qureshi further added these are more difficult to do for HBV, as not all who tested positive for the virus require treatment, she explains. As part of the existing plans; however, the government will make the birth dose of the HBV vaccine mandatory by 2020; the first dose will then be provided within the first 24 hours rather than six weeks after birth.
Pakistan has an ambitious plan to address its hepatitis epidemic through a countrywide screening and testing programme. More broadly, the government's plan focuses on improving the safety of its blood banks, injections and disposal of medical waste. Progress on injection safety, in particular, has been slow and must be expedited. Public awareness campaigns will complement these efforts, educating people about the risk factors and empowering them to take control of their health.
For this programme to work, managing the fragmented healthcare system is essential. "The only way this will be successful is if there is a strong buy-in from the provinces, if there is a strong collaborative effort with the provinces to make it happen," says Dr Hamid. "This needs political will and ability to find common ground for the benefit of the whole country."
Setting up a process for data collection across key performance indicators is pivotal for measuring progress and identifying areas where more aggressive action is needed. There are recommendations that as part of the demographic and health survey conducted every four years, blood tests for HBV and HCV should be included.
Only by taking a comprehensive approach can the government significantly reduce the spread of viral hepatitis, treat those infected and resolve this health crisis.