pakistan

CAN ELIMINATE HEPATITIS

NATIONAL HEPATITIS
ELIMINATION PROFILE U P D AT E D J
J J JJ J J J J J JJ

Hepatitis B virus (HBV) Hepatitis C virus (HBV)

2030 NO DATA 2030

HBV elimination goal Elimination of HBV mother to
1
HCV elimination goal 1
child transmission goal 1

Pakistan’s National Hepatitis

Action Plan Strategic Framework Action Plan
(2017-2021) is now out of date

THE HEALTH BURDEN OF VIRAL HEPATITIS

2.5% 4.3%
Prevalence of HBsAg, 2008 15 Prevalence Prevalence of chronic (viremic) HCV, 2020 21
Modelled estimate Modelled estimate
Prevalence of HBsAg, 2018, Punjab: 2.2% 19,20
Viremic HCV prevalence, 2018, Punjab : 4.8% 20
Prevalence of HBsAg, 2019, Sindh: 1.1% 19 Viremic HCV prevalence, 2020, Sindh: 3.8% 23
Survey/reported Viremic HCV prevalence, 2020, Balochistan: 3.1% 24
Viremic HCV prevalence, 2020, Khyber Pakhtunkhwa: 3.8% 21
Prevalence of anti-HCV, PWID: 62% 1
Survey/surveillance

9.8M
Number of persons living with HCV 21
2nd highest burden in the world

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COALITION FOR GLOBAL HEPATITIS ELIMINIATION

30,400 461,000
New HBV infections 18
New chronic HCV infections, 2019 21
Data from WHO Global Reporting Modelled estimate
Incidence Greatest risk factors for transmission include
blood transfusions (15%), history of hospitalization
(14%), dental treatment (13%), use of injections
(12%), and history of surgery (9%)

12,100 17,644 (12,752-24,554)

HBV-related deaths, 2019 18 HCV-related deaths, 2019 2
Data from WHO Global Reporting Modelled estimate

7.23 (5.30-9.67) Mortality 7.87 (5.69-11.00)

Deaths per 100,000, 2019 2 Deaths per 100,000, 2019 2

PROGRESS TOWARDS 2020 WHO ELIMINATION GOALS

PREVENTION OF NEW INFECTIONS AND MORTALITY

NO DATA
National prevalence of HBsAg declined
Percentage change in new
HBV infections, 2015-2020
from 2.5% in 2008 to 1.1% in Sindh in
2019 and 2.2% in Punjab in 2018, declines
WHO 2020 Target -30%
of 56% and 12% respectively. 15,19,20

HBV Percentage change in 9%

deaths, 2015-2019 WHO 2020 Target -10% 2

Percentage change in new NO CHANGE

PAKISTAN • HEPATITIS ELIMINATION PROFILE

HCV infections, 2018-2022

Modelled estimate for 2022
WHO 2020 Target -30% 21

HCV Percentage change in 5%

deaths, 2015-2019 WHO 2020 Target -10% 2

Prevalence of HBsAg in children

In Punjab and Sindh provinces 0.3%
< 5 years (%), 2018-2019 SDG 2020 Target 1% 19,20

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COALITION FOR GLOBAL HEPATITIS ELIMINIATION

ACCESS TO RECOMMENDED VACCINATION, TESTING AND TREATMENT

Hepatitis B vaccination
50% coverage for newborns, 2016 7
WHO 2020 Target 50%

HepB 3 dose vaccine coverage

77% for infants, 2020 3
WHO 2020 Target 90%

Proportion of persons living

14% with HBV diagnosed, 2018 1
WHO 2020 Target 30%

5% HBV
215
Proportion of diagnosed For persons who inject drugs
HBV persons receiving (PWID), number of sterile
appropriate treatment, 2018 needles per year, 2021 4
PAKISTAN • HEPATITIS ELIMINATION PROFILE

WHO 2020 Target 200

935,438

Number of tested for 494,307

HBsAg, 2018-2020 26 348,236

Data from public health laboratories and

hospitals. Private laboratory data not included.

2018 2019 2020

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21,842
18,913

Number of persons on 7,409

treatment for HBV, 2018-2020 26

2018 2019 2020

Proportion of persons living

22% with HCV diagnosed, 2020 21
WHO 2020 Target 30%

404,400

Number of persons diagnosed 152,200 177,200 163,900

with chronic HCV, 2017-2020 26

2017 2018 2019 2020

Proportion of diagnosed persons who

90-95% have been cured of HCV, 2020 19,21
PAKISTAN • HEPATITIS ELIMINATION PROFILE

SVR data from government programs not readily available due to limited SVR12 testing,
making an accurate assessment of SVR rates difficult. Data from smaller hospital-
based studies or micro-elimination campaigns suggest an SVR rate of 90-95%

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353,695
348,901

2.65 M
324,021
215,261

161,000
Number of persons treated 65,000
for HCV, cumulative,
2004-2020 19,22,26
2015 2016 2017 2018 2019 2020

POLICY ENVIRONMENT FOR THE ELIMINATION OF HEPATITIS

ACHIEVEMENT INNOVATIONS ROADBLOCKS

STRATEGIC INFORMATION

Routine official reports to

monitor HBV and HCV 1,15 Mortality

Incidence
No national prevalence study has been
conducted since 2008 but provincial
studies conducted in 2018 for Punjab
Prevalence province and in 2019 for Sindh province

Estimates of HBV and/or Partially Adopted

HCV cost estimate is $684M
in JJ18, projected to decrease
HCV economic burden 27 to $59JM in JJ3J; Jo cost
estimates for HBV
Monitoring of HBV and HCV Partially Adopted Pakistan can see a return on
diagnosis and treatment its investments in eliminating
hepatitis within 3 years
PAKISTAN • HEPATITIS ELIMINATION PROFILE

Some provinces report number of

persons diagnosed and treated

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ROADBLOCKS
HCV contaminated blood transfusions are The Field Epidemiology and Laboratory Training
major contributors to HCV incidence in Program conducts routine surveilance of acute
Pakistan. Approximately half of the blood hepatitis B and C but not for chronic hepatitis
donors are not screened for HCV, HBV, and HIV and the case definition differs from WHO

Lack of coordination across federal, Lack of effective monitoring and evaluation of

provincial, and local governments the provincial hepatitis control programs

PREVENTION OF MOTHER TO CHILDREN TRANSMISSION

Policy for hepatitis B vaccination of Partially Adopted

Adopted in 2016 but uptake
varies by province
newborns within 24 hours 7
Recommendations for: As of 2019, 97.7% coverage of
antenatal HBV screening 17

In Khyber Pakhtunkhwa, HBsAg

HBV testing of pregnant women 1 Adopted and anti-HCV prevalence among
pregnant women found to be 3.7% and
2.1%, respectively (2019-2020) 28

HCV testing of pregnant women Not Adopted In study of pregnant women in

Peshwar district found the prevalence
of HBsAg to be 1.16% and anti-
HCV 1.42% (2013-2014) 29

ROADBLOCKS
Hepatitis B birth dose is not available across all provinces

ACCESS AND REGISTRATION OF MEDICINES AND TESTS

PAKISTAN • HEPATITIS ELIMINATION PROFILE

Registration of orginator DAAs 5,31 Adopted

Eligible for generic DAAs 9 Eligible

Registration of generic DAAs 5,31 Adopted

Licensed point-of-care PCR testing Adopted

GeneXpert machines approved for
HBV and HCV viral load testing and
to detect HBV and HCV 16 recommended for use in the guidelines

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COALITION FOR GLOBAL HEPATITIS ELIMINIATION

ACHIEVEMENTS

Pakistan locally manufactures hepatitis C medicines at a very low cost

INNOVATIONS
The COVID-19 response has led to large increase in the capcity for PCR testing, electronic
health reporting, and improved coordination across provinces and the federal capital

TESTING TO DIAGNOSE HBV AND HCV INFECTION

Testing recommendations for:

HBV screening is routinely

HBV: Risk-based 18 Adopted counducted for employment,
immigration, and medical care

HCV: Universal one-time screening 16 Adopted

No patient co-pays for HBsAg Adopted

Anti-HCV and HBsAg testing are
and anti-HCV testing 5 free-of-charge in the public sector

ACHIEVEMENTS
The Prime Minister set a target for July 2020 to June 2025 to screen 50% of the eligible population,
aiming to reach 69 M persons with anti-HCV screening and 5.15 M with PCR confirmation testing.
PAKISTAN • HEPATITIS ELIMINATION PROFILE

ROADBLOCKS
General population screening Scale-up of point-of-care testing is needed
implementation has been challenging
and further roll-out is needed HCV NAT and antigen testing remain expensive

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ACCESS TO HBV AND HCV TREATMENT

HBV treatment guidelines developed
HBV: National treatment guidelines 17 Developed by Pakistan Society for the Study
of Liver Diseases in 2010; Ministry
of Health in process of developing
Simplied care: Simplified treatment Not Adopted HBV treatment guidelines
and monitoring algorithm for HBV treatment available at designated
primary care providers 18 HBV treatment centers (district
hospitals and tertiary centers).

Simplified care: No patient Adopted If patient receives care at public

treatment co-pays (public sector) 18 district hopistals and tertiary centers,
then treatment is free of charge.

HCV treatment guidelines

HCV: National treatment guidelines 16 Developed
updated in 2020

Simplified care algorithm: Less than Adopted

2 clinic visits during treatment

Simplifed care algorithm: Non- Adopted

specialists can prescribe treatment 16

Simplified care algorithm: No Adopted

HCV treatment free-of-
patient treatment co-pays 5 charge in the public sector

No fibrosis restrictions 16 Adopted

No sobriety restrictions 16 Adopted

No genotyping 16 Adopted

ACHIEVEMENTS

A model community-based, HCV “test & treat” An ambitious program for HCV Elimination was
PAKISTAN • HEPATITIS ELIMINATION PROFILE

program is underway in Punjab province announced by the Prime Minister in July 2019 and
is awaiting funding to start. This program aims
Cost of HCV treatment is US$ 120 for to treat 9.8 million HCV patients by 2030
12 weeks of SOF/VEL and US$35 (as of
June 2022) for 12 weeks for SOF/DCV

ROADBLOCKS
COVID-19 and limited funding has delayed implementation of
the Prime Minister’s HCV elimination program

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HEALTH EQUITY AND ADDRESSING DISPARITIES

National strategy addresses Adopted

populations most affected 1

National anti-discrimination laws against Not Adopted

people living with hepatitis B and/or C 12

National policy for adult Partially Adopted

Policy recommends healthcare
hepatitis B vaccination 1 worker hepatitis B vaccination
but only 20% of healthcare
workers have been vaccinated

National policy for:

Harm reduction for persons Not Developed The Global Fund for TB, AIDS,
who inject drugs (PWID) 12 and Malaria supports all active
harm reduction programs

Syringe exchange in federal prisons 12 Not Adopted

Number of needles/syringes per 215 WHO 2021 Target 200

PWID per year, 2014 4

Number of opioid substitution therapy 0 No OST program operational

recipients per 100 PWID 13

Decriminalization of possession Adopted

Nai Zindagi Trust in Pakistan provides
of syringes & paraphernalia 12 syringes to at least 70% of PWID in
a given geographical boundary based
on their daily injecting frequency
and the number of days in a week
Decriminalization of drug use 12 Adopted they can access services 30

INNOVATIONS
PAKISTAN • HEPATITIS ELIMINATION PROFILE

A number of successful HCV micro-elimination programs are running in the country, both in the
public and private sector, demonstrating the utility of such an approach in high prevalence areas

FINANCING

Public budget line for HBV and Adopted

HCV testing and treatment
if free-of-charge for patients
HCV testing and treatment 5 in the public sector

Funds from the Global Fund for TB, Adopted The Global Fund for TB, AIDS,
AIDS, and Malaria used for co-infected and Malaria supports all active
harm reduction programs
patients or harm reduction programs
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ACHIEVEMENTS
Pakistan’s government introduced The Corporate Coalition for Viral Hepatitis Elimination in
a National Strategic Framework on Pakistan (CCVHEP) is made up of 12 leading companies
Hepatitis [NHSF] in October 2017 created to support the Government of Pakistan’s effort
to eliminate viral hepatitis in Pakistan by 2030

NEXT STEPS TOWARD ELIMINATION

Update the National Strategic Framework Expand access to a comprehensive package of
for next period of implementation harm reduction interventions, including HBV
and HCV testing and treatment for PWID

Improve implementation of standard guidelines

on blood transfusion, reuse of syringes Build on early micro-elimination and HIV
and needles for tattooing and ear piercing, programs to scale-up HCV testing
and insufficient sterilization of potentially
contaminated surgical and dental equipment

Engage community-based organizations

Implement large-scale mass media in HCV testing and treatment
campaigns to reduce demand for injections
to lower risk of transmission

Continue decentralizing HCV treatment

to health centers and basic health units
Scale-up coverage of hepatitis B
birth dose vaccination nationally

Leverage Field Epidemiology Training

Improve coverage of pentavalent and Laboratory Progam to improve
vaccine (HBV) and introduce catch- surveillance of viral hepatitis B and
up vaccination for children older than C by updating case definitions
5 years at school and out of school

Evolve a comprehensive monitoring

PAKISTAN • HEPATITIS ELIMINATION PROFILE

Introduce HBV vaccination and evaluation framework for provincial

for populations at-risk hepatitis elimination programs

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SOURCES

1. Pakistan Health Research Center, & World Health Organization. (n.d.). National Hepatits Strategic Framework (NHSF) for Pakistan
2017-21. https://www.globalhep.org/sites/default/files/content/action_plan_article/files/2020-04/Pakistan--national-hepatitis-
strategic-framework--09-01-2018.pdf
2. Institute of Health Metrics and Evaluation (IHME). Global burden of Disease Study 2019. https://www.globalhep.org/country-
progress/pakistan
3. WHO and UNICEF. Hepatitis B vaccination coverage, WHO Immunization Data portal. https://immunizationdata.who.int/pages/
coverage/hepb.html?CODE=PAK&ANTIGEN=&YEAR=
4. Ministry of National Health Services, Regulation and Coordination Government of Pakistan. (2015, March 31). Pakistan Global AIDS
Response Progress Report (GARPR) 2015. UNAIDS. https://www.unaids.org/sites/default/files/country/documents/PAK_narrative_
report_2015.pdf
5. WHO (2021). Accelerating access to hepatitis C diagnostics and treatment. https://www.who.int/publications/i/
item/9789240019003
6. Chhatwal J. et al. (2019). Assessment of the Feasibility and Cost of Hepatitis C Elimination in Pakistan. JAMA network open, 2(5),
e193613. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6512462/
7. WHO. HBV Country Profiles: Pakistan. https://whohbsagdashboard.surge.sh/#hbv-country-profiles
8. HepCoalition. (n.d.). mapCrowd. https://mapcrowd.org/en/compare-data
9. MedsPaL. (n.d.). MedsPaL Database. https://www.medspal.org/?countries%5B%5D=Pakistan&disease_
area%5B%5D=Hepatitis+C+(HCV)&page=1
10. Roche Diagnostics. Partnering for positive change in Pakistan. https://diagnostics.roche.com/global/en/c/heptatitis-elimination-
pakistan.html
11. Butt AS (2015). Epidemiology of Viral Hepatitis and Liver Diseases in Pakistan. Euroasian journal of hepato-gastroenterology, 5(1),
43–48. https://doi.org/10.5005/jp-journals-10018-1129 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5578520/
12. Georgetown HIV Policy Lab. Pakistan. https://hivpolicylab.org/pk/
13. Harm Reduction International. Global state of harm reduction: 2019 updates. https://www.hri.global/global-state-of-harm-
reduction-2019
14. Kamani L, Ahmad BS, Kalwar HA (2020). Hepatitis-C Infection: Are we really committed to eliminate? Could it become the second
Polio for Pakistan?. Pak J Med Sci; 36(7):1742-1744. doi:10.12669/pjms.36.7.2804 https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC7674893/#ref5
15. Qureshi H, Bile M, Jooma R, et al. (2010). Prevalence of hepatitis B and C viral infections in Pakistan: findings of a national survey
appealing for effective prevention and control measures. Eastern Mediterranean health journal = La revue de sante de la Mediterranee
orientale = al-Majallah al-sihhiyah li-sharq al-mutawassit, 16 Suppl, S15–S23. https://pubmed.ncbi.nlm.nih.gov/21495584/
16. Government of Pakistan and WHO (2020). Guidelines for the Treatment of Persons Chronically Infected with Hepatitis C. https://
phrc.org.pk/assets/pakistan-national-hcv-treatment-guidelines-sample-2.pdf
17. Abbas Z et al. (2010). Management of Hepatitis B: Pakistan Society for the Study of Liver Diseases (PSSLD) Practice Guidelines.
Journal of the College of Physicians and Surgeons Pakistan. Vol. 20 (3): 198-20 https://www.jcpsp.pk/archive/2010/Mar2010/14.pdf
18. Data provided by Dr. Huma Qureshi, Pakistan National Focal Point for Hepatitis,.
19. Presentation by Dr. Huma Qureshi, Ex-Executive Director Pakistan Medical Research Council, Pakistan National Focal Point for
Hepatitis. International Meeting for Viral Hepatitis Elimination 2021 (December 3rd).
20. APEX Consulting (2019). Final Report - Population based Prevalence Survey of Hepatitis B&C Punjab, 2018. Data provided by Dr.
Huma Qureshi, Pakistan National Focal Point for Hepatitis, on 10 March 2022.
21. CDA Foundation (2021). Modeling for Pakistan Ministry of Health. Data provided by Dr. Huma Qureshi, Pakistan National Focal
Point for Hepatitis, on 10 March 2022.
PAKISTAN • HEPATITIS ELIMINATION PROFILE

22. WHO (2018). Progress on Access to Hepatitis C Treatment. https://apps.who.int/iris/bitstream/handle/10665/260445/WHO-

CDS-HIV-18.4-eng.pdf?sequence=1
23. Qureshi H (2020, unpublished). Prevalence of HCV in Sindh Province, Pakistan. Data provided by Dr. Huma Qureshi, Pakistan
National Focal Point for Hepatitis, on 10 March 2022.
24. Balochistan Hepatitis Screening from Dr. Gul Sabeen Azam Ghorizai 210713 (unpublished). Data provided by Dr. Huma Qureshi,
Pakistan National Focal Point for Hepatitis, on 10 March 2022.
25. Ministry of Health (2020). Prime Minister’s Programme for Elimination of Hepatitis C: Annexures to Programme PC-I. Data
provided by Dr. Huma Qureshi, Pakistan National Focal Point for Hepatitis, on 10 March 2022.
26. Unpublished data from provincial hepatitis control programmes (public sector data), shared by Dr. Hassan Mahmood 200728 and
provided by Dr. Huma Qureshi, Pakistan National Focal Point for Hepatitis, on 10 March 2022.
27. Lim AG, Scott N, Walker JG, Hamid S, Hellard M, Vickerman P (2021) Health and economic benefits of achieving hepatitis C virus
elimination in Pakistan: A modelling study and economic analysis. PLoS Med 18(10): e1003818.

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28. Israr M, Ali F, Nawaz A, Idrees M, Khattak A, Ur Rehman S, et al. (2021). Seroepidemiology and associated risk factors of hepatitis B
and C virus infections among pregnant women attending maternity wards at two hospitals in Swabi, Khyber Pakhtunkhwa, Pakistan.
PLoS ONE 16(8): e0255189. https://dx.plos.org/10.1371/journal.pone.0255189
29. Ahmad I. (2016). Prevalence of Hepatitis B and C Viral Infection Among Pregnant Women in Peshawar, Pakistan. Hepatitis monthly,
16(6), e36383. https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/27630725/
30. Nai Zindagi Trust. Last accessed 24 May 2022. https://www.naizindagi.org/prevention-and-harm-reduction/
31. Drug Regulatory Authority of Pakistan (DRAP). Products. Last accessed 25 May 2022. https://public.dra.gov.pk/rd/HTMLClient/
default.htm
PAKISTAN • HEPATITIS ELIMINATION PROFILE

WORKING TOGETHER,
WE WILL ACHIEVE ELIMINATION.
This National Hepatitis Elimination Profile (N-HEP) was developed by the Coalition for FOR MORE INFORMATION:
GLOBALHEP.ORG
Global Hepatitis Elimination. Funding for this N-HEP was provided by Gilead Sciences. [email protected]
The Coalition for Global Hepatitis Elimination retained final control over the content.
TASKFORCE.ORG
The Coalition thanks Dr. Huma Qureshi, the National Viral Hepatitis Focal Point, 330 W. PONCE DE LEON AVENUE
Dr. Saeed Hamid from Aga Khan University, and Parsa Trust for their input and DECATUR GA 30030
feedback on the development of this National Hepatitis Elimination Profile.

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