How far is Pakistan in HCV elimination?

Dr Huma Qureshi (TI)

Gastroenterologist

Focal Point Hepatitis

Prevalence of hepatitis B & C in Pakistan (2005)

• Hepatitis B• 2.5% (4 million people)

• Hepatitis C• 5% (8 million People)

• Children and Adolescents• Under 5 years: 1.9%

• 5-17 years: 2.1%

• Total: 2.0%

Estimated HCV Infection Burden by Country (2014)

Gower E, Estes CC, Hindman S, Razavi-Shearer K, Razavi H. Global epidemiology and genotype distribution of the hepatitis C virus. J Hepatology 2014.

Pakistan: largest HCV prevalence country in the world

Risk factors for hepatitis C (2005)

Risk Factors No. of Subjects HCV No. (%) OR (95% C.I.)

Blood Transfusion No 46,640 2,235 (4.8) Reference

Yes 403 69 (17.1) ** 4.1 (3.1 – 5.4)

Use of Injections None 10,987 402 (3.7) Reference

>10 2,941 244 (8.3) ** 2.4 (2.0 – 2.8)

History of Hospitalization No 44,757 2,070 (4.6) Reference

Yes 2,286 223 (9.8) ** 2.2 (1.8 – 2.4)

Dental Treatment No 46,347 2,231 (4.8) Reference

Yes 696 63 (9.1) ** 2.0 (1.5 – 2.6)

History of Surgery No 45,189 2,135 (4.7) Reference

Yes 1,854 159 (8.9) ** 1.9 (1.5 – 2.2)

Estimated HCV Incidence (1950 – 2015)

Homie Razavi, APASL STC, Karachi, October 2014

240,000 new infections/year

Time to move in the right direction!

Provincial Action Plans

• Out of 4 Provinces

• Action plan developed for 2 major Provinces

HCV: Modelling to set Treatment Targets for Disease Elimination

• For Pakistan hepatitis modelling was done by University of Bristol, UK & funded by CDC, USA

• To assess the epidemiology of HCV in Pakistan

• Set the targets for HCV elimination by 2030

If We Continue What We Are Doing

Modelling for 2005 to 2030 demonstrates:

• HCV prevalence will rise• data from Punjab surveys 2005 and 2016 demonstrates increasing

prevalence

• Incidence will increase by 21.3%

• Only 24% shall be cured by 2030

• HCV related mortality will increase by 31.7%

Proposed 4 Scenarios For Screening & Treatment 1. To undertake passive screening for all population + perform

active screening of high hepatitis prevalence districts

2. To undertake passive screening of all population + undertake active screening of all >30 years persons

3. To undertake active one time screening of all population

4. Active one time screening of whole population and refer >90% cases for treatment plus reduce the risk factors by 50%

Modeling Study for PakistanTo achieve WHO 2030 elimination targets

2016 2017 2018 2019 2020 2021 ≥2025

Treated 160,700 208,000 208,000 260,000 400,000 400,000 475,000

New infections 211,000 211,000 211,000 105,000 21,000 21,000 21,000

Newly diagnosed 101,000 202,000 202,000 323,000 430,000 430,000 509,000

Fibrosis stage ≥F0 ≥F0 ≥F0 ≥F0 ≥F0 ≥F0 ≥F0

Treated age 15 – 74 15 – 74 15 – 74 15 – 74 15 – 74 15 – 74 15 – 74

SVR 67% 83% 83% 83% 90% 90% 90%

Reduce risk factors by 50%

Working on• Safe blood- German Government support-National Blood transfusion

Authority. Most blood was coming from private blood banks that were not screening properly. Most private blood banks are being closed

• Safe injections- with 8 inj/person/year, there is huge demand for syringes. To avoid syringe reuse, autodisable syringe is being produced locally

• Infection control- 14 hospitals being made as patient friendly and safe model hospitals

• Treatment as Prevention for PWIDs & MSM• Plus NSPs, education, etc.

National HCV Testing & Treatment Guidelines 2018

Anti HCV+ NAT NAT+

CP,ASTAPRIDAAs

NAT at 12 wkspost

treatment ?

Intention to treat all

No genotypingNo quantification of virusNo fibroscansOver 70% cost reduced

Very Affordable Pangenotypic Treatment

SOF+DCV-2016=$ 25/12wk

VAL-2017=$140/12wk

PG

PG

Reaching Targets Provides Value

• Financial modeling has shown that investment in aggressive testing and treating plus prevention will yield results within 3 years!

• Large drop in disease and complications

• Costs incurred for care and management decreases concurrently

Prime Minister’s Program on HCV testing & treatment using scenario 4

Program shall be rolled out in June 2020

• Total Population = 200 million

• Screen 140 million (exclude <12 years)

• with 10% anti-HCV +ve = 14 million

• 90% will undergo NAT testing = 12.6 million

• 80% NAT +ve = 10.1 million. They will require treatment to cure

Pakistan’s model of care- Public + Private Partnership• Revolves around the District Headquarter Hospital (DHQ)

• 25% DHQs has fully automated HCVRNA machines (roche,abbott)

• All DHQs have geneXpert machines used by TB program

• Basic health units, private doctors and private hospitals shall screen both actively and passively using RDTs supplied by the government

• All testing and treatment sites shall have a software with unique identifier for each case to ease tracking

• All anti HCV + cases shall be referred to DHQ for HCVRNA and start of treatment if RNA is detected

Model of HCV Elimination in Slums of Islamabad Capital Territory

Collaborating

Partners

Slums of Islamabad

• Marginalized populations

(7 slums) Pop=54,000

France Colony, Islamabad

Known Risk Factors in Pakistan

Frequent intramuscular (IM) injections (injection safety)

Blood transfusion (unsafe blood)

Surgery, dental treatment, hospitalization, shaving at barbers (poor infection control)

People with risky behaviors like PWIDs, MSM, HIV/AIDS, and Sex Workers

Methodology • A male & female community health worker (CHW) enumerate the houses

• List all family members & their ages

Community Health Workers (CHWs)

• CHWs are selected from the same slum

• They are trained by CSO (THF)

• CHWs go door to door daily to screen for high-risk individuals

• Conduct rapid HCV test and refer HCV positive patients to health facility

• They revisit houses of missing individuals same day and next day (up to 3 total visits)

Dedicated Health Facilitylike a DHQ

• Two rooms of a Federal government dispensary are dedicated to this project

• All supplies (RDT, NAT, Medicines, HBV vaccine) are supported through the project

• The health facility is equipped with:• GeneXpert for NAT

Hematology analyzer

• Biochemistry analyzer

Laboratory Equipment

Same Day Testing & Treatment Initiation!

Anti HCV +ve person referred from community to the Health Facility

Blood is taken for NAT, CBC, and AST

NAT on GeneXpert is reported in 90 min; Patient waits for 2 hours to get results

APRI calculated

NAT +ve patients: given HBV vaccine & treated as per National HCV guidelines (SOF+DAC)

APRI < 1.5 = no cirrhosis (12-week treatment)APRI ≥ 1.5 = cirrhosis (24-week treatment)

Simplified Treatment Management

0weeks

4 weeks

8weeks

12weeks

24weeks

NAT yes x x x yes

CBC yes x x x x

AST yes x x x x

Clinical Assessment

yes

Medication Visit*

yes yes yes

*For 12-week regimen; For 24-week regimen, 3 additional visits.

Data Management

• Questionnaires and RDT result brought to the health facility by CHWs

• Data entered into Excel • Beginning Dec 2019, electronic cloud-based data

recording shall start using tablets in partnership with the University of Maryland’s Institute of Virology

• Data analysis and management by IGH and CDC USA

Preliminary Results

30

Note: Total number of individuals tested for HCV is N=2,288. There are 25 patients currently on treatment.

Preliminary Conclusions

• Door to door HCV testing appears to be effective way of screening

• None previously treated

• High rate of linkage to care

• Same day test and treat model decreases drop out

• CHWs are key to access and linkage to care of marginalized populations

• CHWs belong to same communities they work in, resulting in trust and engagement

Strengths

• All screening, testing & treatment is free for patients through the project

• Non-transient population

• Same day reporting has reduced patient lost to follow up and improved cascade of care

Conclusions• Where are we now?

• Pakistan has a huge HCV disease burden

• We have to catch up the race to achieve elimination

• DAAs are cheap and effective

• To win the race….• Urgently work on reducing the risk factors by 50%

• Screen, test and treat millions (the model of public private partnership with same day testing will work best)

• Robust information systems can monitor progress and identify gaps

Partnerships will be critical

• Federal and Provincial health departments

• Private sector

• Academic

• Technical

• Civil Society/NGOs

• Corporations

• Pharma and Diagnostics

• Funders: Asian Development Bank, World Bank

Thank you to all our partners!

Thank You!!!!!!