HCV Elimination – Pakistan’s Blueprint for 2030

This is a verbatim transcript of an interview conducted with Dr Huma Qureshi in July 2026. The transcript has been lightly edited for clarity.

Introduction

I am Dr Huma Qureshi, I am a consultant hepatologist, a researcher and I have worked as the Executive Director of the Pakistan Medical Research Council for 13 years. I am also the focal point for hepatitis for the government of Pakistan.

What is the current landscape of HCV elimination efforts in Pakistan?

So Pakistan has about 10,000,000 infected hepatitis C cases and the viral prevalence is about 4.3 % and therefore we are the country which has the largest hepatitis C infected cases in the world. There has been a dire need to address this issue and this was in 2005 that the Prime Minister of Pakistan launched a National Hepatitis Elimination Programme, which continued to 2011. Then in 2011, health was devolved to the provinces. Therefore, the national programme was converted into the provincial hepatitis programme with the funding from the provinces. This was an interferon era, you know and we have genotype 3 virus in our population. So our response to the interferon was only 50 %, with a very high relapse rate and very high hepatocellular carcinoma. Therefore, actually we could not show a value for money to the government.

Following the information of a very high disease burden in Pakistan, a special case was put up to the Prime Minister of Pakistan who launched a national Hepatitis C elimination programme where we are initially targeting people who are more than 12 years of age in the federally administered areas and this will be followed by the provinces which have a high HCV prevalence.

First of all is that we have developed our national electronic medical record system. Secondly, we have produced our own, locally, produced direct acting antivirals or the DAAs, which are at a very affordable cost. We have a partially decentralised health system for screening and for testing. We have also developed our hepatitis C treatment guidelines, which are so simple that even a primary care physician or a nurse can also treat these cases.

The biggest challenge is to call these people at the health facilities or at sites for screening, followed by sample transportation. We have got quite a few PCR machines to cater for the large number of people and the test. But if few people come daily for screening, then very few PCRs will come daily and therefore we have to generally wait for a sizeable batch and this delays the reporting.

So critical changes that have been made in the programme is that we have decentralised screening followed by reflex testing, where we do the same day testing and transportation of the test to the lab for PCR. All the reporting is done electronically on the EMR and all positive cases get a call from the call center to come to their primary site for treatment. Rationale is to bring the screening close to the community and make the sample move and not the patient.

Being a recently launched programme, it has some hiccups but we are still sorting them out. Due to financial constraints and low Internet connectivity and less human resource trained on EMR, we shall initially attend to the high infected districts in each province and then scale it up gradually.

What are the main clinical and logistical barriers to completing HCV diagnosis and what strategies could help improve access to testing?

Once you do the anti-HCV then you have to do the PCR and many a time we see that many patients get dropped because they don’t reach the health facility or they don’t get the PCR done. So as I told you earlier that all the screening was done at the district level and the anti-HCV positive patients had to go to the district or the provincial hospital for the PCR. This had multiple issues like access， travelling, travel expenditures, time lost, and then (operating) timing of the health facilities.

So now we are, what we have introduced is a rapid test followed by a reflex testing Pakistan has increased access to the HCV RNA to the sub-district level at many sites. Therefore more manpower is trained, and reporting is much quicker because the batch sizes are smaller and the patients are linked to the care very quickly.

Then I think the second option would be that we should integrate the screening of different tests like for TB, HIV and STIs and even hepatitis. If they could be integrated together and made available as a Multiplex, this could be a real breakthrough. And this could be done at the primary care site where most of these tests are point of care tests so that any healthcare technician with the minimal training can do that. Even screening at the pharmacies and even a self test are also options where the test could be done at a package without overburdening the system.

In Pakistan at least, we have got about 30 to 40 % people who go to the public sector, while about 70% go to the private sector. And when they go to the private sector, they are not only having a consultation there, but they also buy their medicines from the pharmacies. So once they go to the pharmacy, that’s about 70% of the people going to the pharmacies. so that that’s a simple outlet where one could do a simple point of care test maybe for Hepatitis B, Hepatitis C, HIV or STIs and that could actually really lower the burden of these people going to the public or the private sector health facilities.

What specific strategies do you use to keep patients engaged from a confirmatory diagnosis to the completion of treatment?

So actually, you know, people want to be connected to their healthcare person, maybe it is a nurse or a doctor or somebody who can respond to the queries. So by and large, we think that a connection through a call centre or a connection through a nurse is generally thought to be something that makes a difference and people want to be addressed that there’s somebody there to address their calls. So a connection, a very simple connection through a call or a call center I think might be one of the simple ways to keep the patients connected to the doctor.

So as you know that Pakistan is producing the DAAs which are generic. and this is kind of very cost effective and it has minimal side effects. So by and large you know, this is the regimen that we generally recommend to our patients and we see that they tend to adhere to the treatment because once first they start the treatment as the viral count goes down, they start feeling much better, so actually they tend to adhere more to the treatment because they start feeling with the viral count going down, they feel like as if they’re really you know coming back to life. So it’s kind of much, much easier that this is what we see in Pakistan that the adherence rate is quite good once you start them on treatment, but still from anti-HCV to the PCR, there’s a lag and that’s the time where we most of the time lose the patients and that’s where we are trying that we have a reflex testing which would shorten this gap and then put them on the DAAs and then after that it’s kind of easy to really complete the treatment.

So when previously with this very central system, there was a time lag of almost about a month to get a PCR report because you know, the patient had to go to a central lab and then they would give the sample there. And then the lab would continue to collect the samples to get a right batch size and then they would run it. So that generally used to take a month or maybe sometimes more than a month, so the reflex testing is that, you know, if somebody comes to a clinic and wants to get tested for hepatitis, then what we normally do is that we undertake our rapid point of care test which is through a finger prick. And if that test turns out to be reactive or positive, we make the patients sit in that time that the report is generated for the rapid test and if that rapid test is reactive, then straight away there’s a phlebotomist or a nurse, who undertakes venous blood and this venous blood is then transported to the main lab for testing.

Then we have this electronic system which kind of connects these results to the primary healthcare site, so the primary healthcare physician kind of knows whether who is positive or reactive or who’s not and that’s how they call them back and then put them on treatment. So the patients by and large does not move much. so this has really reduced the patient’s travel and is kind of very efficient in getting the test done at the right time.

Now what we see is that by and large we try to go in the community and test maybe a couple of hundred people in a day. So in that way we are able to get large size of maybe about 70 or 80 people who are found positive or reactive and we do the reflex testing, that we have a batch size of 50 to 70, blood samples that goes straight away through the lab, so that sample could be run the same day and we could we generally get a report within 2 to 3 days.

What is one key learning from Pakistan’s HCV elimination efforts you wish to share with the wider APAC community of practice?

Frankly, if you have funds, then what I would really recommend is that we should do one time universal screening of the whole population In Pakistan, we are using the public private model where the rapid test and the treatment is provided to a small portion of private sector by the (National) Hepatitis Programme while PCR is done by the (National) Hepatitis Programme. So this public private partnership has resulted in a wider access and large number of patients that are being treated. So I think the public private partnership should be really encouraged to improve the access and increase the diagnosis.

The views and opinions expressed by Dr Huma Qureshi are her own views and opinions. Roche disclaims all liability in relation to these views and opinions.