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WHO data estimates 325 million patients suffering from Hepatitis B or C worldwide and 1.34 million deaths due to this. Pakistan is among the highest prevalence countries. There are several causes for such a high incidence, but the underlying factors are illiteracy, lack of awareness and an attitude of ill-conceived notions of bravery and fatalism in the society. We don’t know how to protect ourselves against such viral infections and we refuse to protect us and those around us even when we know.
As I mentioned in my last blog, Hep C started becoming known in 1990s. Initially there was ambiguity about what it was and what had to be done with it. As the information base grew, there was greater understanding. Introduction of Interferon by Roche and Schering Plough also became a major source of dissemination of information about Hep C and its treatment. By the time Hep C started getting diagnosed, a lot of people were already infected for long and were at advanced stages of disease. All of a sudden, many people appeared to be dying of Hep C and it became a huge scare.
Interferon and ribavirin combination helped to stem the tide of deaths. It brought a great promise of viral eradication, chances of survival and improved life expectancy. Pakistan had Hep C epidemic and was also declared endemic area for Hep C. We were among the highest incidence countries; probably, only Egypt was ahead of us. An epidemic of such proportion required an equal kind of effort to tackle. Pakistan certainly did it. The government, healthcare organizations, physicians, private sector, international donor agencies, NGOs and local people, all contributed to the effort. We are still far from the goal of eradicating Hep C, but the achievements so far should not be underestimated.
Initially, interferon therapy was quite expensive. Three injections a week for six months plus ribavirin at cost was close to couple of hundred thousand which was not in the access of majority. With the availability of generic interferon and free ribavirin, the cost of interferon came down steeply. Federal government purchased interferon in large quantity under Prime Minister scheme and made it available free of cost at designated hospitals. This brought the price further down. Soon, the total interferon + ribavirin therapy would cost just a few thousand rupees.
Regular interferon was then replaced by Peg-interferon which promised better results but increased the cost of treatment many times, once again. The generic versions of Peg-interferon were few and far between. Those who could afford got Peg-interferon and those who could not got regular interferon. Ribavirin was included in both cases.
Peg-interferon did not have a long rule though. Sovaldi (sofosbuvir) was introduced in the developed world as the first all oral treatment for Hep C. It cost 100 US dollars per tablet and total treatment of 12 weeks cost 8,400 USD. It was impossible kind of cost for Pakistan’s general population. Gilead, the innovator company made it available in Pakistan at 10% of US cost. It was still expensive but affordable for larger number of people. Local Pharma developed generic sofosbuvir preparations but were not granted registrations by the DRAP for quite some time, for reasons best known to them. There were many public explanations circulating among public for this delay. Finally, DRAP allowed couple of companies to introduce generic sofosbuvir.
Currently, several generic sofosbuvir preparations are available. The total treatment cost may be as low as under 10,000 rupees.
Soon after, Gilead introduced sofosbuvir + ledipasvir combination and followed it up with sofosbuvir + velpatasvir combination. More are expected to come.
The all-oral therapies promise 100% viral eradication thereby eliminating/minimizing risk of relapse.
The face of Hepatitis C menace has taken several shapes. We have made great strides and achieved decent milestones but there is still a long way to go. Our achievements are greater on the treatment side. Prevention needs more focus to minimize the incidence of new cases.