Management of chronic Hepatitis C at a primary health clinic in the high-burden context of Karachi, Pakistan

<div><p>Background</p><p>The burden of hepatitis C (HCV) infection in Pakistan is among the highest in the world, with a reported national HCV prevalence of 6.7% in 2014. In specific populations, such as in urban communities in Karachi, the prevalence is suspected to be higher. Interferon-free treatment for chronic HCV infection (CHC) could allow scale up, simplification and decentralization of treatment to such communities. We present an interim analysis over the course of February-December 2015 of an interferon-free, decentralised CHC programme in the community clinic in Machar Colony, Karachi, Pakistan.</p><p>Design</p><p>A retrospective analysis of a treatment cohort.</p><p>Results</p><p>There were 1,089 patients included in this analysis. Aspartate to platelet ratio index score was used to prioritize patients in terms of treatment initiation, with 242 patients placed in high priority for treatment and 202 starting treatment as scheduled. 169 patients started HCV treatment with Sofosbuvir-Ribavirin regimen according to HCV genotype over the course of 2015: of these, 35% had Hemoglobin reductions below 11.0 g/dl during the treatment course. Among the 153 patients (85%) with genotype 3 HCV infection, 84% of patients achieved sustained virologic response at 12 weeks following treatment completion (SVR 12).</p><p>Conclusion</p><p>Outcomes of HCV treatment with all oral combination in an integrated, decentralized model of care for CHC in a primary care setting, using simplified diagnostic and treatment algorithms, are comparable to the outcomes achieved in clinical trial settings for Sofosbuvir-based regimens. Our results suggest the feasibility and the pertinence if including interferon-free treatment regimens in the national programme, at both provincial and national levels.</p></div

Sociodemographic and characteristics of chronic Hepatitis C patients enrolled in a primary health care-based program for management of chronic Hepatitis C, Karachi, Pakistan; February to December 2015.

<p>Sociodemographic and characteristics of chronic Hepatitis C patients enrolled in a primary health care-based program for management of chronic Hepatitis C, Karachi, Pakistan; February to December 2015.</p

Conditions for treatment ineligibility and treatment deferral in a primary health care-based program for management of chronic Hepatitis C, Karachi, Pakistan.

<p>Conditions for treatment ineligibility and treatment deferral in a primary health care-based program for management of chronic Hepatitis C, Karachi, Pakistan.</p

Percentage of chronic Hepatitis C patients who developed anemia while on treatment in a primary health care-based program for management of chronic Hepatitis C, Karachi, Pakistan; February to December 2015.

<p>¹ WHO. Hemoglobin concentrations for the diagnosis of anemia and assessment of severity.</p

Treatment outcome definitions (adapted from the AASLD practice guidelines for Hepatitis C) and screening criteria for Hepatitis C risk factors in a primary health care-based program for management of chronic Hepatitis C, Karachi, Pakistan.

<p>Treatment outcome definitions (adapted from the AASLD practice guidelines for Hepatitis C) and screening criteria for Hepatitis C risk factors in a primary health care-based program for management of chronic Hepatitis C, Karachi, Pakistan.</p

Flowchart for diagnosis and treatment prioritization among CHC patients in a primary health care-based program for management of chronic Hepatitis C, Karachi, Pakistan; February to December 2015.

<p>¹ Initial clinical assessment rules out patients with known medical conditions contraindicated for treatment initiation such as decompensated cirrhosis, hematologic diseases, severe renal insufficency. ²Aspartate aminotransferase (AST) to Platelet Ratio Index ³Patients with low APRI scores (0.1–0.49), with co-infection (TB, HIV, and Hepatitis B), Pregnancy and Lactation ⁴Patients with APRI score 0.5–0.99 ⁵Patients with APRI above 1.0</p

Flowchart for treatment among chronic Hepatitis C patients in a primary health care-based program for management of chronic Hepatitis C, Karachi, Pakistan; February to December 2015.

<p>¹ Sofosbuvir 400mg/day + weight-based Ribavirin 800–1200 mg/day + Pegylated interferon 180 μg/week Subcutaneous for 12 weeks ² Sofosbuvir 400 mg/day +weight based Ribavirin 800–1200 mg/day ³ Sustained virological response (cure)</p

Characteristics of patients in the priority list for Hepatitis C treatment and risk factors for delayed start of treatment in a primary health care-based program for management of chronic Hepatitis C, Karachi, Pakistan; February to December 2015.

<p>Characteristics of patients in the priority list for Hepatitis C treatment and risk factors for delayed start of treatment in a primary health care-based program for management of chronic Hepatitis C, Karachi, Pakistan; February to December 2015.</p