Treating hepatitis C in Pakistan. Strategies to avoid resistance to antiviral drugs

Hepatitis C infection can be cured by affordable drugs, leading to calls to expand treatment among the 70 million infected people worldwide. Many countries have initiated ‘test and treat’ programmes. e.g. India have reported treatment for ~40,000 patients in Punjab. However, 5-10% of infected people don’t respond and may develop viral resistance and go on to develop liver cancer. Salvage regimens are often unaffordable/unavailable. We will address the remaining questions in hepatitis C therapy. We will work in Pakistan where hepatitis C is highly endemic (4.8% sero-prevalence) with regions reaching sero-prevalences of 10-20% (hot-spots). We will link with the government HCV programme to determine the most effective treatment for people who don’t respond to initial therapy. We will examine viral resistance in treatment failures to determine whether resistance dissemination is problematic and develop strategies to address it. We will determine whether some viruses are more oncogenic, allowing targeted surveillance. We will measure incident infection in the uninfected population (in hot-spot areas) and treated people, using modelling to determine what proportion of people must be cured to prevent disease recurrence. These data will inform the global elimination agenda and provide crucial data to develop optimised elimination programmes.