Hepatitis C is Asia’s silent emergency
Produced in collaboration with
Published 28 July 2021
Hepatitis C (HCV) is a life-threatening bloodborne virus that attacks the liver. Around 170 million people live with HCV today. Most live in Asia, with China, Pakistan, India, and Egypt making up 40 percent of all reported cases.
COVID-19 has made things worse by keeping people at home and hampering routine HCV testing and treatment. Those who contract hepatitis C during the pandemic may only get diagnosed much later, when HCV has become both chronic and deadly.
How many people die from infectious diseases each year?
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Each represents 20, 000 deaths
A slow simmer; a fatal blow
Hepatitis C has no obvious symptoms in its early stages. Nobody knows if a HCV-infected person will succumb to sudden, debilitating liver disease or whether the virus will take its time.
This makes it hard to detect and treat. Many infected people live unaware that they are HCV carriers because several countries lack national screening mechanisms.
Without treatment, around 30 percent of those with HCV clear the infection within six months. If the virus persists, the remaining 70 percent will develop chronic HCV. It’s often only after a decade or longer, when cancer or liver failure strikes, that people realise they’ve had it this whole time.
How many people are chronically infected with hepatitis C, as compared to HIV?
Each represents 250,000 people.
How does one get infected with hepatitis C?
Hepatitis C spreads when one is exposed to small quantities of blood or bodily fluids containing the virus. Unsafe injection practices, needle sharing, unscreened blood transfusions, sexual contact, and childbirth are the most common ways. Even getting a piercing or tattoo with unsterilised equipment is risky.
Asia: A hepatitis C hotbed
In Asia, poor public awareness of HCV’s risks and transmission methods has left many people undiagnosed and untreated.
Unsafe injections in both healthcare and non-healthcare settings are the main cause of transmission here in Asia. Today, around 60 percent of intravenous drug users are infected with HCV. A third of all HCV-related deaths come from sharing needles while injecting drugs. In Asia’s resource-strapped, low-income countries, blood transfusions are also not widely available, and reusing needles and syringes for medical procedures has worsened the problem.
Culture contributes to hepatitis C’s spread
Traditional healers and unlicensed medical practitioners across Asia also risk infecting their patients if they perform invasive procedures with dirty or unsterilised equipment.
In Cambodia, spiritual healers use sharp tools to release blood in rituals believed to ward off evil or remove spells. Ceremonial rituals and traditional procedures in Pakistan—such as hijama, a form of wet cupping that involves drawing blood—risk exposure to contaminated blood.
Cosmetic and tattoo parlours and home-based beauty services are popular in Asia, and beauty and grooming treatments may expose customers to infected blood. Vietnam, for example, recognised beauticians and hairdressers as a vulnerable group and required them to get trained in hepatitis C prevention.
Inequality puts hepatitis C’s detection and cures out of reach
Only a fraction of the 58 million people infected with chronic HIV are receiving treatment. Outrageously high prices have put lifesaving direct-acting antiviral (DAA) drugs—a new type of oral medication for hepatitis C produced by big pharmaceutical companies—out of reach for millions in middle- and low-income countries.
For instance, American biopharmaceutical company Gilead Sciences charged a whopping $1,000 per tablet when it launched the HCV drug sofosbuvir (SOF) in 2013. Another multinational company, Bristol-Myers Squibb, charged $750 per tablet for its HCV drug daclatasvir (DCV).
Today, generic versions of Gilead’s HCV drugs—which the company introduced as cheaper alternatives—are priced at $24,000 for a standard course of treatment.
Countries need high-quality rapid tests to scale up HCV screening and treat the infected in just 12 weeks. But measuring the amount of hepatitis C virus in the blood (RNA testing), is still complex and expensive. This makes it hard to identify and focus on who carries the chronic infection at a large scale—especially in countries with weak healthcare systems and financing.
These countries are forced to reserve HCV drugs for late-stage patients only. Even worse, drugmakers have restricted access by refusing to offer cheaper varieties of their drugs to middle-income countries with a high HCV burden—which they see as profitable, untapped markets. Even wealthier countries struggle to afford the more expensive drugs, and HCV patients who cannot pay are forced to live without a cure.
Nowhere is this more stark than in Pakistan and Bangladesh, where international humanitarian organisation Médecins Sans Frontières (MSF) works to make HCV care more affordable and available to the most underprivileged communities.
Pakistan: The struggle for access to healthcare
At the edge of the Port of Karachi lies Machar Colony, a dilapidated settlement in Pakistan’s capital. Its residents, many of whom work as fishermen or labourers in the fishing industry, have little access to healthcare and basic amenities. Clean water is scarce.
This is what happens when someone contracts hepatitis C in the Machar Colony
The biggest hurdle for those with hepatitis C lies in getting cured. Lack of knowledge on the disease and limited access to affordable healthcare lead many to believe that HCV is a death sentence. The hidden costs of treatment also deter people from getting treated.
Living with hepatitis C can be traumatising, and patients need support from the people around them. Patients and their families deeply fear the disease’s consequences and the chance of infecting others. This severe emotional toll leaves many HCV patients anxious or depressed.
Ahmed
Ahmed is part of the Bengali community in Machar Colony and works in the local fishing industry. After being diagnosed with hepatitis C, Ahmed made sure everyone in his household was tested for the virus. All the tests came back negative.
At night when I’m in bed and about to fall asleep, I feel dread and claustrophobia. I break into a sweat. The only thing that helps is going outside for a walk and having the cool, fresh air against my skin. When I come back in I start feeling anxious again and I stay awake. I have to keep going back outside to get relief, but it’s a burden on the entire household.
For a poor man it’s hard to receive treatment that can cost up to Rs150,000 (over US$2000). But I urge anyone with this illness to seek help immediately and to get themselves treated by a doctor.
Juma Gul
It has been two years now since Juma Gul, 40, was cured of hepatitis C. Upon the insistence of a friend who had been cured of the disease, he enrolled and began his three-month treatment. He remembers how he had felt when he first received his diagnosis.
I knew it was a dangerous illness. I couldn’t control my breathing and started hyperventilating upon hearing that I had it. I had found out about it but what good was that going to do me? I didn’t know what would happen next. Everyone is scared of this illness, not just me. Everyone. Whoever finds out they have it, they lose their peace of mind. They wonder, what will happen now? What will become of me? I’ve seen it happen. Three or four boys with bloated stomachs [who had advanced hepatitis C] died within a few months.
Asif Ali
When 19-year-old university student Asif Ali was diagnosed with hepatitis C, he was overwhelmed with fear and anxiety. One of his relatives, who had previously been diagnosed with and cured of hepatitis C, recommended that Ali visit the MSF clinic. Ali, who lived in another colony, began visiting the clinic regularly for treatment.
I was terrified. I didn’t know anything about hepatitis C. Everyone told me that this disease is something very unusual and not a regular illness. I was very scared. I have no idea about how or where I could have caught it.
Noor Alam
Noor Alam is the first patient to be cured of hepatitis C at MSF’s clinic. Approximately seven years ago, Noor Alam started to experience severe pain in his body, and discovered he was infected with hepatitis C through a local clinic. He subsequently had to sell his house to pay for treatment. Despite facing financial ruin and with a young family to feed, Noor Alam was not cured after two courses of treatment, and his condition started to deteriorate. As a migrant from Bangladesh, Noor Alam does not have access to advanced medical treatment in the government health system.
Last year, Noor Alam heard about the MSF clinic in Machar and started treatment there. During this period, he was forced to send his three eldest daughters to work in the shrimp peeling market so that the family would have food for the day. The girls were unable to continue their education.
Bangladesh: The undocumented face even higher barriers to treatment
In 2015, pharmaceutical giant Gilead granted a voluntary license for poor countries to procure cheap, generic copies of sofosbuvir on one condition: patients must provide proof of citizenship and residency in their countries.
The move instantly penalises refugees and undocumented migrants, many of whom live in overcrowded refugee camps with little to no access to basic necessities.
Environmental barriers to getting healthcare
Cox’s Bazar is home to the world’s largest refugee settlement. Around 900,000 Rohingya refugees live in the sprawling Kutupalong-Balukhali camp and the surrounding settlements in harsh conditions, after fleeing violent persecution in Myanmar’s Rakhine State.
An army road runs through the middle of the camp, while a highway curves around the border separating the refugee settlement from the outside world. People travel on these two routes by hopping on auto-rickshaws (CNGs), a popular local mode of transport and the cheapest way to get around.
Several clinics and other health facilities built by local and international NGOs operate in Cox’s Bazar—but only a few test and treat hepatitis C. Earlier this year, a massive fire destroyed MSF’s Balukhali clinic, along with homes and other humanitarian infrastructure. The flimsy materials of makeshift houses mean fires spread rapidly across the camps.
Three MSF clinics treat hepatitis C in Cox’s Bazar, including its newest facility at the settlement’s heart: the hospital on the hill. Opened in 2018, it offers a wide range of medical services to both Rohingya refugees and local Bangladeshis living in the surrounding areas.
Although camp residents can take a CNG on the main road to the hospital, most walk there or are referred to the closest clinic. These journeys on foot can take 40 minutes to an hour.
Walking to get a health check-up or access emergency medical aid is hard—and the monsoon season makes it worse. Heavy rains wash away the makeshift roads connecting the camps. People slip on mud staircases carved into steep hillsides. Extreme weather triggers deadly landslides.
Challenging Big Pharma
Hepatitis C epidemics have swept the world several times in modern history. Yet, there remains no international funding for testing and treating it. Countries must tackle the silent killer with domestic funding.
However, a few middle-income countries such as Egypt, India, and Malaysia have started to domestically finance their HCV programmes. By rejecting drugmakers’ patent applications for their drugs, these countries are able to produce cheaper generic medication and rapidly scale up HCV treatment.
As an NGO, MSF has fought to make HCV treatment more affordable. Through its Access Campaign, MSF purchases HCV drugs at a much lower cost—US$75 for a 12-week treatment course. Since 2017, MSF has offered free diagnosis and simplified treatment in several countries with a high burden of hepatitis C.
Cambodia: Simplifying the long, complex road to recovery
At Preah Kossamak Hospital in Phnom Penh, MSF has been working with the Cambodia Ministry of Health since 2016 to simplify hepatitis C treatment and make it more accessible.
Patients previously had to make 8 visits to the clinic over the span of 140 days just to begin treatment. MSF’s new model of care has drastically cut the number of consultations and steps needed.
Previous model of care (2017):
Initiation (screening, testing and consultations before treatment starts)
140 days
Care pathway
Patients receiving treatment now only need 5 medical consultations instead of 16, easing the cost and stress of a drawn-out treatment period. All patients who have not reached the critical stage of cirrhosis receive the same treatment. The new model, in which nurses rather than doctors start the process, doesn’t need multiple scans and blood tests for pre-treatment analysis. This reduces the need for doctors and enhances the effective role of nurses throughout the process.
Simplified model of care (2020):
Initiation (screening, testing and consultations before treatment starts)
7 days
Care pathway
It all comes down to unequal access to healthcare
MSF’s work with Asia’s most vulnerable communities has shown that a shorter and affordable model of treatment for hepatitis C is possible and scalable. Yet, many treatment regimens around the world remain unattainable. Many people still fork out huge sums for HCV drugs or make arduous journeys just to get to a hospital.
Without improved access to HCV diagnosis and treatment, stemming the spread of hepatitis C and ending the pain of those suffering remains an uphill battle.
In the long run, a decentralised model of treatment will bring treatment to people in remote areas across the region. Local clinics able to both test and treat HCV near people’s homes will save many more lives. Better health financing as well as training workers in healthcare and occupations with regular exposure to blood will help, too.
The gulf between those who can afford treatment and those who suffer in silence is at the root of the HCV epidemic. The disease can only end if the world commits to lifting the burden of unequal access to healthcare from its most deprived.
What can you do to prevent the transmission of hepatitis C?
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A message from our partner
Member states of the World Health Organisation have committed to eliminating HCV by 2030. To do this, people living with HCV need strong leadership from different countries to upscale HCV diagnosis and treatment. This also means implementing sustainable financing mechanisms that ensure HCV patients can access this. Pharmaceutical companies must also commit to making HCV drugs more affordable and accessible to all.
If you’d like to know more from MSF about why hepatitis C is a silent epidemic, visit https://msf-seasia.org/hepatitisc.
