Hepatitis C Virus in Pakistan: Community Education Is an Effective Weapon Against the Killer

Chronic hepatitis and HIV risks amongst Pakistani migrant men in a French suburb and insights into health promotion interventions: the ANRS Musafir qualitative study

BACKGROUND

Seine-Saint-Denis is a deprived departement (French administrative unit) in the North-East of Paris, France, hosting the majority of South Asian migrants in France. In recent years, the number of migrants from Pakistan, which has a high prevalence of hepatitis C globally, increased. As a corollary, this study addressed the high proportion of Pakistani patients in the infectious diseases clinic of a local hospital, diagnosed with hepatitis C, but also hepatitis B and Human Immunodeficiency Virus (HIV). It explored genealogies and beliefs about hepatitis and HIV transmission, including community, sexual and blood risk behaviours. The aim was to understand the ways these risk factors reduce or intensify both en route and once in France, in order to devise specific forms of community health intervention.

METHODS

The study took place at Avicenne University-Hospital in Seine-Saint-Denis, and its environs, between July and September 2018. The design of the study was qualitative, combining semi-structured interviews, a focus group discussion, and ethnographic observations. The sample of Pakistani participants was selected from those followed-up for chronic hepatitis C, B, and/or HIV at Avicenne, and who had arrived after 2010 in Seine-Saint-Denis.

RESULTS

Thirteen semi-structured interviews were conducted, until saturation was reached. All participants were men from rural Punjab province. Most took the Eastern Mediterranean human smuggling route. Findings suggest that vulnerabilities to hepatitis and HIV transmission, originating in Pakistan, are intensified along the migration route and perpetuated in France. Taboo towards sexuality, promiscuity in cohabitation conditions, lack of knowledge about transmission were amongst the factors increasing vulnerabilities. Participants suggested a number of culturally-acceptable health promotion interventions in the community, such as outreach awareness and testing campaigns in workplaces, health promotion and education in mosques, as well as web-based sexual health promotion tools to preserve anonymity.

CONCLUSIONS

Our findings highlight the need to look at specific groups at risk, related to their countries of origin. In-depth understandings of such groups, using interdisciplinary approaches such as were employed here, can allow for culturally adapted, tailored interventions. However, French colour-blind policies do not easily permit such kinds of targeted approach and this limitation requires further debate.

Prevalence and Treatment of Untypable HCV Variants in Different Districts of Punjab, Pakistan

In Pakistan, around 11 million people are infected with, at least, six circulating genotypes and subtypes of hepatitis C virus (HCV). The viral burden is still on rise. HCV genotype determination is necessary to devise appropriate antiviral therapy. Previous reports highlight the prevalence circulating untypable (in diagnostic perspectives) HCV subtype in local Pakistani patients. Present study was designed to investigate the epidemiological distribution of genotypes in different districts of Punjab, Pakistan and focuses on prevalence of diagnostically untypable subtype and its possible antiviral therapy. A total of 8,353 HCV patients were included through 2011 to 2016 for determination of HCV prevalent genotypes in the local community. HCV genotyping was carried out using Ohno et al. method, and five cases of diagnostically untypable patients were treated with interferon-based antiviral regimen to find the possible treatment strategy. Of the 8,353 patients, the genotype 3a (n = 6,650, 79.6%) was most significantly prevalent throughout the study period followed by undetermined genotype that is, untypable (n = 1,377, 16.5%). The presence of untypable variants suggested that there are some novel or quasi species prevailing among HCV patients in local community. Five HCV patients infected with untypable genotype had been treated effectively with interferon alpha plus ribavirin therapy for 24 weeks at standard doses and achieved sustained virological response. This study highlighted an important aspect of HCV treatment for local Pakistani HCV patients. Untypable HCV variants could be treated with interferon-based antiviral regimens such as 3a genotype. The study raises the need of characterization of diagnostically untypable HCV variant. On the basis of these results, it can be proposed that until the availability of pangenotypic direct-acting antiviral for HCV treatment in Pakistan, interferon-based antiviral regimens will be of choice for majority of patients infected with 3a or untypable genotypes.