 Good afternoon everyone. I hope you had a good lunch. I have the enviable task of getting you out of your food coma So I'm presenting on behalf of Demetro and the other the rest of the team in Karachi who's been doing wonderful work Unfortunately, none of them could make it here today The the the title of the abstract is submitted the work they're doing what I'm presenting today is hepatitis C treatment in a Primary health care clinic in the high hepatitis C virus burden setting of Karachi, Pakistan Just to give you some context So this is a map of Pakistan with hepatitis C seroprevalence in Pakistan at the district level Karachi is a city a coastal city and It's the largest Megapolis of the country. It's a financial hub. It's since 1947. There have been refugees migrants IDPs that have migrated there So it's quite a melting pot Hepatitis C infection in Pakistan to give you some background on that. There was a national prevalence survey conducted in 2007-2008 by Pakistan Medical Research Council of Hepatitis C virus antibody Seropositivity which showed it to be at 4.9 percent Later on between 2010 and 2015 a systematic review was also conducted Which showed an even higher adult Pakistani population prevalence of 6.8 percent However, given that the census in Pakistan hasn't been conducted since 1998 making large estimates is is difficult to do. It's not very Reliable I will however give you an idea based on current research provincial prevalence data varies Considerably in sin. So we have four provinces sinned. It's five percent Punjab It's six point seven percent Balochistan one point five percent and Khyber-Pakhtunkhwa not listed on the slide is one point one percent There are pockets of higher prevalence What I mean by that is that within the city? There's urban peri urban and rural You've got within districts as well as within the different provinces. So very big different There's a lot of variabilities of high prevalence. Yeah Give you a context of where the study was conducted where the work was done MSF intervention He's been in much a colony in Karachi Much a colony itself is an informal settlement the population according to MSS project document is one lack 50,000, oh, sorry 150k. Yeah, and 300,000 MSF primary healthcare clinic has been there since 2012 which is actually when I joined there as well And initial the four initially the focus was on emergency care. There's a standalone emergency care, however, they change the project orientation and To suit the needs better to the population and MSF is working with the C now over there Hepatitis C was via was recognized as an important health issue because of all the global work done that In this regard and screening because of this was started by MSF in March 2015 so therefore it is now a primary health care clinic and it has a focus on Hepatitis C Treatment of chronic hepatitis C virus infection was also started later that year in May 2015 To give you an idea of the care delivery, it's an integrated primary care facility It started off as a little corner in the setting. So it was a small corner and over there It was dedicated. They had GPs there who were trained and they were only specializing in working on this the rest of the care We mean the lab the mental health support the nurses all of that is integrated. So it's shared with the rest of the Setting in the facility And the good thing about this is that the colony it suits their needs the primary care setting Screening was conducted according to WHO guidelines. So there was rapid diagnostic point of care tests chronic hepatitis C Confirmation was done via PCR later. Then as you know, you know about the APRI score So it's a it's a ratio index of AST and platelets. It was used to stage Initiation of the treatment. Okay for staging so prioritized treatment So first Povir and weight based ribavirin at 12 or 24 weeks was used And that's why it was important I'll come back to that as to why it's 12 or 24 weeks is based on genotyping The treatment we have hepatitis C virus viral load was conducted at baseline end of treatment And for 12 weeks after treatment completion to ensure there's no relapse or to check for it Data was collected under routine programmatic conditions And because this was a standard of care MSF provided It's ethic review board provided an exemption in this regard Okay, so we have the results We have 4589 patients of MSF clinic was screened between March 2015 and April 2016 27% of these were hepatitis C virus antibody positive. A total we had was of 1598 some of them were screened within the clinic some of them from outside, but Totally we had a 1598 that was our population 25% of these patients had APRI already greater than one As you know APRI gives an idea of how bad the fibrosis and cirrhosis is So you have 368 hepatitis C virus genotype results were already available. I'll show you that in the next slide This is the distribution of the hepatitis C genotypes The green area is have the genotype type 3 which is the most common in Pakistan as well as It's also what we found in our results followed by type 1 and then type 2 So it's exactly the same distribution in Pakistan currently Okay There is according to the results. We have 300 and patients who initiated their treatment between April 2015 and May 2016 136 of these patients completed their treatment 135 and therefore had negative PCR at completion once it had positive 15 were lost to follow-up and One patient discontinued treatment due to other medical reasons 155 patients. So that's almost 51% are still on treatment This is an in-clinic part of the cascade to give you an idea. I hope yeah, I hope you can see that clearly the labels on the axis To give you an idea, this is the complete follow-up outcomes unfortunately Given that this was in routine programmatic conditions. We only have 45 completed follow-ups So the end of treatment response was though at 95 percent, which is quite high and we didn't expect that and SVR 12 Was 78 percent. So this is comparable to a lot of clinical trials and that was also what was very surprising clinical trials show between 75 to 95 percent of SVR and this was 78. So that was under routine programmatic conditions is quite incredible Relapse was of only one patient lost to follow-up before end of treatment was one, which means a patient didn't complete their treatment Only one patient didn't Lost to follow-up after end of treatment was seven, which means that this finished their treatment However, they weren't classified and we couldn't follow up to check to see whether they relapsed or not, which was 15 percent Failure was one percent. Oh, sorry one, which is two percent Just to give you an idea so the conclusions for this that we can draw again It's very interim a very small you saw we had a complete follow-up of only 45 So we have to be a little bit cautious of the conclusions we draw. However It is a simplification of diagnostic and treatment algorithm, which is pretty surprising You would expect hepatitis C care to be in specialized centers However, this was decentralized if you remember. It's a primary healthcare setting. We had 78 percent Which would had as SVR 12 so that showed they had successfully been cured and It shows that it can it can provide care care at primary healthcare setting into the affected communities at the community level and Therefore this feasible so far does this model does seem feasible the challenges that we're still facing However when that need to be addressed or the need for referral of complex cases such as Decompensated cases and things like these two hepatology centers And so we're currently collaborating with our centers and specialists in Karachi to work with them and to have reference special Specialists in place and see if we can go forward with that for the special cases that require further care In IV drug users, which is intravenous drug users in the clinic were not utilized in the study We did not include them because it's a special population And even though Karachi has one of the highest heroin users and IV in the world It is very important to note that these require special case-finding strategy You have to be sensitive We have to try not to alienate these people because we want to make sure we can complete the treatment that we get them on And I think to make sure wanting to thank all these people I saw again on his behalf most importantly the patients who trusted the team with their health and all the Contributors and the medical team and the community workers. Thank you