Research Article| Volume 68, ISSUE 4, P691-698, April 2018

Planning and prioritizing direct-acting antivirals treatment for HCV patients in countries with limited resources: Lessons from the Egyptian experience

Published:December 06, 2017DOI:


      • DAAs are effective as treatment for HCV infection.
      • All stages of fibrosis can be treated effectively.
      • All countries are embarking on a global effort to eliminate HCV.

      Background and Aims

      The introduction of direct-acting antivirals for hepatitis C virus (HCV) in Egypt led to massive treatment uptake, with Egypt’s national HCV treatment program becoming the largest in the world. The aim of this paper is to present the Egyptian experience in planning and prioritizing mass treatment for patients with HCV, highlighting the difficulties and limitations of the program, as a guide for other countries of similarly limited resources.


      Baseline data of 337,042 patients, treated between October 2014 to March 2016 in specialized viral hepatitis treatment centers, were grouped into three equal time intervals of six months each. Patients were treated with different combinations of direct-acting antivirals, with or without ribavirin and pegylated interferon. Baseline data, percentage of patients with known outcome, and sustained virological response at week 12 (SVR12) were analyzed for the three cohorts. The outcomes of 94,258 patients treated in the subsequent two months are also included.


      For cohort-1, treatment was prioritized for patients with advanced fibrosis (F3-F4 fibrosis, liver stiffness ≥9.5 kPa, or Fibrosis-4 ≥3.25). Starting cohort-2, all stages of fibrosis were included (F0-F4). The prioritization strategy in the initial phase caused delays in enrollment and massive backlogs. Cohort-1 patients were significantly older, and more had advanced fibrosis compared to subsequent cohorts. The percentage of patients with known SVR12 results were low initially, and increased with each cohort, as several methods to capture patient results were adopted. Sofosbuvir-ribavirin therapy for 24 weeks had the lowest SVR12 rate (82.7%); while other therapies were associated with SVR12 rates between 94% and 98%.


      Prioritization based on fibrosis stage was not effective and enrollment increased greatly only after including all stages of fibrosis. The availability of generic drugs reduced costs, and helped massively increase uptake of the program. Post-treatment follow-up was initially very low, and although this has increased, further improvement is still needed.

      Lay summary

      We are presenting the largest national program for HCV treatment in the world. We clearly demonstrate that hepatitis C can be cured efficiently in large scale real-life programs. This is a clear statement that global HCV eradication is foreseeable, providing a model for other countries with limited resources and prevalent HCV. Moreover, the availability of generic products has influenced the success of this program.

      Graphical abstract


      Linked Article

      • The Egyptian hepatitis C programme: A model of HCV treatment intervention?
        Journal of HepatologyVol. 68Issue 4
        • Preview
          The Egyptian HCV epidemic, and the country’s response to it, are unlike any other country to date. Egypt has a very high burden of infection and disease: Egypt ranks 5th amongst all countries for the burden of disease from viral hepatitis,1 close to 15% of the adult population are seropositive for HCV and over four million individuals remain viraemic.2,3 As a lower middle-income country, Egypt is relatively poor with a gross national income per capita of $3,410 in 2016 according to the World Bank.
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