The world's largest hepatitis C burden, a national elimination programme built for non-specialists, and generic drugs that cure 98% of the time. No biopsy required.
This is the one pathway in this section where Pakistan is ahead. This is the part worth telling patients. Pakistani real-world series report sustained virological response at 12 weeks of 98.5% for sofosbuvir plus daclatasvir in genotype 3, and around 94–95% across large cohorts treated with sofosbuvir/daclatasvir or sofosbuvir/velpatasvir. Those are cure rates equal to anywhere in the world, achieved with generics.
A genuine multi-society national guideline. The national consensus guidelines were produced jointly by the Pakistan Society of Gastroenterology & GI Endoscopy, the Pakistan Society of Hepatology and the Society of Therapeutic Endoscopy Pakistan, with 30 named authors, and published in the Journal of Rawalpindi Medical College. They are structured as a formal guideline — pre-treatment assessment, drug interactions, retreatment, decompensated cirrhosis and special groups.
Same as international guidelinePakistan-adaptedLocal data onlyNational guideline outdated
The guideline's own design principle. Their stated design principle is the reason this page exists: patients in Pakistan "are unable to gain access to the latest DAAs at the pace, as they are available globally", so the guidance weighs "efficacy of the drugs as well as their availability" rather than recommending what cannot be obtained.
Decision-support only. Every threshold, interaction, retreatment regimen, decompensated regimen and paediatric dose here is quoted directly from the national guideline. The two named first-line regimens are drawn from its adolescent section and the National Hepatitis Control Programme — see step 5 for why. Confirm first-line therapy against your current programme protocol.
✓ Clinically reviewed by Dr Soban Bin Salman Meer, MBBS · 05 Aug 2026.
Step 1 · Why this one is different
National epidemiology · PM's Elimination Programme
The largest hepatitis C burden in the world Local data only
People living with HCV in Pakistan
≈ 9.8 million
Prevalence
7.5% — described as the highest in the world
Deaths per year from hepatitis B and C
≈ 37,000
Genotype 3 (all subtypes)
72.73%
Genotype 3a specifically
60%
Genotype 1
9.75%
Genotype 3 dominance is itself a divergence — much international guidance is written against a genotype 1 background. One exception worth knowing: in end-stage renal disease and post-renal-transplant patients, the prevalent genotype is type 1 rather than type 3.
There is now a national elimination programme Pakistan-adapted
The Prime Minister's Programme for the Elimination of Hepatitis C aims to screen 50% of the population over 12 years old in its first phase — around 82.5 million people.
The stated targets are treating 50% of people living with hepatitis C by 2027 and meeting WHO elimination targets by 2030, with the federal government financing half the cost.
National HCV treatment guidance under the programme is deliberately simplified — fewer than two clinic visits during treatment, and care that can be delivered by non-specialists.
Why this page is written for you. That last point is the reason this pathway is written for a general medical audience rather than for hepatologists. The national approach is explicitly task-shifted: the intent is that a medical officer can cure hepatitis C, not only a liver unit.
Why it is flagged: International guidance assumes specialist-led care. The Pakistani programme is designed around non-specialist delivery, because that is the only way to reach 9.8 million people.
Step 2 · Stage the liver — without a biopsy
National consensus guidelines §2.1
Liver biopsy is not required Pakistan-adapted
Liver biopsy is not required. For the purpose of this guidance, a patient is presumed to have cirrhosis if they have a FIB-4 score >3.25 or any of the following findings from a previously performed test.
Transient elastography indicating cirrhosis — for example FibroScan stiffness above 12.5 kPa
Non-invasive serologic tests above proprietary cut-offs — FibroSure, Enhanced Liver Fibrosis test and similar
Clinical evidence of cirrhosis — liver nodularity or splenomegaly on imaging, platelet count below 150,000/mm³
Prior liver biopsy showing cirrhosis
And if you have no FibroScan.In resource limited regions and in places where fibroscan is not available scores such as FIB-4, APRI or RFI can be used.
Then stage the cirrhosis. Calculate a Child-Pugh score. A CTP score of 7 or more — that is, Child B or C — means decompensated cirrhosis, which changes both the regimen and where the patient should be treated.
FIB-4 — the score the guideline makes the decision point
FIB-4 = (age × AST) ÷ (platelets × √ALT) — Age in years, AST and ALT in U/L, platelets in ×10⁹/L.
FIB-4 is a triage score, not a substitute for clinical judgement. It performs less well at the extremes of age, and a normal score in a patient who looks cirrhotic should not close the question.
Step 3 · Before the first tablet
National consensus guidelines §2.1
What to do before the first tablet Same as international guideline
Within 6 months of initiating treatment: complete blood count (CBC); hepatic function panel (albumin, total and direct bilirubin, alanine aminotransferase [ALT], and aspartate aminotransferase [AST]); calculated glomerular filtration rate (eGFR).
Medication reconciliation — and mean it
The guideline asks you to record current medications "including over-the-counter drugs, and herbal/dietary supplements". In a country where most drug classes are obtainable without a prescription, this is not a formality — it is how you find the rifampicin, the omeprazole and the amiodarone before they undermine the cure.
A full drug history before any DAA
The guideline is explicit: "Prior to starting treatment with a DAA, a full and detailed drug history should be taken including all prescribed medications, over-the-counter drugs, herbal and vitamin preparations and any illicit drug use discussed and documented."
Education on adherence and reinfection
Educate the patient about proper administration, adherence, and prevention of reinfection. Cure does not confer immunity — a patient re-exposed through the same route will be reinfected.
Pregnancy testing and counselling
Serum pregnancy testing and counselling about the pregnancy risks of hepatitis C medication should be offered to women of childbearing age.
Step 4 · The interactions that matter here
National consensus guidelines §2.2
Three interactions that matter more in Pakistan than anywhere else
Tick anything the patient is taking — including anything bought without a prescription.
Sofosbuvir should not be administered with known inducers of P-gp, such as rifampicin, carbamazepine, phenobarbital, phenytoin.
Pakistan has one of the world's highest tuberculosis burdens alongside the world's highest hepatitis C burden, so co-treatment is common rather than theoretical. Rifampicin significantly lowers sofosbuvir concentrations and may render the DAA course ineffective — an expensive, wasted 12 weeks that also risks resistance.
Sofosbuvir-based regimens are contraindicated in patients treated with the anti-arrhythmic amiodarone because of the risk of life-threatening arrhythmias.
If the patient has no cardiac pacemaker in situ, the guideline recommends waiting 3 months after discontinuing amiodarone before starting a sofosbuvir-based regimen.
As pH increases the solubility of velpatasvir decreases ... For most patients, proton pump inhibitors should be avoided during sofosbuvir/velpatasvir treatment.
PPIs are heavily prescribed and freely available over the counter here, so many patients are taking one without regarding it as medication. If a PPI is genuinely necessary, the guideline directs that sofosbuvir/velpatasvir be given with food and taken 4 hours before the PPI, at a maximum dose comparable to omeprazole 20 mg.
Rosuvastatin is contraindicated because of a 19-fold increase in plasma exposure of the statin.
Relevant to the retreatment regimen rather than first-line. Velpatasvir and voxilaprevir both inhibit P-gp, BCRP, OATP1B1 and OATP1B3, so other substrates of those transporters may also accumulate.
For women of childbearing age, concomitant use with ethinylestradiol-containing contraception is contraindicated because of the risk of ALT elevations. Progestogen-containing contraception is allowed.
Worth checking specifically, since a combined oral contraceptive is easy to omit from a drug history.
There are no significant drug interactions between sofosbuvir and antiretroviral drugs like emtricitabine, tenofovir, rilpivirine.
HIV co-infection is not a barrier to sofosbuvir-based treatment on interaction grounds.
Step 5 · Regimens
National consensus guidelines §2.3–2.4
The principle the guideline states plainly Local data only
All patients with detectable HCV RNA, both Naïve and compensated cirrhosis are given IFN free DAA therapy regardless off genotype.
Interferon-free, pan-genotypic in practice, and not conditional on genotyping the patient first. For treatment-naive adults without cirrhosis or with compensated cirrhosis, sofosbuvir 400 mg plus velpatasvir 100 mg once daily for 12 weeks is the regimen the guideline cross-refers to when it instructs that adolescents be treated "like in adults", and sofosbuvir plus daclatasvir for 12 weeks is the combination carried by the National Hepatitis Control Programme for genotype 3.
How the guideline is structured, and where these two regimens come from. Worth knowing how the guideline is built: its treatment chapter states the naive and compensated-cirrhosis case in that single sentence, then spends its detailed recommendations on the harder scenarios — retreatment, decompensated cirrhosis, renal impairment, children, co-infection. It does not print a separate first-line table, because for the straightforward patient the answer is simply an interferon-free DAA regardless of genotype. The two specific regimens named above are therefore drawn from the guideline's adolescent section, which instructs treating "like in adults", and from the National Hepatitis Control Programme. Confirm first-line therapy against your current programme protocol — the Prime Minister's Programme postdates this guideline.
Retreatment after DAA failure — non-cirrhotic or compensated cirrhosis (Child A) Same as international guideline
Sofosbuvir 400 mg — one tablet after breakfast, once a day, for 12 weeks
Velpatasvir 100 mg — one tablet after breakfast, once a day, for 12 weeks
Voxilaprevir 100 mg — one tablet after breakfast, once a day, for 12 weeks
Patients who fail or relapse after any DAA regimen should preferably be retreated within a multidisciplinary team. Those who have relapsed twice to NS5A inhibitors or protease inhibitors are considered very difficult cases. Where the triple combination is used in that difficult group, it is extended to 24 weeks.
Decompensated cirrhosis (Child B or C) Same as international guideline
Protease inhibitors are contraindicated in decompensated cirrhosis — so the voxilaprevir-containing regimen above cannot be used. These patients should preferably be treated at specialised centres with close monitoring during and after treatment.
Treatment-naive, first option
Sofosbuvir 400 mg daily for 12 weeks
Velpatasvir 100 mg daily for 12 weeks
Weight-based ribavirin — 1,000 mg if under 75 kg, 1,200 mg if over 75 kg — for 12 weeks, if ribavirin-eligible
Treatment-naive, second option
Sofosbuvir 400 mg daily for 12 weeks
Daclatasvir 60 mg daily for 12 weeks
Weight-based ribavirin for 12 weeks, if ribavirin-eligible
Genotype 1, 4, 5 and 6
Sofosbuvir 400 mg daily for 12 weeks
Ledipasvir 90 mg daily for 12 weeks
Weight-based ribavirin for 12 weeks, if ribavirin-eligible
Retreatment in decompensated cirrhosis
Sofosbuvir 400 mg daily for 24 weeks
Velpatasvir 100 mg daily for 24 weeks
Weight-based ribavirin for 24 weeks
Ribavirin should be started at the lowest possible dose of 600 mg once daily and increased to the required dose if tolerated. Patients intolerant of ribavirin should be treated with the respective fixed-dose combination without it.
Step 6 · Special groups, and what you cannot get
National consensus guidelines §2.5
What the guideline recommends but you cannot get Pakistan-adapted
The guideline marks certain regimens with the heading "RECOMMENDED BUT NOT AVAILABLE IN PAKISTAN" — a rare and useful piece of honesty in a clinical guideline, and the clearest possible statement of the availability constraint it was written around.
Glecaprevir 300 mg plus pibrentasvir 120 mg for 8 weeks — recommended for adolescents and, in weight-banded doses, for children aged 3–11, but not available in Pakistan.
Glecaprevir/pibrentasvir is also named as the preferred option for genotype 1b in renal impairment, and grazoprevir/elbasvir for severe renal impairment and haemodialysis — the same availability caveat applies.
The practical consequence is that the 8-week course is not an option here, and the 12-week sofosbuvir-based regimens are what you will actually be prescribing.
Groups the guideline addresses specifically
Children aged 3–11
DAAs can be offered to all HCV-infected children aged 3 and over, irrespective of disease severity. Sofosbuvir plus velpatasvir for 12 weeks, weight-banded: under 17 kg, 150/37.5 mg; 17 to under 30 kg, 200/50 mg; over 30 kg, 400/100 mg. For genotypes 1, 4, 5 and 6, sofosbuvir plus ledipasvir for 12 weeks — under 17 kg, 150/33.75 mg; 17 to under 30 kg, 200/45 mg; over 30 kg, 400/90 mg. An oral granule formulation of sofosbuvir 50 mg with velpatasvir 12.5 mg was pending approval.
Adolescents 12–17
Treatment-naive or treatment-experienced, without cirrhosis or with compensated cirrhosis, treated as in adults: sofosbuvir 400 mg plus velpatasvir 100 mg for 12 weeks; or sofosbuvir plus ledipasvir for 12 weeks in genotypes 1, 4, 5 and 6.
Family screening
All siblings born from the same mother should also be screened for hepatitis C, and encouraged to have hepatitis B and A vaccination if not already done.
Pregnancy
Hepatitis C treatment including DAAs is not recommended during pregnancy or within six months before conception. Women of childbearing age should take precautions during DAA therapy. Accidental conception during treatment needs a full discussion between the patient, the hepatologist and the obstetrician.
Renal impairment
Patients with HCV and chronic kidney disease, including those on haemodialysis, can follow standard DAA recommendations without dose adjustment. Those with eGFR below 30 or on haemodialysis should be treated at specialised centres under a multidisciplinary team. Decompensated cirrhosis with eGFR of 30 or above: sofosbuvir/velpatasvir with ribavirin for 12 weeks, ribavirin starting at 600 mg daily. Decompensated cirrhosis with eGFR below 30: avoid ribavirin, and use sofosbuvir/velpatasvir for 24 weeks.
Hepatitis B co-infection
Treat the hepatitis C as standard, and test for HIV as well. Where HBV treatment criteria are also met, treat both. A patient who is HBsAg-positive but only needs HCV therapy should receive a nucleoside/nucleotide analogue as prophylaxis during hepatitis C treatment and for at least 12 weeks afterwards, with monthly monitoring for reactivation once it stops. A patient who is HBsAg-negative but anti-HBc positive needs monthly ALT monitoring during treatment.
Haemoglobinopathies and bleeding disorders
Treated as per the general recommendations. Relevant here given the β-thalassaemia carrier rate in Pakistan and the transfusion-associated transmission route.
What generic DAAs actually achieve here Local data only
Older sofosbuvir/ribavirin regimens performed markedly worse in the same populations — one head-to-head series reported 98.5% with sofosbuvir/daclatasvir against 75% with sofosbuvir/ribavirin. If you still have patients on ribavirin-based regimens outside the indications above, that gap is the argument for changing.
Common questions
Do I need a liver biopsy before treating hepatitis C?
No. The national consensus guideline states plainly that liver biopsy is not required. Cirrhosis is presumed if FIB-4 is above 3.25, or on FibroScan above 12.5 kPa, platelets below 150,000, liver nodularity or splenomegaly on imaging, or a prior biopsy showing cirrhosis.
What if FibroScan is not available?
The guideline addresses this directly: in resource-limited regions and where FibroScan is unavailable, scores such as FIB-4, APRI or RFI can be used. FIB-4 needs only age, AST, ALT and a platelet count.
Can a non-specialist treat hepatitis C in Pakistan?
That is the explicit design of the national programme. National HCV treatment guidance under the Prime Minister's Programme is simplified to fewer than two clinic visits during treatment, with care deliverable by non-specialists — because reaching 9.8 million people any other way is not possible.
Which genotype is commonest in Pakistan?
Genotype 3, at 72.73% of all genotypes, with subtype 3a alone accounting for 60%. Genotype 1 is 9.75%. One exception: in end-stage renal disease and post-renal-transplant patients, genotype 1 predominates rather than genotype 3.
Can I give a DAA to a patient on TB treatment?
Not with rifampicin. The guideline states sofosbuvir should not be administered with known P-gp inducers such as rifampicin, carbamazepine, phenobarbital and phenytoin. Given Pakistan has both the highest hepatitis C burden and one of the highest TB burdens, this combination comes up often, and rifampicin can render the DAA course ineffective.
Can patients take omeprazole during treatment?
For most patients on sofosbuvir/velpatasvir, proton pump inhibitors should be avoided — velpatasvir solubility falls as pH rises. If a PPI is genuinely necessary, give sofosbuvir/velpatasvir with food and take it 4 hours before the PPI, at a maximum dose comparable to omeprazole 20 mg.
Why is amiodarone a problem?
Sofosbuvir-based regimens are contraindicated with amiodarone because of the risk of life-threatening arrhythmias. If the patient has no pacemaker, the guideline recommends waiting 3 months after stopping amiodarone before starting a sofosbuvir-based regimen.
Do generic DAAs actually work?
Yes — this is the good news in Pakistani hepatology. Real-world Pakistani series report SVR12 of 98.5% for sofosbuvir plus daclatasvir in genotype 3, and around 94 to 95% across large cohorts. Those are cure rates matching anywhere in the world, achieved with generics.
Clinically reviewed by Dr Soban Bin Salman Meer, MBBS
MBBS — Postgraduate Trainee in the Department of Urology at the Pakistan Institute of Medical Sciences (PIMS), Islamabad. Graduated from Federal Medical & Dental College, Islamabad.
Sources
Syed SH, Umar M, Khaar HB, Akhter TS, Hussain T, Khan AA, et al. An Update on National Consensus Practice Guidelines for the Treatment of Hepatitis C & Literature Review in Epidemiology of Hepatitis C in Pakistan — 2022. Journal of Rawalpindi Medical College, published February 2024. Produced jointly by the Pakistan Society of Gastroenterology & GI Endoscopy, the Pakistan Society of Hepatology, and the Society of Therapeutic Endoscopy Pakistan. Source of every quoted recommendation, threshold, regimen and interaction on this page.
Overview of Hepatitis C Elimination Efforts in Pakistan and the Launch of the Prime Minister's Programme for the Elimination of Hepatitis C. Journal of the Pakistan Medical Association — source of the 9.8 million, 7.5% prevalence and 37,000 deaths figures.
Prime Minister's Programme for the Elimination of Hepatitis C — phase one screening targets, the 2027 and 2030 goals, and the simplified, non-specialist care model.
Pakistani real-world DAA outcome series reported within the national guideline's own literature review — source of the SVR12 figures.
SCOPE AND SOURCING NOTE: the guideline's treatment chapter states the treatment-naive and compensated-cirrhosis case as a single principle — interferon-free DAA regardless of genotype — and reserves its detailed, numbered recommendations for retreatment, decompensated cirrhosis and special groups. The two named first-line regimens on this page are therefore drawn from the guideline's adolescent section, which directs treating "like in adults", and from the National Hepatitis Control Programme. Every threshold, interaction, retreatment regimen, decompensated regimen and paediatric dose is quoted directly from the guideline. Liver transplant and HCC surveillance are out of scope.
Background reading — why this is the one condition where Pakistan is ahead, the FIB-4 threshold that replaces the biopsy, and the TB drug that wrecks a twelve-week course: hepatitis C in Pakistan.