# Bridging Gaps in Hepatitis Delta Virus Care: A Cross-Sectional Mixed-Methods Study of Clinician Perspectives From Major Urban Centers in Pakistan

## TL;DR

This study explores challenges in diagnosing and treating Hepatitis Delta Virus in Pakistan through clinician perspectives, highlighting the need for national policies and affordable diagnostics.

## Contribution

The study provides novel insights into clinician experiences and barriers to HDV care in Pakistan, emphasizing the need for policy and diagnostic improvements.

## Key findings

- HDV co-infection rates among HBV patients are estimated at 10-20% by clinicians.
- Only 50% of clinicians routinely perform HDV RNA PCR due to high costs and limited availability.
- Most clinicians advocate for HDV inclusion in national hepatitis programs and emergency treatment pathways.

## Abstract

Background

Hepatitis delta virus (HDV) is the most aggressive form of viral hepatitis, accelerating progression to cirrhosis, hepatocellular carcinoma, and liver failure. Despite its severity, HDV remains underdiagnosed and under-prioritized in Pakistan, where hepatitis B virus (HBV) prevalence is high. Understanding clinician perspectives is essential for informing national strategies related to diagnosis, treatment, and policy integration.

Methods

A non-interventional, cross-sectional mixed-methods survey was conducted among 12 clinicians, including hepatologists, gastroenterologists, and infectious disease specialists from Karachi, Islamabad/Rawalpindi, Lahore, Peshawar, and Nowshera. Data were collected using a structured questionnaire adapted from international HDV surveys and contextualized for Pakistan. Quantitative data were analyzed descriptively, while qualitative responses underwent thematic analysis to identify barriers, gaps, and recommendations.

Results

Twelve clinicians from major urban centers in Pakistan participated, representing diverse specialties with 5-30+ years of experience. Fifty percent reported frequently encountering HDV among HBV patients, and most estimated HDV co-infection rates between 10% and 20%. Anti-HDV testing was routinely performed by 75% of clinicians, whereas HDV RNA PCR was routinely performed by only 50%, primarily due to high cost and limited availability; 83.3% reported that HDV diagnostics were available but unaffordable for most patients. Key diagnostic barriers included high cost (75%), lack of awareness (66.7%), limited test availability (41.7%), and absence of national screening guidelines (50%). Two-thirds classified HDV severity as moderate, while 33.4% rated it severe or life-threatening. Perceived clinical risks included rapid progression to cirrhosis (75%), liver failure (66.7%), hepatocellular carcinoma (66.7%), and increased mortality (33.3%). Most clinicians identified major treatment gaps, with 75-83.3% describing an urgent or critical need for a national HDV treatment program. Policy support was strong: 83.3% favored HDV inclusion in the National Hepatitis Program, 83.3% endorsed national screening guidelines and awareness campaigns, and all clinicians (100%) supported an Emergency Use Authorization pathway with safeguards such as Phase II/III data and advisory oversight. Qualitative insights reinforced concerns about worsening liver disease burden, inequitable access, and escalating healthcare costs without immediate policy action.

Conclusion

This study reveals substantial diagnostic, therapeutic, and policy gaps in HDV management in Pakistan. Clinicians strongly advocate for nationwide screening, cost reduction of diagnostics, integration of HDV into the national hepatitis program, and early treatment access through regulatory innovation. Urgent action is needed to prevent worsening disease burden, improve equity, and align with global hepatitis elimination targets.