“They took us from the school and made us stand in line and 'tak, tak, tak' with the same syringe from one child’s arm to the next,” Anwar, a Cairo-based journalist in his early fifties, recalled about when he and his schoolmates were taken to receive an anti-Bilharzia injection at the local hospital in their Nile Delta village when he was 15.
Anwar and his three brothers were all infected with the Hepatitis C virus.
Some seven million children were given the same injections against the Bilharzia disease, which is caused by parasites found along the banks of the Nile, as part of a mass government-led campaign in the 1960s and 70s. But the widespread use of poorly-sterilised glass syringes in the injections gave rise to a new epidemic, according to a year 2000 study that has gained near-full medical consensus.
"I don't think there was one person in our village and the ones around us that didn't catch it," Anwar said.
Egypt has the world’s highest prevalence of HCV, a blood-borne virus that in most cases causes chronic liver disease, leading to fatal liver failure and cancer. Seven percent of the adult population has a chronic infection, according to the latest World Health Organisation (WHO) figures.
Anwar’s brother, Ahmed, died in 2004 at age 38 from liver cancer. Anwar and his brother Hossam both got liver transplants two years ago after failing to respond to interferon-based therapy. The fourth brother, who preferred not to be named, died of liver disease during the writing of this article.
With new, more effective treatments and renewed political will, Egypt is on track to control a nation-wide endemic, but it will need to spend unprecedented billions at a time when its economy is only starting to recover from years of turmoil.
“A revolutionary time”
Almost a dozen local companies are already producing licensed generics of a new generation of game-changing orally administered drugs called Direct Antiviral Agents (DAA) approved by the US Food and Drug Administration (FDA) in recent years.
“This is a revolutionary time” for HCV treatment in Egypt and worldwide, said Dr Manal Hamdi El-Sayed, supervisor of the National Programme for Viral Hepatitis at the Ministry of Health.
The first such drug, the US-based Gilead’s Sovaldi (generic name Sofosbuvir), was introduced in Egypt in October 2014.
Over 140,000 Egyptians have received the new treatments in specialised government centres nationwide since then, Dr Wahid Doss, head of the National Committee for the Control of Viral Hepatitis, told Ahram Online in a 14 September interview.
The success rate, measurable three months after the end of a treatment course, was 85 percent, based on data from patients who concluded a three-month course by the end of January 2015, Dr Magdy El-Serafy, head of the National Hepatology and Tropical Medicine Research Institute, said in a 7 September interview.
The new treatments are much shorter and better-tolerated than the previous standard one, which was based on a 48-week course of pegylated interferon injections, a drug known for its harsh side-effects such as fatigue, depression and hair loss.
Treatment cheaper, but not cheap
Local generics are pushing the price of the new treatments down, but without insurance coverage or government aid they remain out of reach for most Egyptians.
Since September 2015, the government facilities have been using six locally-produced generics of Sofosbuvir, pricing at LE680 per bottle (a month-long dose), compared with LE2,200 for the originator Sovaldi, said El-Sayed.
Now Sovaldi is being phased out of the national programme in favour of local generics, but it will still be available to cash patients willing to pay LE2,200 for it out of pocket, El-Serafy told Ahram Online.
Egypt bought US-based Abbvie’s Qurevo (commercial name outside Egypt Viekirax or Technivie), launched earlier this month, for use in its national treatment centres at “around 1 percent” of its international price, or “close to LE3,000 per box (a monthly dose),” according to El-Serafy.
Last year, Egypt had struck a similar agreement with Gilead over Sovaldi, which was sold to the government for 1 percent of its international price at LE2,200 per monthly dose.
The discounted price served as a benchmark for future agreements with foreign and local pharmaceutical companies, said Doss.
Although Gilead did not succeed in obtaining a patent for Sovaldi in Egypt, allowing local companies to produce generics, Abbvie may obtain one for Qurevo.
The company applied for a patent in Egypt, Nibal Dahaba, the director of public affairs for the Middle East, Africa and Pakistan, told Ahram Online in a phone interview.
“Maybe some of the [foreign companies] will be able to get patency,” said Doss, “but I think there will be generics eventually, because the push for generics is too strong.”
But even at the government-subsidised generic price, LE680 a month for three months is difficult to afford for millions in a country where over 26 percent live on less than LE3,570 a year, or $1.2 a day, according to the latest official figures.
Only 20 percent of the patients at the government facilities pay for their own treatment in cash at the discounted government price, while the remaining 80 percent of the patients are covered by either national health insurance, an employer’s insurance scheme, or are fully-funded by the Ministry of Health, according to El-Serafy.
While Anwar and his brother Hossam had most of their treatment expenses covered by the national insurance programme as public sector employees, others struggle.
Malak, a 53-year-old electronics shop owner from Minya in Upper Egypt, had to sell the family car to pay for his liver transplant surgery, even after he received a LE160,000 donation from a Coptic TV channel programme on the recommendation of his local priest.
“I thank God for this miracle,” he said.
8 out of 10 infections from hospitals and clinics
Egypt already needs to allocate LE2 billion of its healthcare budget just for the treatment of Hepatitis C in 2016, according to El-Sayed.
However, the cost of upgrading the healthcare system to control the spread of the virus, for which a full budget has not been finalised, will be “outstanding,” added El-Sayed, who is in charge of the prevention side of the national programme.
About 150,000 Egyptians are infected with the virus every year, according to Doss.
Unlike HIV and other forms of Hepatitis, HCV is very rarely transmitted through sexual contact with an infected person or passed from a mother to her child at birth. It is mostly transmitted through the blood of an infected person through syringes, blood transfusions, illegal drug injections, piercings, tattoos and razors.
In Egypt, an astounding 8 out of every 10 new infections take place in hospitals and clinics, according to a WHO July 2015 report.
This is because the country has long-suffered from a fragmented and underfunded healthcare sector, explained El-Sayed.
“The Ministry of Health controls 30 percent” of the sector, she says. University-affiliated hospitals under the Ministry of Higher Education handle 40 percent of the patients, but the budget allocated to the ministry mostly goes to education rather than to the hospitals, she said.
“The Ministry of Defence and the Ministry of Interior have their own hospitals where infection control and services are fantastic because they have the resources,” she said.
With little spent on training and resources, poor hygiene standards and the repeated use of syringes and other medical equipment is common, said El-Sayed.
Egypt’s main blood bank, which only covers 30 percent of the country’s needs, is only able to use costly state-of-the-art HCV detecting tests thanks to funding from the Swiss government, according to El-Sayed, while other banks can only afford less sensitive tests.
The current national strategy for 2013-2018, supported by the WHO and other international partners, gives unprecedented weight to preventing the spread of HCV as well as treatment, said Abdel-Hamid Abaza, a member of the National Committee and former deputy minister of health.
Supported by the WHO, Egypt is launching an injection safety programme, including the introduction of auto-disabling needles manufactured by a local company, said El-Sayed, “one of the largest current syringe makers in the country,” which she declined to name because negotiations are ongoing with the foreign firm.
“A treacherous disease”
Anwar was not diagnosed until 11 years after he was infected, while running check-up tests while on a work assignment in the United Arab Emirates.
“It is a treacherous disease,” he said. “You can have it for a long time without feeling anything except fatigue.”
Mona*, a 61-year-old upper-middle class housewife from Cairo who requested to be anonymous, was only cured of her chronic HCV infection this year, 37 years after she was infected by a blood transfusion following the birth of her first child.
She only started feeling mild symptoms in her late thirties.
“I like to exercise, and I found myself feeling short of breath very fast, and I went to the doctor thinking I had a heart problem,” she said.
The tests revealed an HCV infection, though the damage to her liver then was still at an early stage.
Malak discovered his infection only two years before he needed a new liver, after seeking medical attention for a discoloured patch of skin on his hand.
“I felt fine in every other way, my health was iron-clad,” he said.
After he ran the tests the doctors told him he had had HCV for 20 years, and that his liver had reached an advanced state of fibrosis caused by inflammation.
“The problem is that 90 percent of people who have Hepatitis C are not aware of it,” said Doss.
The trouble with introducing nationwide systematic compulsory screening is not the cost but that “we might be inducing discrimination against HCV patients,” said Doss, referring to the widely practiced employment discrimination against HCV carriers in Egypt.
"It’s very cheap, the government can pay" to screen people, said Doss.
It costs between LE30 and LE60 to get a blood test to detect HCV, according to El-Sayed.
“A national priority”
The National Committee’s aim is to reduce the HCV prevalence rate to 2-3 percent, the rate found in developed European countries, according to the WHO.
That can take between 10 to 15 years “if we reach the stage where we are treating 300,000 patients a year,” said El-Serafy, who added that the national programme is now treating 15,000 patients per month, so 180,000 a year.
But without reducing the incidence rate, “you are always playing catch up" with the disease, he said, but infection control to stem the spread of the disease will require much more resources to be pumped into the healthcare sector.
“We need a thousand percent more [than what is being spent on healthcare],” said El-Sayed.
In 2013, Egypt ranked 149th out of 188 countries in public healthcare expenditure as a percentage of GDP, according to World Bank data.
Egyptian President Abdel-Fattah El-Sisi, elected in 2014, has publically spoken about battling HCV as "a national priority."
The government has allocated LE1 billion for the national programme against HCV this year, doubling the amount it had given during the 2014-2015 fiscal year, according to Doss.
“The push is so strong politically and socially and in the media that the government is keen to provide a good amount [of funds],” said Doss.
But government spending on healthcare has so far fallen short of meeting the 3 percent of Gross National Product mandated in the country’s 2014 constitution.
In fact, government spending on healthcare this fiscal year, representing around 1.8 percent of GNP, is lower than in the previous year when adjusted for inflation, according to Salma Hussein, economic researcher at the Egyptian Initiative for Personal Rights.
“The resources are not enough to deal with the numbers of patients in the hospitals and we are pleading for all stakeholders to start supporting prevention as well as treatment,” said El-Sayed.
“I am a special case,” said Anwar, “because I had a high-profile job and [powerful] contacts who helped get me the best care… others don’t."
*Source has requested to be quoted under a false name to protect her identity.
*Correction: A previous version of this article named Viekira Pak as the commercial name for Qurevo outside Egypt. The correct name is Viekirax or Technivie, as clarified by Abbvie's spokesperson after publication.