Islamabad: Pakistan may be missing a fast moving liver infection inside its Hepatitis B population as senior hepatologists and gastroenterologists estimate that over 20 percent of Hepatitis B patients could also be carrying Hepatitis Delta, a coinfection that can push people to cirrhosis, liver failure and liver cancer much earlier, yet remains largely undetected because confirmatory testing is costly, patchy and not backed by national screening guidance.
The warning comes from a clinician led mixed methods survey conducted from September to November 2025 in Karachi, Islamabad Rawalpindi, Lahore, Peshawar and Nowshera, which gathered responses from 12 specialists with experience ranging from five years to over three decades.
Half of hepatologists said they frequently encounter Hepatitis Delta in routine practice among people already diagnosed with Hepatitis B, a signal that the burden is not rare but often overlooked.
Hepatitis Delta, also called Hepatitis D, is caused by a defective virus that cannot infect on its own and depends on Hepatitis B to enter and replicate in the body. That dependence makes it easy to miss because many patients and even health facilities stop at the Hepatitis B diagnosis and do not proceed to Delta testing.
Clinicians say that delay is dangerous because Delta is widely considered the most aggressive form of viral hepatitis, linked to rapid progression of liver scarring and earlier complications.
The survey findings show a clear diagnostic gap. While 75 percent of clinicians reported they routinely request anti HDV antibody testing for Hepatitis B patients, only 50 percent said HDV RNA PCR testing is routinely performed. RNA testing is the confirmatory test that determines whether the infection is active and helps guide monitoring and treatment decisions. Doctors said the main reasons for the drop off are affordability and uneven availability, particularly outside major tertiary centres.
In fact, 83.3 percent of respondents described Hepatitis Delta diagnostics as available but not affordable for most patients. Three quarters identified the high cost of testing as a core barrier. Two thirds pointed to lack of awareness. About half cited the absence of national screening guidelines, while 41.7 percent flagged limited test availability.
The combined effect, clinicians warned, is that a large number of people living with Hepatitis B are never properly assessed for Delta until they present with advanced liver disease.
When asked about consequences of delayed or missed diagnosis, 75 percent of clinicians highlighted rapid progression to cirrhosis. Two thirds pointed to higher risks of liver failure and hepatocellular carcinoma compared with Hepatitis B alone. One third flagged increased mortality.
Several specialists noted that many patients first arrive at tertiary hospitals only when complications have already set in, which limits treatment options and increases the cost of care for families.
The doctors also described a serious treatment and policy vacuum as most respondents, between 75 and 83.3 percent, said Pakistan needs an urgent or critical national program for Hepatitis Delta care and treatment access.
A large majority, 83.3 percent, supported adding Hepatitis Delta as a distinct component within the National Hepatitis Program, alongside Hepatitis B and Hepatitis C, so case finding and follow up are not left to individual hospitals and personal clinical judgement.
There was strong agreement on what should come first. Most clinicians backed national screening guidelines and awareness campaigns at both community and physician levels. Their preferred approach is routine screening of all Hepatitis B surface antigen positive individuals for Hepatitis Delta, rather than selective testing, because selective testing misses silent disease and delays diagnosis.
On medicines, all 12 clinicians supported a regulated Emergency Use Authorization pathway in Pakistan for emerging Hepatitis Delta therapies where there is high unmet need and no widely accessible local treatment options.
They recommended safeguards such as reliance on Phase II or Phase III trial data, preference for drugs already approved in other countries or available under supervised access mechanisms, oversight by a national expert advisory board, informed consent and registry based monitoring of treated patients. Most also supported a DRAP led task force and pilot access programs at selected tertiary hospitals before any broader rollout.
Clinicians warned that if Hepatitis Delta remains outside routine screening and diagnostics stay unaffordable, Pakistan will continue paying the price through late presentation, repeated hospital admissions, long term management of cirrhosis and liver cancer, rising transplant needs and lost productivity among working age adults.
They argue that Pakistan’s hepatitis elimination ambitions will be harder to achieve unless Hepatitis Delta is brought out of the shadows through clear national guidance, cheaper confirmatory testing and a controlled pathway to treatment for patients who are currently slipping through the cracks.
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