The hepatitis C virus in the EMRO Region: health policy, historical, ethical aspects and future challenges


Hepatitis C virus
policy analysis
ethical features
policy triangle framework


Background: Hepatitis C infection (HCV) can have a harmful effect on the health of people and can impose relevant health care costs. The World Health Organization has eliminated Hepatitis C by 2030 as an important goal for all countries. This study aimed to identify the HCV-related policies in Iran.

Methods: A qualitative approach was used for this study. Data was collected through a comprehensive search of documents and interviews with different stakeholders related to the HCV program. Data was analyzed and validated using content analysis based on the policy triangle framework.

Results: Our findings highlighted that certain social and cultural issues related to stigma can impact on awareness-raising processes. It is also necessary to consider HCV directly in the context of government policies. All stakeholders must act in their own right. Continued talks need to be made between them for the participation of all stakeholders.

Conclusion: The findings of this study can provide useful information for improving, supporting and developing policy processes. Healthcare providers must address all aspects of the disease by 2030 in order to achieve the goal of HCV elimination. Evidence-based planning, support for up-to-date policies and resource mobilization are needed to achieve this ambitious goal.


1. Papatheodoridis G, Hatzakis A. Public health issues of hepatitis C virus infection. Best Pract Res Clin Gastroenterol. 2012;26(4):371-80.
2. Razavi H, Elkhoury AC, Elbasha E, Estes C, Pasini K, Poynard T, et al. Chronic hepatitis C virus (HCV) disease burden and cost in the United States. Hepatology. 2013;57(6):2164-70.
3. Stanaway JD, Flaxman AD, Naghavi M, Fitzmaurice C, Vos T, Abubakar I, et al. The global burden of viral hepatitis from 1990 to 2013: findings from the global burden of disease study 2013. Lancet. 2016;388(10049):1081-8.
4. WHO. Global hepatitis report, 2017 2017 [Available from: (accessed 30 August 2018).
5. WHO. Combating hepatitis B and C to reach elimination by 2030 2016 [Available from: (Last access 30 August 2018).
6. Tachi K. Hepatitis C virus infection in Ghana: time for action is now. Ghana Med J. 2018;52(1):1-2.
7. Ara AK, Paul JP. New direct-acting antiviral therapies for treatment of chronic hepatitis C virus infection. Gastroenterol Hepatol (N Y). 2015;11(7):458-66.
8. Schietroma I, Scheri GC, Pinacchio C, Statzu M, Petruzziello A, Vullo V. Hepatitis C virus and hepatocellular carcinoma: pathogenetic mechanisms and impact of direct-acting antivirals. Open Virol J. 2018;12:16-25.
9. Burki T. Elimination on the agenda for hepatitis C. Lancet Infect Dis. 2014;14(6):452-3.
10. El-Akel W, El-Sayed MH, El Kassas M, El-Serafy M, Khairy M, Elsaeed K, et al. National treatment programme of hepatitis C in Egypt: Hepatitis C virus model of care. J Viral Hepat. 2017;24(4):262-7.
11. Nasrullah M, Sergeenko D, Gamkrelidze A, Averhoff F. HCV elimination - lessons learned from a small Eurasian country, Georgia. Nat Rev Gastroenterol Hepatol. 2017;14(8):447-8.
12. Maddalena V. Evidence-based decision-making 8: health policy, a primer for researchers. Methods Mol Biol. 2015;1281:501-17.
13. Gilson L, Raphaely N. The terrain of health policy analysis in low and middle income countries: a review of published literature 1994-2007. Health Policy Plan. 2008;23(5):294-307.
14. Green A, Gerein N, Mirzoev T, Bird P, Pearson S, Anh le V, et al. Health policy processes in maternal health: a comparison of Vietnam, India and China. Health Policy. 2011;100(2-3):167-73.
15. Taherkhani R, Farshadpour F. Epidemiology of hepatitis C virus in Iran. World J Gastroenterol. 2015;21(38):10790-810.
16. Mirminachi B, Mohammadi Z, Merat S, Neishabouri A, Sharifi A H, Alavian SH, et al. Update on the prevalence of hepatitis C virus infection among Iranian general population: a systematic review and meta-analysis. Hepat Mon. 2017;17(2):e42291.
17. Khodabandehloo M, Roshani D, Sayehmiri K. Prevalence and trend of hepatitis C virus infection among blood donors in Iran: A systematic review and meta-analysis. J Res Med Sci. 2013;18(8):674-82.
18. Nematollahi S, Ayubi E, Almasi-Hashiani A, Mansori K, Moradi Y, Veisani Y, et al. Prevalence of hepatitis C virus infection among high-risk groups in Iran: a systematic review and meta-analysis. Public Health. 2018;161:90-8.
19. Behzadifar M, Gorji HA, Rezapour A, Bragazzi NL. Prevalence of hepatitis C virus infection among prisoners in Iran: a systematic review and meta-analysis. Harm Reduct J. 2018;15(1):24.
20. Behzadifar M, Gorji HA, Rezapour A, Bragazzi NL. Prevalence of hepatitis C virus among street children in Iran. Infect Dis Poverty. 2018;7(1):88.
21. Behzadifar M, Gorji HA, Bragazzi NL. The prevalence of hepatitis C virus infection in thalassemia patients in Iran from 2000 to 2017: a systematic review and meta-analysis. Arch Virol. 2018;163(5):1131-40.
22. Hutin Y, Low-Beer D, Bergeri I, Hess S, Garcia-Calleja JM, Hayashi C, et al. Viral hepatitis strategic information to achieve elimination by 2030: key elements for HIV program managers. JMIR Public Health Surveill. 2017;3(4):e91.
23. Dore GJ, Hajarizadeh B. Elimination of hepatitis C virus in Australia: laying the foundation. Infect Dis Clin North Am. 2018;32(3):269-79.
24. Alavian S M, Sharafi H. Update on Recommendations for the Clinical Management of Hepatitis C in Iran 2017. Hepat Mon. 2017;17(11):e63956.
25. Hesamizadeh K, Sharafi H, Rezaee-Zavareh MS, Behnava B, Alavian SM. Next steps toward eradication of hepatitis C in the era of direct acting antivirals. Hepat Mon. 2016;16(4):e37089.
26. Alavian SM, Hajarizadeh B, Bagheri Lankarani K, Sharafi H, Ebrahimi Daryani N, Merat S, et al. Recommendations for the clinical management of hepatitis C in Iran: a consensus-based national guideline. Hepat Mon. 2016;16(8):e40959.
27. Hajarizadeh B, Razavi-Shearer D, Merat S, Alavian SM, Malekzadeh R, Razavi H. Liver disease burden of hepatitis C virus infection in Iran and the potential impact of various treatment strategies on the disease burden. Hepat Mon. 2016;16(7):e37234.
28. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-57.
29. Walt G, Gilson L. Reforming the health sector in developing countries: the central role of policy analysis. Health Policy Plan. 1994;9(4):353–70.
30. Morse JM. Critical analysis of strategies for determining rigor in qualitative inquiry. Qual Health Res. 2015;25(9):1212-22.
31. Lavis JN, Røttingen JA, Bosch-Capblanch X, Atun R, El-Jardali F, Gilson L, et al. Guidance for evidence-informed policies about health systems: linking guidance development to policy development. PLoS Med. 2012;9(3):e1001186.
32. Treloar C, Rance J, Backmund M. Understanding barriers to hepatitis C virus care and stigmatization from a social perspective. Clin Infect Dis. 2013;57(Suppl 2):S51-5.
33. Karimi-Sari H, Bayatpoor ME, Aftabi Khotbesara M, Ebrahimi MS, Sattari Z, Sattari P, et al. Knowledge, attitude, and practice of Iranian health sciences students regarding hepatitis B and C virus infections: a national survey. Am J Infect Control. 2017;45(11):e135-e41.
34. Khodayari-Zarnaq R, Ravaghi H, Mohammad Mosaddeghrad A, Sedaghat A, Mohraz M. HIV/AIDS policy agenda setting in Iran. Med J Islam Repub Iran. 2016;30:392.
35. WHO. Prevention and control of viral hepatitis infection: framework for global action 2012 [Available from: 27 September 2018).
36. Wittenborn J, Brady J, Dougherty M, Rein D. Potential epidemiologic, economic, and budgetary impacts of current rates of hepatitis C treatment in medicare and non‐medicare populations. Hepatol Commun. 2017;1(2):99-109.
37. Hosseini Divkolaye NS, Burkle FM Jr. The enduring health challenges of Afghan immigrants and refugees in Iran: a systematic review. PLoS Curr. 2017;9:ecurrents.dis.449b4c549951e359363a90a7f4cf8fc4.
38. Sharma S, Carballo M, Feld JJ, Janssen HL. Immigration and viral hepatitis. J Hepatol 2015 Aug;63(2):. 2015;63(2):515-22.
39. Mukamel DB, Haeder SF, Weimer DL. Top-down and bottom-up approaches to health care quality: the impacts of regulation and report cards. Annu Rev Public Health. 2014;35:477-9.
40. Behzadifar M, Gorji HA, Rezapour A, Bragazzi NL, Alavian SM. The role of the primary healthcare network in Iran in hepatitis C virus elimination by 2030. J Virus Erad. 2018;4(3):186-8.
41. Duffell EF, Hedrich D, Mardh O, Mozalevskis A. Towards elimination of hepatitis B and C in European union and European economic area countries: monitoring the world health organization’s global health sector strategy core indicators and scaling up key interventions. Euro Surveill. 2017;22(9):30476.
42. El-Jardali F, Lavis JN, Ataya N, Jamal D, Ammar W, Raouf S. Use of health systems evidence by policymakers in eastern Mediterranean countries: views, practices, and contextual influences. BMC Health Serv Res. 2012;12:200.
43. Nedjat S, Gholami J, Yazdizadeh B, Nedjat S, Maleki K, Majdzadeh R. Research’s practice and barriers of knowledge translation in Iran. Iran J Public Health. 2014;43(7):968–80.
44. Walt G, Shiffman J, Schneider H, Murray SF, Brugha R, Gilson L. 'Doing' health policy analysis: methodological and conceptual reflections and challenges. Health Policy Plan. 2008;23(5):308-17.
45. Miri-Bonjar M, Khorram A, Ansari-Moghaddam A. The necessity of enhanced harm reduction programs to prevent blood-borne infections amongst injection drug users. Health Scope. 2016;5(1):e32754.
46. Sharhani A, Mehrabi Y, Noroozi A, Nasirian M, Higgs P, Hajebi A, et al. Hepatitis C virus seroprevalence and associated risk factors among male drug injectors in Kermanshah, Iran. Hepat Mon. 2017;17(10):e58739.
47. Bielen R, Stumo SR, Halford R, Werling K, Reic T, Stöver H, et al. Harm reduction and viral hepatitis C in European prisons: a cross-sectional survey of 25 countries. Harm Reduct J. 2018;15(1):25.
48. Iversen J, Wand H, Topp L, Kaldor J, Maher L. Reduction in HCV incidence among injection drug users attending needle and syringe programs in Australia: a linkage study. Am J Public Health. 2013;103(8):1436–44.
49. Hedrich D, Alves P, Farrell M, Stöver H, Møller L, Mayet S. The effectiveness of opioid maintenance treatment in prison settings: a systematic review. Addiction. 2012;107(3):501-17.
50. Hajarizadeh B. Generic direct acting antiviral treatment: the first step towards elimination of hepatitis C in Iran. Hepat Mon. 2017;17(1):e45788.
51. Farnia M, Shahbazi M, Moradi G, Alizadeh S, Ebrahi B, Kandi Kalle M. Evaluation of Harm reduction Programs in prisons from the attitude and viewpoint of Iranian prison staff. SJSPH. 2013;11(1):29-44.
52. McDonnell A, Wilson R, Goodacre S. Evaluating and implementing new services. BMJ. 2006;332(7533):109–12.