Every medical student in Pakistan meets this patient before final year. A man in his fifties, sugar still high on two tablets, tired all the time, with a raised ALT from an old report that nobody followed up. Ask him about injections and he laughs. He has had dozens, most of them from the dispenser down the street.
In Pakistan, this is not an unusual case. It is an ordinary Tuesday in a medical OPD. Textbooks teach diabetes and hepatitis C in two different chapters, and exams test them separately. The patients do not arrive separately. Learning to see both conditions in the same person is one of the most useful habits a future clinician can build here.
How heavy is Pakistan’s double burden?
Pakistan now carries one of the largest combined loads of diabetes and hepatitis C anywhere in the world. The numbers from the last two years are hard to ignore.
The 11th edition of the IDF Diabetes Atlas, released in 2025, reported that Pakistan has the highest age-standardised diabetes prevalence in the world, at 31.4% of adults aged 20 to 79. That works out to about 34.5 million adults living with diabetes. Roughly 9.3 million of them do not know they have it.
Hepatitis C tells a similar story. The WHO Global Hepatitis Report 2026 estimated that about 9 million people in Pakistan were living with hepatitis C in 2024, making Pakistan the single largest contributor to the global total. WHO puts that global total at about 47 million. In other words, close to one in five people with chronic hepatitis C worldwide lives in Pakistan.
So when a house officer in Lahore or Hyderabad sees a patient with both conditions, it is not bad luck. It is simple arithmetic.
Why diabetes and hepatitis C are not two separate chapters
Hepatitis C does not just damage the liver. It also makes the body worse at handling sugar. The liver is the main organ that responds to insulin, and chronic infection interferes with that response. The result is insulin resistance, the same problem that sits at the root of type 2 diabetes.
The link has been measured many times. A 2008 meta-analysis of 34 studies in the Journal of Hepatology found that people with hepatitis C had about 1.7 times the odds of developing diabetes compared with uninfected people. The excess risk showed up even when they were compared with people who had hepatitis B, which points towards a direct effect of the virus itself.
A later meta-analysis of 33 studies, published in 2017, confirmed the association and found it runs both ways. Hepatitis C was more common in people with type 2 diabetes than in people without it. The authors called for an integrated approach to treating the two conditions together.
The damage also compounds. A 2023 meta-analysis in Heliyon found that among patients with hepatitis C cirrhosis, those who also had diabetes had a 74% higher risk of developing liver cancer. One disease does not simply sit beside the other. It makes the other more dangerous.
What the national data actually shows
Pakistan’s own surveys show a diabetes epidemic that starts earlier and hides longer than most students expect. The second National Diabetes Survey of Pakistan, run from 2016 to 2017 across all four provinces and published in BMJ Open, tested more than 10,800 adults. It found a diabetes prevalence of 26.3%, and 7.1% of adults had diabetes that had never been diagnosed. Another 14.4% had pre-diabetes.
The resources to manage all this are thin. The IDF Atlas estimates that Pakistan spends about USD 79 a year per person with diabetes, one of the lowest figures in the world, and linked around 230,000 adult deaths to diabetes in 2024.
On the hepatitis side, much of the spread traces back to healthcare itself. A 2020 study in the WHO Eastern Mediterranean Health Journal reported that Pakistanis receive 4.2 to 4.6 therapeutic injections per person each year, and that 17% to 50% of these are given with reused syringes. The WHO Global Hepatitis Report 2026 also showed sharp regional differences, with hepatitis C prevalence of 8.9% in Punjab, 6.5% in Khyber Pakhtunkhwa, 6.2% in Sindh and 5.2% in Balochistan.
For a future clinician, that last point stings. Much of Pakistan’s hepatitis C was not spread by lifestyle. It was spread through unsafe clinical practice.
Why so many patients reach the clinic late
Most patients with either condition feel well for years. By the time they come in, there is often damage that earlier care could have slowed. There are a few honest reasons for that.
Both diseases are quiet:
Early type 2 diabetes rarely hurts, and chronic hepatitis C can stay silent for decades. Many patients only find out during a pre-surgery screen, a blood donation, or a visa medical.
Injections are trusted more than tablets:
In many communities, a drip or an injection feels like “real” treatment. Patients ask for it, and unqualified practitioners are happy to provide it, often with equipment that has been used before.
Cost and distance get in the way:
A proper diabetes review needs an HbA1c, kidney tests, and an eye check. A hepatitis workup needs a viral load and a liver fibrosis assessment. For a family outside the big cities, that can mean several days of travel and lost wages.
Stigma still follows hepatitis:
Many people still link hepatitis C with drug use or “bad blood”. Families sometimes hide a diagnosis because they worry about marriage prospects or how relatives will react.
Care is split between clinics:
The diabetes clinic manages sugar and the liver clinic manages the virus. Unless one doctor thinks to check for the other condition, a patient can be followed for years with half the picture missing.
Why missing one diagnosis can make the other worse
Treating one condition while missing the other is not a neutral mistake. It changes how both diseases behave.
A patient with uncontrolled sugar and undiagnosed hepatitis C may be told to lose weight and take more medicine, while the virus quietly keeps driving insulin resistance. A patient cured of hepatitis C may be discharged from the liver clinic without anyone checking whether diabetes has already set in. And a patient with both conditions and cirrhosis carries a higher liver cancer risk than either disease would cause alone.
There is good news in the same data. Clearing the virus seems to help the sugar side too. A 2025 study from Lahore, published in Scientific Reports, followed 190 patients treated with sofosbuvir and daclatasvir. After 12 weeks of treatment, every patient cleared the virus, and average insulin resistance (measured by HOMA-IR) fell from 13.63 to 3.16.
That is one reason a sugar profile is worth watching during and after hepatitis C treatment. Any change in diabetes medicine should be decided by the treating doctor, not guessed at by the patient.
How screening and treatment access are changing in Pakistan
Hepatitis C is now one of the few chronic infections that can be cured with a short course of tablets. According to WHO, direct-acting antivirals cure more than 95% of people with hepatitis C. There is still no vaccine, so testing and safe practice remain the main protection.
Pakistan’s policy response has also grown. The Prime Minister’s Hepatitis C Elimination Programme aims to offer free screening, diagnosis and treatment. Its goals are to treat half of all people living with hepatitis C by 2027 and to eliminate it as a public health threat by 2030.
Access to specialists is the other half of the problem. Hepatologists and diabetologists are concentrated in a few large cities. Video consultation has made a real difference here. Patients in smaller towns can now consult a verified hepatologist online to review their viral load, fibrosis results, and treatment options without a long trip. For many families, that first conversation is what turns a positive screening test into completed treatment.
What future clinicians can do differently
The most useful lessons from Pakistan’s double burden are small habits that fit into an ordinary consultation. Here is a practical way to start.
Think of both conditions together:
When you see a newly diagnosed diabetic, ask whether they have ever been tested for hepatitis C. When you see a hepatitis C patient, ask when their sugar was last checked. The research supports an integrated approach, even where local protocols are still catching up.
Take an injection history:
Ask about drips, injections, dental work, blood transfusions, and shared razors. It takes two minutes, and it often explains a positive result the patient cannot make sense of.
Do not add to the problem:
Avoid unnecessary injections, use a new syringe every time, and explain to patients why tablets often work just as well. This is where prevention begins.
Explain cure in plain words:
Many patients still believe hepatitis C is a death sentence. Telling them clearly that most people can be cured is often what brings them back for treatment.
Refer early, not late:
A patient with cirrhosis and diabetes needs specialist follow-up, including regular liver cancer surveillance as advised by the treating team.
Warning signs that should not wait
Some symptoms in a patient with diabetes, hepatitis C, or both should not wait for the next routine visit. Patients and families should seek care promptly if they notice any of the following:
· Yellowing of the eyes or skin
· Swelling of the belly or legs
· Vomiting blood or passing black, tarry stools
· New confusion, drowsiness, or unusual behaviour
· Extreme thirst, frequent urination, and weight loss with very high sugar readings
· A foot wound or ulcer that is not healing
For patients who want to understand their condition better before a visit, a clear guide on diabetes symptoms and complications is a useful place to start.
Important: If a patient is vomiting blood, becomes confused, or loses consciousness, call Rescue 1122 or go to the nearest emergency department straight away.
A realistic way forward
Pakistan will not solve its diabetes and hepatitis C burden in one budget cycle or one elimination programme. The numbers are too large, and the habits behind them are too old. But the tools are better than they have ever been. Tests are cheaper, the cure for hepatitis C works, and specialists are reachable by phone.
What is still missing, in many clinics, is the habit of looking for both diseases at once.
A normal-looking sugar report is not a healthy liver. A cured virus is not a finished job. Future clinicians who learn this early, and who read enough to understand the basics (a reliable overview of hepatitis symptoms and prevention is a good start for patients too), will catch what others miss.
The Pakistan of ten years ago made this hard. Between free hepatitis C treatment, better screening, and online access to specialists, the Pakistan of today makes it much easier. The reasons for missing these patients are shrinking. The reasons to find them are not.
This article is for educational purposes and is not a substitute for medical advice. Treatment decisions should be made with a qualified healthcare provider.
Sources
1. International Diabetes Federation. (2025). IDF Diabetes Atlas, 11th edition, Chapter 3: The global picture of diabetes. https://www.ncbi.nlm.nih.gov/books/NBK618744/
2. The News. (2025). Pakistan ranks first globally in diabetes prevalence (reporting IDF Atlas 11th edition figures). https://www.thenews.com.pk/print/1299445-pakistan-ranks-first-globally-in-diabetes-prevalence
3. Dawn. (2026). Pakistan pushes for global action against hepatitis amid alarming WHO findings (WHO Global Hepatitis Report 2026). https://www.dawn.com/news/2010592
4. World Health Organization. (2026). Hepatitis C fact sheet. https://www.who.int/news-room/fact-sheets/detail/hepatitis-c
5. White DL, Ratziu V, El-Serag HB. (2008). Hepatitis C infection and risk of diabetes: a systematic review and meta-analysis. Journal of Hepatology. https://pubmed.ncbi.nlm.nih.gov/18814931/
6. Hepatitis C virus infection and development of type 2 diabetes mellitus: systematic review and meta-analysis. (2017). Reviews in Endocrine and Metabolic Disorders. https://link.springer.com/article/10.1007/s11154-017-9440-1
7. Zang Y, Xu W, Qiu Y, Jiang X, Fan Y. (2023). Presence of diabetes further heightens hepatocellular carcinoma risk in patients with hepatitis B or hepatitis C virus-related cirrhosis: a meta-analysis. Heliyon. https://pubmed.ncbi.nlm.nih.gov/37520959/
8. Basit A, Fawwad A, Qureshi H, Shera AS. (2018). Prevalence of diabetes, pre-diabetes and associated risk factors: second National Diabetes Survey of Pakistan (NDSP), 2016-2017. BMJ Open. https://pubmed.ncbi.nlm.nih.gov/30082350/
9. Khan et al. (2020). Reuse of syringes for therapeutic injections in Pakistan: rethinking determinants. Eastern Mediterranean Health Journal. https://www.emro.who.int/emhj-volume-26-2020/volume-26-issue-3/reuse-of-syringes-for-therapeutic-injections-in-pakistan-rethinking-determinants.html
10. Jabeen et al. (2025). Modulation of glucose metabolism and insulin resistance following hepatitis C virus clearance via direct-acting antivirals. Scientific Reports. https://www.nature.com/articles/s41598-025-97827-1
Farwa Hassan is the Web Acquisition Lead at Marham.pk. A homeopath pursuing further studies in psychology, she creates health content that helps patients across Pakistan find reliable information and the right doctors. Reach her at farwa.hassan@marham.pk
or on LinkedIn.
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