Hepatitis D in the Middle East: A Review of Disease Burden, Health-System Barriers, and Strategic Directions for Management and Elimination.

Hepatitis delta virus (HDV) is the most aggressive form of viral hepatitis and worsens outcomes in people with chronic hepatitis B (HBV). It speeds up fibrosis, causes early cirrhosis, hepatic decompensation, and increases hepatocellular carcinoma risk. In the Middle East, presumed high HBV prevalence, uneven surveillance, and significant diagnostic and treatment barriers lead to under-recognition of HDV and uncertainty about its true prevalence. This review summarizes current regional evidence on HDV distribution, diagnostic gaps, emerging treatments, and health policy shortcomings. The results show wide variation in prevalence, with some populations exhibiting endemic levels and others lacking reliable screening data due to limited testing and limited availability of HDV RNA. Diagnostic issues are exacerbated by high costs, limited laboratory resources, gaps in provider awareness, and delayed patient presentation. While new therapies like bulevirtide and lonafarnib show promising virologic and biochemical results, access remains limited due to regulatory delays, costs, and fragmented care. Policy analysis finds HDV is rarely prioritized in national hepatitis plans, leading to weak surveillance, poor registry systems, and little focus on high-risk groups. Hence, improving routine screening for HBsAg-positive individuals, expanding access to affordable RNA testing, increasing access to approved and emerging therapies, and establishing integrated HBV-HDV management protocols are vital for reducing the disease burden. Including HDV in national elimination efforts, boosting surveillance, and enhancing workforce capacity are crucial steps to meet the WHO 2030 hepatitis goals and curb HDV's growing public health impact in the Middle East.