Although testing for hepatitis C virus (HCV) increased between 2014 and 2021, only about a third of people diagnosed with the virus in the United States received treatment. These findings, published in the Journal of Viral Hepatitis, suggest that the United States remains far from meeting the World Health Organization (WHO) hepatitis C elimination goals.

“Treatment uptake across the U.S. remains low, underscoring the need for additional measures to expand access to testing and treatment, necessary to reach the U.S. goals for HCV elimination by 2030,” the study authors concluded.

The WHO targets for eliminating hepatitis C as a public health threat by 2030 include diagnosis of at least 90% of people with hepatitis C and treatment of at least 80% of those with active infection. Left untreated, chronic hepatitis C can lead to serious liver complications, including cirrhosis and liver cancer. But direct-acting antiviral therapy cures hepatitis C in more than 95% of those who complete treatment, which typically takes two or three months.

Marc Ghany, MD, of the National Institutes of Health’s National Institute of Diabetes and Digestive and Kidney Diseases, and colleagues sought to understand trends in the hepatitis C care cascade. They used deidentified data from LabCorp and Quest Diagnostics for the period between January 2014 and December 2021. These laboratories provide HCV testing in 51 U.S. states and territories.

Over the study period, 46,646,661 people were tested for HCV antibodies, with 2,253,500 (5%) testing positive. Testing rates increased steadily from 2014 to 2019, dropped during the height of the COVID-19 pandemic, then rose again in 2021.

After a positive antibody test, an HCV RNA test is done to determine if a person has active infection and is eligible for treatment. Of the 3,117,372 people who received HCV RNA tests, 1,951,742 (63%) had detectable virus. Men were more likely than women to test HCV RNA positive (63% versus 37%). People ages 51 to 64 accounted for the highest proportion of positive tests (40%), followed by those ages 31 to 50 (34%); 2% were living with HIV. More people who tested HCV RNA positive lived in the Southeast (33%) compared with the West (22%), Northeast (21%), Midwest (15%) and Southwest (10%). About three quarters (76%) lived in urban areas and 24% in rural areas. Just over half (52%) had absent or minimal liver fibrosis at the time of diagnosis, but 26% had already progressed to advanced fibrosis or cirrhosis.

Among those with active infection, 672,745 people (35%) were treated, and of those, 643,043 (96%) were cured. Treatment rates were higher for older people, those with higher fibrosis scores and those who had HIV. The treatment rate was highest in the Northeast (47%) and lowest in the Midwest (28%), and it was higher in urban compared with rural areas (40% versus 35%). People who received reflex testing—in which HCV RNA testing is automatically done when an antibody test is positive, using the same blood sample—were four times more likely to be treated. Reflex testing increased from 21% in 2014 to 36% in 2021.

Compared with 2019, 24% more HCV antibody tests were done, but 23% fewer people were treated and 25% fewer people were cured in 2021. Most diagnosis and treatment was done by primary care providers, followed by hepatitis C specialists and other providers.

“For the U.S. to reach goals for HCV elimination, linkage to treatment for persons diagnosed with HCV infection must improve,” the researchers wrote. “Our analysis suggests that several simple measures may provide large dividends in the U.S. elimination efforts. These include expanding, through training, the number of primary care providers treating HCV infection, removal of restrictions to accessing treatment, implementation of reflex HCV RNA testing, and updating the diagnostic algorithm to include the use of rapid point-of-care tests, which may reduce loss of persons between diagnosis and linkage to care. The U.S. has all the tools required for HCV elimination—now is the time to act.”

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