Identifying Progress and Gaps Towards Hepatitis C Elimination in the United States

Identifying Progress and Gaps Towards Hepatitis C Elimination in the United States

Jagpreet Chhatwal; Qiushi Chen; Emily D. Bethea; Chin Hur; Anne C. Spaulding; Fasiha Kanwal


Aliment Pharmacol Ther. 2019;50(1):66-74. 

In This Article

Abstract and Introduction


Background: The hepatitis C virus (HCV) care cascade has changed dramatically following the introduction of direct-acting anti-virals (DAAs). Up-to-date estimates of the cascade are needed to monitor progress, identify key gaps and inform policy.

Aim: To estimate the current and future HCV care cascade in the United States, nationally and in select subpopulations of interest.

Methods: We used a previously validated mathematical model to simulate the landscape of HCV in the United States from 2011 onwards, accounting for HCV screening policy updates, newer HCV treatments and rising HCV incidence.

Results: By the end of 2018, of 4.29 million HCV persons alive, 2.71 million (63%) were actively viremic, 2.24 million (52%) aware and 1.58 million (37%) cured. By 2030, under the status quo, of 3.65 million HCV persons alive, 1.88 million (51%) would be viremic, 2.25 million (62%) aware and 1.77 million (49%) cured. The HCV care cascade in 2018 differed substantially by subpopulation: of 1.34 million incarcerated HCV persons, 96% were viremic, 36% aware and 4% cured; of 0.87 million HCV persons in Medicare, 31% were viremic, 72% aware and 69% cured; and of 0.37 million HCV persons in Medicaid, 49% were viremic, 54% aware and 51% cured. Implementing universal screening, providing unrestricted treatment and controlling HCV incidence were factors found to have the largest effect on improving the HCV care cascade.

Conclusions: Since the launch of DAAs, the HCV care cascade has shifted towards higher awareness and treatment rates; however, additional interventions are needed to move towards HCV elimination.


More than 2 million people are infected with chronic hepatitis C virus (HCV) in the United States.[1] Until recently, HCV was the leading indication for liver transplantation. However, with the availability of highly effective oral direct-acting anti-virals (DAAs) beginning in 2014, the landscape of HCV has changed dramatically. Since then, despite more than a million patients achieving successful HCV cure, a large percentage of those with active viremia are still unaware of their HCV status and remain chronically infected.[2]

In 2016, the World Health Assembly pledged to eliminate HCV as a public health threat (ie 90% reduction in HCV incidence; 65% reduction in HCV-mortality) by 2030. To achieve HCV elimination, the World Health Organization (WHO) launched a global strategy with an ambitious goal of diagnosing 90% of HCV-infected people and treating 80% of all eligible patients by 2030.[3] Similarly, the National Academy of Medicine launched a national strategy to eliminate HCV in the US.[4] To monitor progress towards elimination goals and to identify gaps in HCV screening and treatment services, the WHO has defined the cascade of care to analyse the continuum of services that people living with HCV should receive as they go through various stages—from testing to diagnosis, to treatment, and through cure.[3]

Available studies published on HCV care cascade date back to the pre-DAA era,[5] which estimated that 50% HCV patients were aware of their disease and only 9% achieved sustained virologic response (SVR), surrogate for cure.[5] Since the availability of DAAs, the cascade of HCV care has changed as the result of increased treatment uptake—more than a million people have received treatment with DAAs.[2] In addition, many people have become aware of their disease status because of updates in HCV screening—the US Preventive Services Task Force in 2013 recommended one-time HCV testing for all people born between 1945 and 1965.[6]

Up-to-date estimates of HCV care cascade are therefore needed to track progress towards HCV elimination goals. Furthermore, HCV care cascade in different subpopulations are required to identify potential gaps in care at the subpopulation level. For instance, despite the wide availability of DAAs, the uptake of HCV screening and treatment in correctional settings remains low.[7] Similarly, several state Medicaid programs have restricted DAAs access to select patients that meet strict criteria, including advanced fibrosis. The HCV care cascade of each of these populations can provide a useful metric to evaluate the progress towards HCV elimination.[8]

The objective of our study was to estimate the current and future HCV care cascade at the national level and in key subpopulations—privately insured, Medicaid, Medicare, incarcerated and baby boomers. Our study accounted for recent uptake in HCV treatment, changes in HCV screening policies, increasing HCV incidence rates and HCV persons in National Health and Nutrition Examination Survey (NHANES) as well as non-NAHES populations. We estimated HCV care cascade for the years 2011 (ie the year first-generation DAAs became available), 2018 (current situation) and 2030 (the target year for HCV elimination).