Loss to Follow-up in the Hepatitis C Care Cascade: A Substantial Problem but Opportunity for Micro-elimination

A Substantial Problem But Opportunity for Micro-elimination

Marleen van Dijk; Joost P.H. Drenth


J Viral Hepat. 2020;27(12):1270-1283. 

In This Article


The global hepatitis C virus (HCV) epidemic stimulated the World Health Organization (WHO) to develop viral hepatitis elimination targets in 2016.[1] An estimated 71 million people worldwide were infected by HCV in 2015.[2] Thus, the WHO set the target of a 90% reduction in new infections and a 65% reduction in viral hepatitis-related mortality by 2030 as compared to 2015. These are ambitious but feasible goals, since we have ample tools at hand to curtail the current HCV epidemic. The diagnosis of active HCV can be readily made, by means of sample analysis in a central facility or through point-of-care testing. Direct-acting antivirals (DAAs) cure the infection in ≥95% of cases.[3] Pangenotypic DAAs can be used in all patients with only a few barriers such as potential drug-drug interactions or presence of (decompensated) cirrhosis.[4,5] Most countries have assessed their specific HCV population and the availability of tools in their countries and subsequently developed national hepatitis plans in line with the WHO elimination targets.[6]

HCV elimination according to the WHO goals can be achieved in various ways, which ideally should be incorporated in a multifaceted approach. We can focus on prevention, by developing a vaccine or by increasing awareness and educating groups at risk of transmission of the virus. Secondly, we can develop or augment existing screening strategies, in order to diagnose more patients. Lastly, we can treat as many infected patients as possible. Since the development of highly effective and tolerable DAAs, HCV elimination projects have primarily focused on prevention and screening, since treatment was not seen as a problem anymore. However, ensuring treatment for all diagnosed patients remains a problem to this day.

Loss to follow-up (LTFU) prevents patients from receiving the care they need to be cured of their infection. The extent of this problem remains unclear, especially in the DAA era. In order to grasp the scope of the LTFU problem, one needs to understand the HCV care cascade and how patients move through its phases. This review aims to assess published literature on LTFU in the HCV cascade of care during the DAA era and will provide an overview of issues and possible solutions.