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 HCV Care Cascade

In order to grasp the magnitude of the LTFU problem in chronic HCV patients, we must first understand the HCV care cascade. Reviewing published literature on this subject shows that definitions of the care cascade vary with each paper. However, efforts to come up with an unambiguous description of the HCV care cascade have been made. In 2018, the WHO established a monitoring framework that includes 10 core indicators addressing prevention, diagnosis, treatment and mortality.[10] The WHO states that four of the 10 core indicators should be used for cascade of care reporting: the number of patients infected, diagnosed, treated and cured.[11] Recently, a study group comprised of clinical, epidemiological and public health experts from Australia, Europe and North America have proposed a clarified and slightly extended care continuum.[12] Their Consensus HCV Cascade of Care (CHCoC) is based on the WHO indicators, a review of published literature on HCV care continuums and on methodological issues in HIV cascade of care monitoring. It can be divided into four key steps (the four WHO indicators) and three supplementary steps: (a) estimated HCV prevalence; (b) diagnosed with chronic HCV; (c) linked to HCV care; (d) liver disease assessed; (e) started on treatment in (year); (f) achieved sustained virological response (SVR) in (year); and (g) accessed chronic post-SVR care. The authors provided pragmatic definitions for the four key steps, which stakeholders can use to report on elimination progress. Understandably, by increasing the number of steps in the care cascade, the chances of being lost from care also increase. LTFU is seen as a major problem, because it remains unsure whether the patient is cured or not. Liver disease in these patients may progress, and they may even contribute to HCV transmission if they still exhibit certain risk behaviour. When reviewing the literature published on HCV care cascades in the DAA era and their LTFU rates, we used the CHCoC to report our findings (see Figure 1). And overview and characteristics of the included studies in this review can be found in Table 1.

Figure 1.

Hepatitis C care cascade. Step 1: HCV prevalence; step 2: diagnosed with chronic HCV; step 3: linked to care; step 4: liver disease assessed; step 5: started on treatment; step 6: achieved SVR; step 7: accessed chronic post-SVR care. Figure freely adapted with permission from Safreed-Harmon et al.12 HCV, hepatitis C virus; LTFU, lost to follow-up; SVR, sustained virological response