Global Cascade of Care for Chronic Hepatitis C Virus Infection

A Systematic Review and Meta-analysis

Mohammad T. Yousafzai; Sahar Bajis; Maryam Alavi; Jason Grebely; Gregory J. Dore; Behzad Hajarizadeh


J Viral Hepat. 2021;28(10):1340-1354. 

In This Article

Abstract and Introduction


The World Health Organization 2030 targets for hepatitis C virus (HCV) elimination include diagnosing 90% of people with HCV and treating 80% of people diagnosed with HCV. This systematic review assessed reported data on the HCV care cascade in various countries and populations, with a focus on direct-acting antiviral (DAA) treatment uptake. Bibliographic databases and conference presentations were searched for studies reporting the HCV care cascade (DAA treatment uptake was a requirement) among the overall population with HCV or sub-populations at greater risk of HCV. Population-based studies, with participants representative of a city, province/state or country were eligible. Twenty eligible studies were included, reporting HCV care cascade in 28 populations/sub-populations from 11 countries. DAA treatment uptake at national levels was reported from Iceland (95%), Egypt (92%), Georgia (79%), Norway (18%) and Sweden (8%), and at sub-national levels from the Netherlands (52%), Canada (50%), the United States (29%) and Denmark (5%). Among people with HIV-HCV co-infection, DAA treatment uptake was 62% in Canada, 44% in the Netherlands, 21% in Switzerland and 18% in the United States. Among people who inject drugs, DAA treatment uptake was 50% in Georgia, 40% in Canada, 37% in Australia and 13% in the United States. Data among people experiencing homelessness were only available from the United States (treatment uptake: 12%–14%). We found no eligible study reporting HCV care cascade data in prisons. Relatively few countries reported HCV care cascade at the national level. DAA treatment uptake was widely varied across populations/sub-populations, with higher rates reported in recent years.


In 2015, an estimated 71 million of global population were living with hepatitis C virus (HCV) infection,[1] among whom 20% had been diagnosed and 7% of those diagnosed had initiated treatment.[2] In 2016, the World Health Organization (WHO) endorsed a global viral hepatitis strategy, setting specific targets for elimination of HCV as a 'public health threat', including diagnosing 90% people living with HCV infection and treating 80% of people diagnosed with HCV infection by 2030.[3]

Introduction of highly curative direct-acting antiviral (DAA) therapy raised optimism for achieving WHO's ambitious HCV elimination goals. There are, however, major barriers to overcome in various levels related to access to affordable HCV testing and DAA treatment, and linkage of patients to HCV care.[4] The cascade of care or care continuum, also used for the monitoring of HIV treatment programs, is an effective tool in assessment of different stages of the clinical care pathway for a particular disease.[5,6] Several modelling studies in different countries have estimated HCV care cascade components, particularly diagnosis and treatment uptake, and projected progress in achieving HCV elimination.[7–10] However, real-world representative data of the HCV care cascade are crucial to confirm modelling-based estimations and identify gaps in the HCV care continuum where interventions are required.

In this study, we conducted a systematic review to evaluate reported data of the HCV care cascade in various countries, with a particular focus on DAA treatment uptake among the overall population living with HCV and among sub-populations at greater risk of HCV infection.