The World Health Organization’s hepatitis C elimination goals for 2030 include major reductions in new infections and liver-related deaths, plus high treatment coverage for people living with chronic hepatitis C (HCV). Despite major advances—highly effective direct-acting antivirals and simpler testing—most countries are off track. A key reason is that HCV burden is concentrated in marginalized groups, especially people who use drugs (including people who inject drugs) and people who are incarcerated. These groups are often left out of HCV control efforts due to stigma, criminalization, limited harm reduction, and practical barriers like transportation, housing instability, and poor access to specialty care. In some places, abstinence requirements for treatment add another access barrier.

The article argues that elimination will require care models that meet high-risk groups where they are. That means integrating HCV testing and treatment with harm reduction and supportive services (e.g., opioid agonist therapy, syringe services, basic needs support). It also means expanding community-based and primary care delivery and using telehealth—approaches shown to improve uptake and completion while maintaining cure rates, even with ongoing drug use. In prisons, HCV care is often even more limited, yet prisons can be sites of continued transmission. Treatment scale-up can reduce transmission, but reinfection remains a risk without stronger prevention (including opioid agonist therapy and prison needle-syringe programs). The authors stress that leaving people who use drugs and incarcerated people behind threatens progress toward 2030 targets. They argue that policy and funding shifts are needed to reduce punitive barriers and expand equitable access.

Reference: Rockstroh JK, Swan T, Chang J, Elamouri F, Lloyd AR. The path to hepatitis C elimination: who are we leaving behind and why? J Int AIDS Soc. 2023 Jul;26(7):e26136. doi: 10.1002/jia2.26136. PMID: 37494827; PMCID: PMC10371387.

This cohort study followed people with hepatitis C-related cirrhosis who achieved cure with direct-acting antivirals in the Veterans Affairs health care system between January 2014 and December 2022. The goal was to evaluate whether staying up to date with recommended hepatocellular carcinoma (HCC) screening after cure is associated with better survival outcomes, since guidelines advise continued screening but real-world outcome data have been limited. Among 16,902 patients (median age 64; 97% male), 1,622 developed HCC. Over follow-up, the cumulative incidence of HCC declined from 2.4% in year 1 to 1.0% by year 7, reinforcing that risk falls over time after cure but does not disappear.

The authors measured screening exposure as the percentage of time patients were “up to date” with recommended screening, focusing particularly on the four years before HCC diagnosis (the detectable asymptomatic phase). Being up to date for at least 50% of that four-year window was associated with improved overall survival after HCC diagnosis, and each 10% increase in time up to date was linked to a 3.2% lower hazard of death (HR 0.97). More consistent screening also was associated with better clinical endpoints at diagnosis and treatment: each 10% increase in time up to date corresponded to higher odds of early-stage HCC detection (+10.1%) and receipt of curative therapy (+6.8%). There was a significant interaction with time since cure, with no survival association observed among patients diagnosed with HCC more than 5 years after cure—suggesting the measurable benefit of screening may be strongest in the earlier post-cure period. Overall, the findings support continued screening in eligible patients with hepatitis C-related cirrhosis who achieve cure.

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Reference: Mezzacappa C, Kim NJ, Vutien P, et al. Screening for Hepatocellular Carcinoma and Survival in Patients With Cirrhosis After Hepatitis C Virus Cure. JAMA Netw Open. 2024 Jul 1;7(7):e2420963. doi: 10.1001/jamanetworkopen.2024.20963. PMID: 38985470; PMCID: PMC11238019.

In this study, researchers used national data from the Veterans Health Administration (VHA) to study new cases of hepatocellular carcinoma (HCC) after direct-acting antiviral (DAA) treatment for hepatitis C. They identified adults treated in 129 VHA hospitals in 2015 and followed them from DAA completion until HCC, death, or September 30, 2016. Patients with HCC before or during DAA initiation were excluded from the primary analysis, and sustained virologic response (SVR) was defined as negative hepatitis C RNA at least 12 weeks after treatment. They also captured key risk factors (including cirrhosis, FIB-4, diabetes, alcohol use, and drug use) and used Cox models to compare HCC risk in patients with SVR vs no SVR, plus subgroup analyses to understand who remains at highest risk after cure.

Among 22,500 treated patients, 19,518 achieved SVR and 2,982 did not. Over 22,963 person-years of follow-up, 271 patients developed HCC after treatment completion, for an overall annual incidence of 1.18 per 100 person-years. HCC incidence was much lower with SVR (0.90 per 100 person-years) than without SVR (3.45 per 100 person-years), and SVR was linked to about a 76% lower adjusted risk of HCC (adjusted HR ~0.28). Even after cure, risk persisted—especially in patients with cirrhosis (about 1.82% per year) and those with high FIB-4 (>3.25), and alcohol use also increased risk. The study did not find evidence that DAAs “promote” HCC: the small number of cases diagnosed during treatment looked similar in demographics and tumor stage/size to those diagnosed afterward. The practical takeaway is that SVR substantially lowers HCC risk, but surveillance remains important for patients with cirrhosis or advanced fibrosis.

Reference: Kanwal F, Kramer J, Asch SM, et al. Risk of Hepatocellular Cancer in HCV Patients Treated With Direct-Acting Antiviral Agents. Gastroenterology. 2017 Oct;153(4):996-1005.e1. doi: 10.1053/j.gastro.2017.06.012. Epub 2017 Jun 19. PMID: 28642197.