Closing the Hepatitis C Treatment Gap: United States Strategies to Improve Retention in Care

Austin T. Jones; Christopher Briones; Torrence Tran; Lisa Moreno-Walton; Patricia J. Kissinger


J Viral Hepat. 2022;29(8):588-595. 

In This Article

Abstract and Introduction


The hepatitis C virus (HCV) treatment landscape is shifting given the advent of direct-acting antivirals and a global call to action by the World Health Organization. Eliminating HCV is now an issue of healthcare delivery. Treatment is limited by the complexity of the HCV care continuum, expensive therapy and competing health burdens experienced by an underserved HCV population. The objective of this literature review was to assess strategies to improve retention in HCV care, with particular focus on those implemented in the United States. We identified barriers in HCV care retention and propose solutions to increase HCV treatment delivery. The following recommendations are herein described: improving the cohesion of health services through localized care and integrated case management, expanding the supply of non-specialist HCV treatment providers, leveraging patient navigators and care coordinators, improving adherence through directly observed therapy and reducing cost barriers through value-based payment and pharmaceutical subscription models.


Globally, 71 million people have chronic hepatitis C virus (HCV) infection, of whom 2.4 million live in the United States (US).[1,2] Untreated HCV infection results in cirrhosis, hepatocellular carcinoma (HCC) and increased mortality.[3] HCV also causes significant extra-hepatic morbidity including vascular, cardiometabolic and renal disease.[4]

The advent of direct-acting antivirals (DAAs) in 2011 revolutionized HCV therapy. Boasting HCV cure rates exceeding 95%, DAAs have replaced interferon-based therapy as standard of care for HCV.[5] In addition to their superior efficacy, DAAs have proven to be safe, simple to administer as oral tablets, of short duration (8–12 weeks) and well-tolerated compared with interferon-based regimens.[6]

With the paradigm shift in treatment, there has been renewed action to reduce the global burden of HCV. In 2016, the World Health Assembly adopted the Global Health Sector Strategy on viral hepatitis to eliminate the disease by 2030.[7] To accomplish this, the World Health Organization (WHO) aims to close the diagnostic and treatment gap by diagnosing 90% of people with HCV and treating 80% of people diagnosed.[1] In 2018, the WHO began recommending treating all persons with chronic HCV infection over the age of 12 with pan-genotypic DAAs, regardless of disease stage.[1]

With the advent of DAAs, and a renewed global call to action, eliminating HCV is now limited by healthcare delivery. The HCV continuum of care is a population health model that outlines successive stages of HCV care delivery from diagnosis to cure (Figure 1).[8] The continuum of care includes HCV antibody screening, HCV ribonucleic acid (RNA) confirmation of chronic infection, linkage to an HCV specialist, hepatic fibrosis staging, HCV therapy and achieving sustained virologic response at 12 weeks (SVR12).[8–10] Patients are considered functionally cured once achieving SVR12; failure to successfully complete one step in the continuum results in untreated HCV. This model demonstrates that curing HCV is predicated on patients' access to and completion of multiple stages of specialty healthcare.

Figure 1.

Hepatitis C care continuum. A theoretical framework of hepatitis C care delivery

Assessing retention at each stage in the care continuum demonstrates extensive gaps in HCV healthcare delivery. In the US in 2016, 76.5% of HCV seropositive patients received RNA confirmation, while among those chronically infected, 17.4% saw an HCV specialist.[11] Among the British Columbia Hepatitis Testers Cohort in 2018, post-DAA introduction, 83% of HCV seropositive individuals received confirmatory RNA testing, while of those chronically infected, 39% initiated therapy and 35% achieved SVR.[12] This treatment gap is more pronounced globally. Of the 71 million persons worldwide with HCV infection in 2015, 14 million (20%) were diagnosed. Of those diagnosed, 5.4 million (39%) had started HCV therapy, including both interferon-based and DAA regimens, while an estimated 843,000 (6%) reached SVR.[13]

Despite the high efficacy of DAAs, failed retention in the care continuum reduces the effectiveness of HCV therapy by approximately 75%.[14] Increasing retention in the HCV care continuum is imperative to close the profound HCV treatment gap. The objective of this literature review was to assess US strategies to improve HCV healthcare delivery and retention in HCV care (Table 1).