State-Specific Hepatitis C Virus Clearance Cascades — United States, 2013–2022

Discussion

This is the first state-specific HCV clearance cascade report, comprising data from all 50 U.S. states and DC, including approximately 1.7 million persons with evidence of a positive hepatitis C test result from a large commercial laboratory during 2013–2021, and followed through the 10-year period 2013–2022. This analysis provides insight into state-specific successes and gaps along each step of the HCV clearance cascade during the DAA treatment era.

The number of persons identified as ever having been infected with HCV varied widely by state, from 125 in North Dakota, to 338,715 in California. Multiple factors can affect these numbers, including differences in the state’s population size, the scope of laboratory coverage within the state, and hepatitis C prevalence by state.

HCV testing is necessary to distinguish past from current infection. Among persons in this cohort identified as ever having been infected (i.e., received any positive HCV test result), the median viral testing rate (having an HCV RNA test performed) was 91% across jurisdictions, reflective of recommended best practices promoting automatic HCV RNA testing for all specimens with reactive HCV antibody results.

Among states, the median percentages of persons cured or cleared (i.e., having an undetectable HCV RNA test result) was 29% (range = 10%–51%), well below both the HHS hepatitis C viral clearance goals for 2025 (at least 58%) and 2030 (at least 80%). These findings are consistent with recent studies highlighting low DAA treatment and viral clearance rates among persons with diagnosed hepatitis C infection (9,10). The proportion of cured or cleared persons also varied substantially by state (from 10% to 51%). Southern Appalachian states and most north central states had HCV cure or clearance rates below the national average, highlighting the importance of improving linkage to care and treatment coverage in these regions, which are experiencing high rates of acute hepatitis C cases in association with injection drug use (2).

The median state-level estimate for persistent infection or reinfection (e.g., a detectable HCV RNA test result after a previously undetectable HCV RNA test result) was 5%, ranging from 2% to 11%. Because this clearance cascade does not distinguish between persistent infection and reinfection, factors contributing to these ranges might include those affecting viral clearance (e.g., duration of infection and treatment adherence) or risk for reinfection (e.g., access to syringe services programs for persons who inject drugs), highlighting the need to investigate reasons for persistent infection and reinfection.

Development of hepatitis C viral clearance cascades is important for monitoring and identifying gaps in hepatitis C elimination efforts. Ideally, each state would have comprehensive public health hepatitis C surveillance registries, including detectable and undetectable HCV RNA results, and generate their own HCV clearance cascades. Such cascades would include results from all laboratories in a state, account for persons who moved out of state or died, and use person-level data to link individual persons to treatment and prevention services.

Limitations

The findings in this report are subject to at least four limitations. First, the results were based on a population of persons who received a positive test result for HCV and do not represent all persons with HCV infection. Second, data from a single laboratory are not necessarily representative of a jurisdiction and characteristics of persons tested might differ by jurisdiction. Third, results for persons who received HCV laboratory testing from laboratories other than Quest Diagnostics are not represented in these estimates; inclusion of these data could lead to different estimates reported for each step. Finally, the cascade does not capture data from persons who did not receive an HCV RNA test after initial infection or after cure or clearance, which might result in underestimation of the number and proportion of persons with viral clearance or persistent viremia, respectively.

Implications for Public Health Practice

The state-specific clearance cascades presented here facilitate the availability of data for all states, irrespective of current hepatitis C surveillance capacity to enable jurisdictional-level monitoring of hepatitis C elimination. These data demonstrate that all states have HCV clearance rates well below established national elimination goals, a finding that could serve to stimulate state-level public health action to implement best practices for diagnosing, treating, and preventing HCV infection. These practices include focusing efforts on increasing hepatitis C testing in all settings in which persons with hepatitis C receive care, ensuring unrestricted access to treatment irrespective of insurance coverage, and providing comprehensive harm reduction services for persons who use and inject drugs.