Global hepatitis C elimination: Updates, challenges, and opportunities from real-world experiences in Europe and North America

INTRODUCTION The global burden of hepatitis C virus (HCV) infection is significant. An estimated 50 million people worldwide have chronic HCV infection, and ~1 million new infections occur yearly.1 The World Health Organization (WHO) estimated that in 2022, ~242,000 people died from HCV, most of them from HCV-related cirrhosis and hepatocellular carcinoma (HCC).1 Historically, HCV infection was difficult to treat, with a relatively slow but inexorable progression toward liver cirrhosis. Important therapeutic advances over the past 15 years have transformed HCV infection into a curable infection. These advances make it theoretically possible to eliminate HCV using effective diagnostic, therapeutic, and public health approaches. Reaching this goal, however, requires targeted effort to diagnose all patients living with HCV infection and to link them to appropriate care, a very ambitious undertaking. It is estimated that in 2020, only 23% of the patients living with active HCV infection around the world had been diagnosed. The undiagnosed fraction differs between low-income, middle-income, and high-income regions and differs from country to country.2 Consequently, as initial steps on the elimination pathway, different countries have deployed different micro-elimination programs for specific groups, for example, patients with hemophilia, patients undergoing hemodialysis, patients with cancer, people living with HIV, people who inject drugs (PWID), people who are incarcerated, and people experiencing homelessness.3–6 In 2016, the WHO launched the first global health sector strategy on viral hepatitis, intending to eliminate viral hepatitis as a major public health threat by 2030.7 This strategy was updated in 2022 into a consolidated global health sector strategy on HIV, viral hepatitis, and sexually transmitted infections.8 The strategy includes impact indicators, such as decrease in new HCV infections per year from 1.575 million in 2020 to 350,000 by 2030 and decrease in HCV-related deaths per year from 290,000 in 2020 to 140,000 by 2030; coverage indicators, such as increases in the proportions of people with HCV infection who are diagnosed and cured from 30% and 30%, respectively, in 2020 to 90% and 80%, respectively by 2030; and implementation rates for harm reduction programs, blood safety programs, and safe injection practices.8 In this article, we summarize the status of the national HCV elimination efforts in different countries of Europe and North America, describe remaining barriers to implementing these national plans, and outline opportunities to create or improve existing national plans. METHODS In 2024, the chairs of the European Society of Clinical Microbiology and Infectious Diseases Study Group for Viral Hepatitis (ESGVH) and the American Association for the Study of Liver Diseases (AASLD) Hepatitis C Special Interest Group agreed to collaborate on a review mapping HCV elimination efforts in Europe and North America. When this review was launched, ESGVH had 180 members from 39 countries within and beyond Europe. The European countries represented in ESGVH were identified, and members from all 16 countries that had at least 5 ESGVH members were invited to contribute to the manuscript or recommend a national expert on the topic of HCV elimination. When this review was launched, the AASLD Hepatitis C Special Interest Group had 530 members. Its chair, vice-chair, and key experts were invited to contribute on behalf of countries in North America: the United States of America, Canada, and Mexico. Although Egypt is outside Europe and North America, an ESGVH executive committee member was invited to contribute a section on Egypt, as Egypt was the first nation to achieve WHO’s gold tier on the path to HCV elimination.9 For each country, 1 author was invited to write that country’s section of this review. Authors were asked to consider all data available regarding HCV elimination in their country. No standard data collection form was used, but a word limit was set, and authors were asked to address the following standard questions: What are the latest data on the prevalence of HCV infection in your country? Does your country have an HCV elimination plan, or is it working on one? What priorities and indicators are being used, or could be used, to measure the progress of the plan? Is your country on track for achieving HCV elimination? What are the barriers and challenges to eliminating HCV? What opportunities should be targeted to improve the nation’s plan? Authors were asked to provide examples of how their countries delivered HCV care for PWID, incarcerated persons, migrants, and other marginalized groups. Authors were also encouraged to discuss prevention services, community involvement, and the for and to such as the of for and and the of of the in or national plans, and status and expert of challenges and the country were the chairs of the ESGVH and AASLD Hepatitis C Special Interest Group for the on these and the and of the The manuscript was and by all HCV the HCV elimination efforts of Canada, Egypt, the the United and the United States of these countries have a national HCV elimination plan, and are on track to eliminate The HCV elimination efforts are in by country and in 1 data on HCV prevalence and prevalence HCV prevalence of patients living with HCV infection living with HCV infection for track to eliminate HCV? for and available are No coverage is to public health for with PWID, plan, No for but No No No PWID, strategy for HCV elimination by with to and of for key No for No No with a of injection or or infection, or 2016, updated 2020 year for achieving all for specific or liver patients with liver and but efforts are for the by health in in the in in in PWID, 2016, No No No No of No No 2020 No No No No years updated 2020 No 2022 No No No United No United States but toward the to estimated new HCV infections by and the to HCV-related deaths by national health to for Egypt in in in No on HCV or HCV on the HCV are all over Egypt with the for of Viral in to health are the national committee and are by who a updated by the are a and a all and data and PWID, people who inject sexually transmitted and living with HCV infection and a prevalence of HCV of with most in coverage of HCV is by health in The of been for and for all patients The to improve the of patients diagnosed and on the to address HCV, for HCV and are with for HCV The to the of in HCV infection and to care to The for and be and to a been and is to be by the of to eliminate HCV in have challenges the of an estimated people in were living with HCV infection, of had been diagnosed. 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