Direct-acting Antivirals for Hepatitis C Infection Are Underused in the US, Study Finds


While the use of direct-acting antiviral treatment for hepatitis C virus increased from 2014 to 2018, treatment rates have declined since 2019 and remain suboptimal.

Direct-acting antivirals (DAAs) have significantly changed the treatment of hepatitis C virus (HCV) in recent years, but data on treatment rates and factors associated with treatment are lacking. A study published in Gastroenterology and Hepatology found that treatment rates in the United States are still suboptimal and have been declining since 2019.

HCV is a global concern and is among the leading causes of liver transplantation in the United States, as well as a main contributor to the increased incidence of hepatocellular carcinoma (HCC). Injectable interferon-based therapy used to be the norm in HCV treatment; however, oral, short-course, well-tolerated DAAs changed the treatment landscape in 2014 and have shown cure rates of nearly 100%. Still, factors such as low awareness of HCV, suboptimal screening, a lack of resources, and additional barriers related to the COVID-19 pandemic are thought to have impeded DAA treatment for individuals with HCV.

The observational study aimed to determine treatment rates and notable changes over time among individuals with confirmed viremic HCV infection between 2014 and 2021 using the Optum Cliniformatics Data Mart Database, a national database of patients with private health insurance that covers all US regions.

A total of 133,348 individuals with HCV infection were included in the study cohort. More than half (59.7%) were men, and the mean age was 59 years. Only approximately half of the population (53.4%) had visited a gastroenterologist (GI) or infectious disease (ID) specialist at least once during the study period, and 20.5% had cirrhosis and/or HCC. A total of 38,180 (28.6%) patients had HCV RNA test results available at baseline, and 20,277 (53.1%) of those patients had positive HCV RNA results.

Of the patients with viremic HCV, 13,214 (65.2%) received DAA treatment. The highest rate of treatment was among patients who had visited a GI or ID with advanced practice practitioners (APPs) such as nurse practitioners, physician assistants, or clinical nurse specialists (adjusted odds ratio [aOR], 1.64).

Of 7278 patients who received care from a GI or ID with APPs, 5342 (73.4%) received DAA treatment. Of 6043 patients who visited a GI or ID without APPs, 4104 (67.9%) received DAAs.

A total of 1908 (58.4%) out of 3269 patients who were treated by a primary care physician (PCP) with APPs received DAAs. Patients who were seen by a PCP without APPs had the lowest rate of treatment, with 1860 out of 3687 (50.4%) receiving DAAs (aOR, 0.58).

Notably, patients with decompensated cirrhosis and/or HCC were less likely to receive treatment compared with those without these conditions (aOR, 0.69), despite the finding that those who did receive treatment had a 95% rate of sustained virologic response (SVR). A lack of financial and social support for patients and clinician hesitation to treat patients with end-stage liver disease may contribute to this trend.

Taken together, these findings suggest that the overall DAA treatment rate for patients with HCV is unsatisfactory, according to the study authors. And after adjusting for age, sex, race and ethnicity, the authors found that the treatment rate was 0.5 times greater in 2018 versus 2014 but declined after 2018.

Between April 2018 and March 2019, the rate was 64.8%, while the rate from April 2019 to March 2020 was 61.2%. Between April 2020 and March 2021, the rate dropped to less than 60%. Far fewer patients were diagnosed with HCV after the start of the COVID-19 pandemic (April 2020 and March 2021) compared with previous years.

Although the treatment rates were not optimal, the overall cure rate was promising. A total of 6634 patients received DAAs and had SVR data available. Of those patients, 6456 (97.3%) showed SVR.

Patients coinfected with HIV/AIDS and those with a history of injection drug use had slightly lower SVR rates (90.6% and 95.1%, respectively). SVR rates were similar across different regions, education levels, household income levels, and clinician types.

Initiatives to increase DAA awareness and access for patients with HCV in the United States are needed to improve treatment rates and move toward elimination of viral hepatitis, the authors wrote. Community outreach programs and access to specialists through referral pipelines are also crucial, particularly for patients with cirrhosis and/or HCC.


Nguyen VH, Kam L, Yeo YH, et al. Characteristics and treatment rate of patients with hepatitis C virus infection in the direct-acting antiviral era and during the COVID-19 pandemic in the United States. JAMA Netw Open. 2022;5(12):e2245424. doi:10.1001/jamanetworkopen.2022.45424

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