Hepatitis C Is Curable — So Why Were Only a Third Cured? The U.S. Clearance Cascade, 2013–2022

About 2.4 million U.S. adults were estimated to have hepatitis C during 2013–2016. Untreated, it can lead to advanced liver disease, liver cancer and death. Yet it is curable: an 8–12 week course of well-tolerated oral direct-acting antiviral (DAA) pills — recommended for nearly everyone with the infection — cures 95% or more of cases. The national Viral Hepatitis Strategic Plan aims for at least 80% of people with hepatitis C to clear the virus by 2030, and a national elimination program had recently been proposed.

How close is the country? Tracking that means following people from testing through cure — a clearance cascade. No single data source covers every step, so CDC devised a simplified cascade built only on lab results. This report applies it to a decade of testing data from Quest Diagnostics, covering patients in all 50 states and DC, since DAAs became available.

The cascade

(About a third of people with an acute infection clear it without treatment.)

People at each step of the clearance cascade, from national commercial laboratory data, 2013–2022. Quest Diagnostics data; CDC chart

In short: of the roughly 1.0 million people with a confirmed infection, only about a third had evidence of clearing the virus — nearly a decade after highly effective treatment arrived.

Who was in it

Of those ever infected, 60% were male; 29% were aged 20–39, 43% 40–59 and 27% 60 or older.

Where the gaps are

• Viral testing ranged from 79% (payor not specified) to 91% (commercial and Medicare).
• Confirmed infection was least common among ages 0–19 (41%); by payor it ranged from 63% (commercial) to 82% (not specified).
• Clearance rose with age within every payor type, and was highest among people 60 and older (42%).
• Clearance was lowest among people paying for themselves: 23% for "other" payors, 31% for Medicaid and 33% for unspecified, and higher for people with Medicare or commercial insurance. The best result anywhere was 49%, among commercially insured people 60 and older.

Young adults fared worst. People aged 20–39 had the lowest clearance of any age group, 24%, and the highest rate of persistent infection or reinfection, 9%. Within that group:

Share of people with a confirmed infection who cleared the virus, by age group and payor type, 2013–2022. Quest Diagnostics data; CDC chart

What it means

The findings show large missed opportunities to diagnose, treat and prevent hepatitis C, and a wide gap between today's clearance and the 80% goal. Closing it, the authors write, needs:

• universal hepatitis C screening as recommended, including an RNA test for everyone with a positive antibody test;
• treatment for everyone, whatever their insurance;
• prevention services for people at risk of new infection — with particular need among younger adults.

A cascade built on one large lab's results can be updated easily and is big enough to follow trends precisely.

Limits. It covers only people who tested positive, not everyone infected, and one laboratory is not necessarily representative. Follow-up time varied. People who never had a follow-up RNA test are missed, so later steps are probably undercounted, as are tests done at other labs. Other cascade models may be better where fuller prevalence, diagnosis and treatment data exist.

Sources

Based on Wester C, Osinubi A, Kaufman HW, et al., "Hepatitis C Virus Clearance Cascade — United States, 2013–2022," MMWR volume 72, number 26, Centers for Disease Control and Prevention, with authors from CDC and Quest Diagnostics; a work of the United States government in the public domain. The report's results give the 45% clearance to Medicare while its discussion gives Medicare 40% and commercial insurance 45%, so neither figure is assigned here; one mention of the lowest-clearance age group as "20–29" is taken to mean the 20–39 group named everywhere else.