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Most People with HCV Infection Are Not Treated with Direct-Acting Antivirals

A new report underscores a persistent problem of patients not receiving antivirals despite their high curative rate.


Direct-acting antivirals (DAA) cure around 95% of cases of hepatitis C virus (HCV) infection, and yet a new report from the Centers for Disease Control and Prevention (CDC) shows uptake of the therapy remains low.

The new findings, published in the CDC’s Morbidity and Mortality Weekly Report, found only about 3 in 10 people who tested positive for HCV infection initiated DAA therapy within 360 days. The low rate of therapy utilization was true regardless of insurance type, though people on Medicare and Medicaid were less likely than those on private insurance to start DAA treatment.

“Hepatitis C treatment saves lives, prevents transmission, and is cost saving,” noted Carolyn Wester, MD, MPH, of the CDC’s National Center for HIV, Viral Hepatitis, Sexually Transmitted Disease, and Tuberculosis Prevention. “...However, only an estimated 1.2 million persons initiated hepatitis C treatment with DAA agents in the United States during 2014–2020, far below the number needed to achieve national hepatitis C elimination goals.”

Wester and colleagues wanted to get a better sense of the current utilization and trends regarding DAAs, as well as disparities in usage between different ages, sexes, racial/ethnic groups, and insurance types. The investigators used administrative claims and encounters data from HealthVerity to identify nearly 47,000 people between the ages of 18 and 69 years who were diagnosed with HCV infection between January 30, 2019, and October 31, 2020, and who had insurance continuously for at least 60 days before diagnosis and 360 days following diagnosis.

Among the cohort, the investigators found that just 23% of Medicaid patients, 28% of Medicare patients, and 35% of privately insured patients who were diagnosed with HCV infection initiated DAA therapy within 360 days of their diagnosis.

After adjusting for insurance type, the authors found younger patients (those 18-29 and those 30-39) were less likely than older patients (those 50-59) to start therapy with DAAs. Among people on Medicaid, the authors found living in a state that imposed restrictions on medication access made a person less likely to start therapy compared to people in states without restrictions (adjusted odds ratio [aOR] = 0.77; 95% confidence interval [CI] = 0.74–0.81). Restrictions included requiring the presence of liver fibrosis meeting fibrosis stage criteria, mandating that patients be sober or abstain from alcohol or drugs for a month before treatment, or requiring a prescription by or in consultation with a specialist before the drug would be provided. Also among the Medicaid cohort, the authors found people who were Black or African American (aOR = 0.93; 95% CI = 0.88–0.99), or another racial minority (aOR = 0.73; 95% CI = 0.62–0.88) were less likely to start DAA therapy, compared to White patients.

Wester and colleagues noted that while the first DAAs initially cost more than $90,000 for a full course of treatment, the cost of therapy has dropped significantly. Still, they said, that has not translated into wider uptake

“Treating all eligible patients without restriction would result in substantially reducing downstream negative clinical outcomes, decreasing the proportion of total costs attributable to future care, and producing considerable cost savings,” they said.

In cases where patients were treated with DAAs, the authors found most patients began therapy within 180 days (75-84%, depending on insurance type). Those who did not begin therapy within 6 months likely faced difficulty accessing providers or may have had to push back after an initial insurance denial, the authors said.

The investigators said removing restrictions on DAA prescriptions is necessary, but they said it is not sufficient to solve the problem.

“Addressing other barriers, including burdensome preauthorization requirements as well as integrating routine screening and treatment into primary care and other settings where persons with hepatitis C receive services, could also increase treatment coverage,” they said.