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Progressing towards global hepatitis C elimination: a systematic review and meta-analysis of care cascades in key populations
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Discussion
This systematic review and meta-analysis synthesises global HCV care cascade data for four key populations-PLHIV, PWID, MSM, and incarcerated individuals-and highlights critical gaps towards the WHO's HCV elimination targets. Four key findings emerged. First, screening coverage remains suboptimal worldwide, particularly among MSM. Second, linkage to care and treatment uptake are the weakest cascade stages, with limited monitoring data and attrition between diagnosis and treatment. Third, although SVR among those assessed exceeds 90% across groups, substantial disparities in treatment adherence (completion and SVR assessment) persist, with PLHIV showing the strongest retention and incarcerated individuals the weakest. Fourth, high-income countries generally report better monitoring and coverage across the care continuum.
Summary
Background
Hepatitis C virus (HCV) remains a global health concern, with cascade gaps hindering elimination. We aim to assess and compare HCV care cascades in four key populations: people living with HIV (PLHIV), people who inject drugs (PWID), men who have sex with men (MSM), and incarcerated individuals.
Methods
We conducted a systematic review and meta-analysis of observational studies (Jan 2019–Sept 2025) reporting ≥1 care cascade stage, including screening, confirmatory testing, linkage to care, treatment uptake and completion, and cure, among key populations (PROSPERO CRD42024577740). Four databases were searched. Pooled stage-specific proportions were estimated using random-effects meta-analysis, stratified by population and region.
Findings
We included 219 studies (884,450 individuals) from 46 countries.
HCV screening coverage remained suboptimal across populations and was lowest in MSM, below 70% in half of countries. Linkage-to-care data were limited yet indicated low linkage in most countries. Treatment uptake was the weakest stage: <70% of PLHIV initiated treatment in 11 of 19 countries, PWID in 16 of 24, MSM in 3 of 10, and incarcerated individuals in 9 of 14.
Treatment completion was generally favourable. SVR assessment and SVR among those initiating treatment were lowest in incarcerated individuals, with both indicators falling to about 40% in the poorest-performing countries. Analyses showed better performance in high-income settings. Western Europe performed best, with screening coverage 56.2–87.0%, confirmatory diagnosis 86.8–95.5%, 92.2–97.6% of diagnosed linked to care, and 46.9–79.2% initiating treatment; >90% of those treated completed therapy and >85% were assessed for SVR. In contrast, indicators were substantially worse in lower-income countries, with gaps across stages.
Interpretation
Suboptimal HCV screening, weak care linkage, treatment gaps, and regional inequities persist. Enhanced integrated services, better screening, expanded access, and robust data systems are critical to accelerate elimination in resource-limited settings.
HCV care cascade in PLHIV
Data for PLHIV came from 31 countries/territories, yielding 111 country-level indicator data points (Table 1); seven regions contributed ≥1 estimate, with the fullest indicator coverage in East Asia and Pacific and North America. By income group, no indicator estimates were available for LICs, whereas HICs had the most complete coverage across indicators (Table 1).
Regionally, Western Europe showed the most robust cascade: screening and confirmatory diagnosis were 83.3% and 92.3%, treatment uptake 69.9%, and treatment completion and SVR assessment 95.9% and 94.2% (Table 1; Fig. 3). In contrast, screening in Australasia was 51.8%, confirmatory diagnosis in East Asia and Pacific 66.2%, and treatment uptake in North America 44.4%; treatment completion and SVR assessment were generally high (>90%) elsewhere. Linkage to care was available only for East Asia and Pacific and North America (76.2% and 65.8%), and among those initiating treatment, SVR achievement was poorer in Eastern Europe and in the Middle East and North Africa (Table 1; Fig. 3). By income group, HICs had the most complete and best-performing cascades (screening ∼70% and most subsequent steps ≥90%), whereas UMIC and LMIC data were sparse and concentrated in downstream steps, and no cascade data were identified for LICs (Table 1; Fig. 3).
At the country level, screening ranged from 51.8% in Australia to 99.8% in Taiwan (China), and confirmatory testing from 64.2% in Indonesia to 98.7% in Spain; only six countries reported linkage to care, ranging from 50.0% in Israel to 96.6% in Canada (Table 1). Treatment uptake was the weakest step-11 of 19 estimates were below 70%, with Russia as low as 13.7%-while most countries reported high treatment completion and SVR assessment (often >90%); among those initiating treatment, SVR achievement ranged from 31.3% in Iran to 98.8% in Egypt (Table 1; Fig. 4).
HCV care cascade in PWID
Data for PWID came from 35 countries/territories, yielding 138 country-level indicator data points (Table 2); six regions contributed ≥1 estimate, with the fullest indicator coverage in Australasia, North America, and Western Europe. By income group, no indicator estimates were available for LICs, whereas HICs had the most complete coverage across indicators (Table 2).
Regionally, Eastern Europe performed worst for screening and confirmatory diagnosis (55.5% and 76.6%) versus 87.0% and 95.5% in Western Europe (Table 2; Fig. 3). Linkage to care was highest in Western Europe (92.2%) and lowest in North America (41.4%); treatment uptake was also low in North America (35.2%) versus 71.2% in Eastern Europe. Although treatment completion and SVR assessment generally exceeded 80–90% across regions, completion reached only 78.2% in North America and SVR assessment only 60.8% in Australasia; SVR among those initiating treatment was also lowest in Australasia (56.8%) (Table 2; Fig. 3). By income group, lower-income countries consistently underperformed at screening, treatment completion, and SVR assessment (Table 2; Fig. 3).
At the country level, screening ranged from 19.0% in Croatia to 98.2% in Austria, and confirmatory testing from 67.0% in Turkey to 100.0% in Malaysia and Iran; only nine countries reported linkage to care, highest in Norway at 93.1% and lowest in the USA at 40.4% (Table 2). Treatment uptake remained the weakest link-16 of 24 estimates were below 70%, lowest in France at 14.6%-and the cross-country range in treatment completion and SVR assessment reached 41.7% and 42.4%, respectively; SVR among those initiating treatment ranged from 41.7% in Puerto Rico to 98.0% in Czechia (Table 2; Fig. 4).
HCV care cascade in MSM
Data for MSM came from 16 countries/territories, yielding 42 country-level indicator data points (Table 3); three regions contributed ≥1 estimate, with the fullest indicator coverage in North America. By income group, indicator estimates were available only for HICs, with no data for other income groups (Table 3).
Regionally, Western Europe had the lowest screening (56.2%) and Australasia the lowest confirmatory diagnosis (45.5%), whereas North America reached 71.5% and 95.0% (Table 3; Fig. 3). However, in North America, linkage to care and treatment uptake were only 16.7% and 26.0%, while treatment uptake was highest in Australasia (80.0%); no regional estimates were available for treatment completion. SVR assessment and SVR among those initiating treatment were reported only for North America and Western Europe (North America: 77.4% and 57.5%; Western Europe: 98.7% and 92.0%) (Table 3; Fig. 3). By income group, data were available only for HICs (Table 3; Fig. 3).
At the country level, screening ranged from 12.4% in Hong Kong (China) to 100% in Taiwan (China); confirmatory testing was reported for four countries (95.0% in the USA, 93.5% in Italy, 75.2% in Austria, and 45.5% in Australia), and linkage to care only for two (16.7% in the USA vs 90.5% in the UK) (Table 3). Treatment uptake ranged from 24.3% in the USA to 98.1% in the Netherlands, treatment completion was reported only in Austria at 100%, and SVR assessment ranged from 77.4% in the USA to 100% in the UK and Austria; among those initiating treatment, SVR ranged from 57.5% in the USA to 100% in Austria (Table 3; Fig. 4).
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