A 2024 global report on national policies, programmes, and progress towards hepatitis C elimination: findings from 33 hepatitis elimination profiles

Abstract

The Coalition for Global Hepatitis Elimination’s National Hepatitis Elimination Profiles assess the status of national data, policy, and programme development for the elimination of viral hepatitis. To date, profiles from 33 countries and territories have been developed. These profiles reveal that 30 (91%) countries and territories have hepatitis C national action plans, 11 (33%) have systems to monitor hepatitis C-related mortality, 16 (48%) have systems to monitor hepatitis C incidence, and 18 (55%) have systems to track the number of people tested and treated. Some countries and territories continue to uphold barriers to hepatitis C treatment, with 12 (36%) still having partial or full restrictions on prescribing authority for non-specialists. Ten (30%) countries and territories have met the WHO 2025 diagnosis coverage target of 60%, five (15%) have met the treatment target of 50%, and seven (21%) have met the needle and syringe exchange target. Although there are examples of countries and territories across the income spectrum meeting these targets, policy development in low-income and middle-income countries and territories generally lags behind that in high-income countries and territories.

Introduction

In 2022, an estimated 50 million people were living with hepatitis C globally, and around 240 000 people died from complications of hepatitis C virus (HCV) infection, such as liver cirrhosis or hepatocellular carcinoma.¹ Based on modelling estimates, in 2022, only 36% of people with hepatitis C were diagnosed and 20% of people living with hepatitis C had been treated.¹

In 2016, WHO published a global strategy with health impact goals for the elimination of hepatitis B and hepatitis C as public health threats, defined as a 90% reduction in incidence and a 65% reduction in mortality by 2030.² The global strategy also included targets for the scale-up of prevention and care services needed to reach these goals. In 2022, WHO updated the global strategy to include interim goals (to be reached by 2025) and final goals (to be reached by 2030) for reductions in incidence and mortality, alongside targets for the delivery of prevention, testing, and treatment services to enable the elimination goals to be reached.³ In 2023, WHO updated country guidance for validation of viral hepatitis elimination, which included a path to elimination with tiered options (bronze, silver, and gold).^4,5 This path to elimination allows countries to show progress by documenting the achievement of specific coverage targets for prevention, diagnosis, and treatment indicators at each tier, without the need to reach impact targets for incidence and mortality.⁵

In 2021, to assess the status of national data, policy, and programme development, the Coalition for Global Hepatitis Elimination (CGHE) began development of National Hepatitis Elimination Profiles. This Health Policy brings together data from the profiles for 33 countries and territories regarding the burden of hepatitis C, the status of policy and programme development, and the progress made towards WHO elimination goals. The objective of this analysis is to document achievements and reveal challenges in developing effective hepatitis C elimination programmes and the next steps needed to improve service delivery and accelerate progress towards hepatitis C elimination.

Methods

Process for developing a National Hepatitis Elimination Profile

CGHE staff (LH-S and JWW), in consultation with the CGHE Technical Advisory Board, developed a standard data template to collect data on 27 hepatitis C-related policy indicators and key epidemiological and programme coverage information (panel 1; appendix pp 2-6). Indicators were compiled from a review of a WHO checklist (unpublished) for alignment of national hepatitis plans with the Global Health Sector Strategy on Viral Hepatitis 2016–2021; The Lancet Gastroenterology & Hepatology Commission on accelerating the elimination of viral hepatitis;⁶ the World Hepatitis Alliance’s Viral Hepatitis: Global Policy report;⁷ and Pan American Health Organization’s report Hepatitis B and C in the Spotlight: a public health response in the Americas 2017.⁸ Select policies from the published profiles, such as the status of medicine registration, were excluded from our analysis. Data templates for each country or territory were completed by CGHE staff based on a review of publicly available literature published from Jan 1, 2010, to the date of the profile release. Sources of publicly available data reviewed included government action plans, programme progress reports, surveillance reports, and peer-reviewed literature identified through searches of PubMed and Google Search (appendix p 7). Additional sources of data included the WHO Global Health Observatory data dashboards;⁹ the Institute of Health Metrics and Evaluation Global Burden of Disease study for 2019 and 2021;¹⁰ regional reports, such as those from the Pan American Health Organization and European Centre for Disease Prevention and Control;^8,11 the Georgetown HIV Policy Lab; Clinton Health Access Initiative Market Reports;¹² and the Center for Disease Analysis Foundation dashboards.¹³ When data were available for multiple years, data for the most recent year were used. Data sources in all languages were included, where possible, if they could be translated into English by CGHE staff who were fluent, or Google Translate.

Panel 1: Hepatitis C indicators for hepatitis elimination profiles.

Hepatitis C national planning (two policies)

• Hepatitis action plan that includes hepatitis C

• Hepatitis C elimination goal

Hepatitis C strategic information (five policies)

• Routine official reports to monitor hepatitis C mortality

• Routine official reports to monitor hepatitis C incidence

• Routine official reports to monitor hepatitis C prevalence

• Estimates of hepatitis C economic burden

• Monitoring of hepatitis C diagnosis and treatment

Access to hepatitis C screening (five policies)

• Universal antenatal hepatitis C screening recommendations

• Risk-based hepatitis C screening recommendations

• Expanded hepatitis C screening recommendations: birth cohort, age cohort, other special group, or universal

• No patient co-payments for hepatitis C virus (HCV) antibody screening

• Approval of point-of-care RNA testing to detect HCV

Access to hepatitis C treatment (seven policies)

• National hepatitis C treatment guidelines

• Simplified hepatitis C care algorithm: fewer than two clinic visits during treatment

• Simplified hepatitis C care algorithm: non-specialists can prescribe treatment

• Simplified hepatitis C care algorithm: no patient treatment co-payments

• Simplified hepatitis C care algorithm: no fibrosis restrictions for treatment initiation

• Simplified hepatitis C care algorithm: no sobriety restrictions for treatment initiation

• Simplified hepatitis C care algorithm: no genotyping required for treatment initiation

Equity in access to hepatitis C care and prevention services among disproportionately affected populations (six policies)

• National strategy addresses disproportionately affected populations (eg, people who inject drugs, Indigenous people, men who have sex with men, people with co-infections)

• Laws preventing discrimination against people living with hepatitis C

• Harm reduction for people who inject drugs included in national policy

• Policy for syringe and needle exchange programmes in federal prisons

• Decriminalisation of possession of syringes and associated paraphernalia

• Decriminalisation of drug use

Hepatitis C financing (two policies)

• Public budget line for hepatitis C prevention, testing, and treatment

• Support from The Global Fund to Fight AIDS, Tuberculosis and Malaria used to support prevention, screening, or treatment for patients with co-infections, or harm reduction, as relevant

The data collection template was shared via email and virtual interviews with at least three local stakeholders from each country or territory, when possible, for feedback on the accuracy and completeness of the data. Local stakeholders included clinicians, ministry of health officials, academics, and civil society or non-governmental organisation representatives. All stakeholders had professional roles related to hepatitis prevention, testing, or treatment or had lived experience (appendix pp 8-18). Stakeholders were identified through the CGHE’s network of partners, including recommendations from global health organisations (eg, WHO and the Pan American Health Organization), liver disease professional associations (eg, the American Association for the Study of Liver Diseases, the European Association for the Study of the Liver, the Asian Pacific Association for the Study of the Liver, and the Latin American Association for the Study of the Liver), and global patient organisations (eg, the World Hepatitis Alliance and the European Liver Patients’ Association). National ministries of health of each country and territory were also invited to propose clinicians and representatives from civil society organisations as local collaborators. Based on initial feedback from the stakeholders, first drafts of National Hepatitis Elimination profiles were developed by a graphic designer. Stakeholders then provided further feedback on the draft profile data, missing information, formatting, or any other aspect they noted; multiple rounds of revisions were coordinated between CGHE and the stakeholders until consensus, which was confirmed through written sign-off by stakeholders, was reached. In all but three profiled countries (the Philippines, Switzerland, and Senegal), profiled data were reviewed by officials in national ministries of health or their designated partners. To resolve differences in opinion across partners, the preferences of the health ministries were prioritised. In cases where there were no ministry officials, consensus was reached between the other stakeholders by either showing a range of quantitative data or providing additional context on the policy status that represents the viewpoint of both stakeholders. Each final profile includes citations for the data presented in the profile.

The first four profiles were published on July 28, 2021, and five to ten new profiles have been published each year subsequently. From July 1, 2024, until Sept 30, 2024, elimination profiles were updated with new local data (eg, from government reports or policies, websites, or unpublished data shared with CGHE) or new data from peer-reviewed publications published since the profile’s initial release and data from the 2024 WHO Global Hepatitis Report,¹ as available.

Selection and classification of countries and territories

Profiles were prioritised for countries and territories with the highest hepatitis B and C burden (considered together) in the six WHO regions. This list was adjusted to align with the Lancet Gastroenterology & Hepatology Commission on elimination of viral hepatitis, which included the 20 countries and territories most heavily burdened by viral hepatitis.¹⁴ Profiles for the Commission countries of Democratic Republic of Congo, India, and Russia were not completed in time for inclusion in this analysis.¹⁴ Additional country profiles were developed based on requests from ministries of health and other partners. At the time of this Health Policy, profiles for 33 countries and territories have been developed, representing an estimated 73% of the number of people living with hepatitis C globally (figure 1).⁹

Figure 1: Map showing countries and territories with National Hepatitis Elimination Profiles.

African region: Ethiopia, Ghana, Nigeria, Rwanda, Senegal, and South Africa. Region of the Americas: Argentina, Brazil, Canada, Colombia, Mexico, Peru, and the USA. Eastern Mediterranean region: Egypt and Pakistan. European region: England, Georgia, Italy, Portugal, Spain, Switzerland, and Ukraine. South-East Asia region: Bangladesh, Indonesia, Myanmar, and Thailand. Western Pacific region: Australia, China, Japan, South Korea, the Philippines, Taiwan, and Viet Nam.

Based on World Bank income criteria for the 2025 fiscal year, countries and territories were grouped into three income categories: high-income countries and territories (HICs; n=11; Australia, Canada, England (assumed from the United Kingdom classification), Italy, Japan, Portugal, South Korea, Spain, Switzerland, Taiwan, and the USA); upper-middle-income countries and territories (UMICs; n=11; Argentina, Brazil, China, Colombia, Georgia, Indonesia, Mexico, Peru, South Africa, Thailand, and Ukraine); and low-income and lower-middle-income countries and territories (LLMICs; n=11; Bangladesh, Egypt, Ethiopia [low income], Ghana, Myanmar, Nigeria, Pakistan, the Philippines, Rwanda [low income], Senegal, and Viet Nam).¹⁵

Analysis of policy data

The proportion of countries and territories adopting the 27 policies related to hepatitis C elimination is described across six categories: hepatitis C national planning; hepatitis C strategic information; access to hepatitis C screening; access to hepatitis C treatment; equity in access to hepatitis C care and prevention services among disproportionately affected populations; and hepatitis C financing (panel 1). The significance of differences in policy adoption across country income levels was assessed at the 95% confidence level for each policy with Pearson’s χ² test. p values less than 0·05 were considered significant.

Across the policies (panel 1), countries and territories were given a score of 0 for no policy, 0·5 for a partially adopted policy, and 1 for an adopted policy. Definitions of adopted, partially adopted, and not adopted for each policy indicator can be found in the appendix (pp 2-6). For example, for the indicator of expanded screening recommendations, countries and territories were given a score of 1 if they adopted an age-based, birth-cohort, or universal screening policy, a score of 0·5 for such a policy having been developed but not yet implemented, and a score of 0 if there were no other screening recommendations beyond risk-based screening. The policy on whether funds from The Global Fund to Fight AIDS, Tuberculosis and Malaria were used to support hepatitis C initiatives was excluded from policy score analyses as not all countries and territories are eligible for funding.¹⁶ Therefore, the maximum hepatitis C policy score was 26. Tests of mean differences across the three income classifications were performed for individual policy categories and the overall policy score, after first testing each category and the overall score for normality by use of the Shapiro–Wilk test. ANOVA was used for categories with an estimated normal distribution and Kruskal–Wallis tests were used for categories with estimated non-parametric distributions. Significance testing was estimated at the 95% confidence level.

Recommendations for priority next steps suggested by profile stakeholders are highlighted at the end of each profile. To examine whether there are associations between income level and the type of recommendations given, Pearson’s χ² test was performed and associations tested at the 95% confidence level.

Assessment of progress towards hepatitis C elimination

Based on epidemiological and programme data from the profiles, progress towards the WHO 2025 (interim) and 2030 (final) targets for hepatitis C elimination was assessed (panel 2).^2,3,5 For this analysis, rates of hepatitis C diagnosis, treatment, and related deaths were evaluated, along with coverage of needles and syringes for people who inject drugs; incidence, blood safety, and injection safety targets were not evaluated. Achievement of the combined hepatitis B and hepatitis C mortality 2030 target was not assessed, as this was not a standard profile indicator collected, and there was no available global data source. The significance of differences in achievement of WHO 2025 targets for programme coverage and mortality goals across country income levels was assessed at the 95% confidence level with Pearson’s χ² test.

Panel 2: WHO goals for hepatitis C elimination as a public health problem and path to elimination tiers.

2025 goals

• Impact targets: at most three hepatitis C-related deaths per 100 000 people; at most 13 new annual hepatitis C virus (HCV) infections per 100 000 people; and at most three new annual HCV infections per 100 people who inject drugs

• Programmatic targets: at least 60% diagnosis coverage of people with hepatitis C; at least 50% treatment coverage of people with hepatitis C; 200 or more needles and syringes distributed per person who injects drugs per year; 100% blood safety coverage; and 100% injection safety coverage

2030 goals

• Impact targets: at most six hepatitis B-related or hepatitis C-related deaths per 100 000 people (combined target introduced in 2023; originally at most two deaths per 100 000 people for hepatitis C); at most five new annual HCV infections per 100 000 people; and at most two new annual HCV infections per 100 people who inject drugs

• Programmatic targets: at least 90% diagnosis coverage of people with hepatitis C; at least 80% treatment coverage of people with hepatitis C; and 300 or more needles and syringes distributed per person who injects drugs per year; 100% blood safety coverage; and 100% infection safety coverage

WHO elimination tiers for hepatitis C elimination as a public health problem

• Bronze: at least 95% blood safety coverage; at least 95% injection safety coverage; needle and syringe exchange present; at least 60% diagnosis coverage of people with hepatitis C; and at least 50% treatment coverage of people diagnosed with hepatitis C

• Silver: 100% blood safety coverage; 100% injection safety coverage; needle and syringe exchange and opioid agonist therapy present; at least 70% diagnosis coverage of people with hepatitis C; and at least 60% treatment coverage of people diagnosed with hepatitis C

• Gold: 100% blood safety coverage; 100% injection safety coverage; at least 150 needles and syringes distributed per person who injects drugs per year (or opioid agonist therapy coverage for people who inject drugs >20% in countries and territories with defined opioid epidemics); at least 80% diagnosis coverage of people with hepatitis C; at least 70% treatment coverage of people diagnosed with hepatitis C; and establishment of sentinel surveillance programme for hepatitis sequelae

Countries and territories were also assessed for estimated achievement of the gold, silver, and bronze tiers of WHO’s path to elimination (panel 2) based on available data from the profiles.⁵ The path to elimination criteria for blood safety, injection safety, opioid agonist therapy, and sentinel surveillance for hepatitis C sequelae were not collected as part of the standard profile data collection sheet and were not available for this analysis. WHO have a formal process for countries to apply to be validated for elimination and to be acknowledged for reaching any tier. The estimated achievement of the gold, silver, and bronze tiers described here is only suggestive based on available data.

Results

All 33 National Hepatitis Elimination Profiles are available at the CGHE website.

Hepatitis C national planning

As of Sept 30, 2024, of the 33 countries and territories, 30 (91%) have hepatitis elimination action plans that include hepatitis C. Most countries and territories (n=29, 88%) have also established national hepatitis C elimination goals; 27 (82%) have both a current action plan and a hepatitis C elimination goal (table 1; appendix pp 19-21).

Table 1:

Status of essential hepatitis C policies for hepatitis elimination by income classification of countries and territories

	High income (n=11)					Upper-middle income (n=11)					Low income and lower-middle income (n=11)					All countries and territories (N=33)					p value
	Adopted	Partially adopted	Not adopted	No data*	NA	Adopted	Partially adopted	Not adopted	No data*	NA	Adopted	Partially adopted	Not adopted	No data*	NA	Adopted	Partially adopted	Not adopted	No data*	NA
HepatitisC national planning
Hepatitis C national action plan	10 (91%)	1 (9%)	0	..	..	10 (91%)	1 (9%)	0	..	..	10 (91%)	0	1 (9%)	..	..	30 (91%)	3 (9%)	0	..	..	1·000
Hepatitis C elimination goal	10 (91%)	1 (9%)	0	..	..	10 (91%)	0	1 (9%)	..	..	9 (82%)	0	2 (18%)	..	..	29 (88%)	1 (3%)	3 (9%)	..	..	0·40
HepatitisC strategic information
Routine official reports to monitor hepatitis C mortality	6 (55%)	3 (27%)	2 (18%)	..	..	3 (27%)	5 (45%)	3 (27%)	..	..	2 (18%)	4 (36%)	5 (45%)	..	..	11 (33%)	12 (36%)	10 (30%)	..	..	0·37
Routine official reports to monitor hepatitis C incidence	11 (100%)	0	0	..	..	3 (27%)	4 (36%)	4 (36%)	..	..	2 (18%)	4 (36%)	5 (45%)	..	..	16 (48%)	8 (24%)	9 (27%)	..	..	0·001
Routine official reports to monitor hepatitis C prevalence	8 (73%)	1 (9%)	2 (18%)	..	..	4 (36%)	4 (36%)	3 (27%)	..	..	5 (45%)	2 (18%)	4 (36%)	..	..	17 (52%)	7 (21%)	9 (27%)	..	..	0·38
Estimates of hepatitis C economic burden	11 (100%)	0	0	..	..	6 (55%)	1 (9%)	4 (36%)	..	..	6 (55%)	1 (9%)	4 (36%)	..	..	23 (70%)	2 (6%)	8 (24%)	..	..	0·13
Monitoring of hepatitis C diagnosis and treatment	9 (82%)	2 (18%)	0	..	..	6 (55%)	3 (27%)	2 (18%)	..	..	3 (27%)	5 (45%)	3 (27%)	..	..	18 (55%)	10 (30%)	5 (15%)	..	..	0·13
Access to hepatitis C screening
Universal antenatal hepatitis C screening policy	6 (55%)	2 (18%)	3 (27%)	..	..	6 (55%)	1 (9%)	4 (36%)	..	..	5 (45%)	3 (27%)	3 (27%)	..	..	17 (52%)	6 (18%)	10 (30%)	..	..	0·86
Approval of point-of-care RNA testing to detect HCV	7 (64%)	1 (9%)	3 (27%)	..	..	6 (55%)	2 (18%)	2 (18%)	1 (9%)	..	5 (45%)	2 (18%)	4 (36%)	..	..	18 (55%)	5 (15%)	9 (27%)	1 (3%)	..	0·757
Hepatitis C risk-based screening recommendations	11 (100%)	0	0	..	..	9 (82%)	2 (18%)	0	..	..	9 (82%)	1 (9%)	1 (9%)	..	..	29 (88%)	3 (9%)	1 (3%)	..	..	0·370
Hepatitis C age cohort or birth cohort or other special group screening recommendations	2 (18%)	2 (18%)	4 (36%)	..	3 (27%)	3 (27%)	0	5 (46%)	..	3 (27%)	0	0	7 (64%)	..	4 (36%)	5 (15%)	2 (6%)	16 (49%)	..	10 (30%)	..
Hepatitis C universal screening recommendations	3 (27%)	0	6 (55%)	..	2 (18%)	3 (27%)	0	5 (45%)	..	3 (27%)	3 (27%)	1 (9%)	7 (64%)	..	..	9 (27%)	1 (3%)	18 (55%)	..	5 (15%)	..
Expanded hepatitis C screening recommendations: birth cohort, age cohort, other special group, or universal	5 (46%)	2 (18%)	4 (36%)	..	..	6 (55%)	..	5 (45%)	..	..	3 (27%)	1 (9%)	7 (64%)	..	..	14 (42%)	3 (9%)	16 (49%)	..	..	0.423
No patient co-payments for anti-HCV antibody screening	9 (82%)	2 (18%)	0	..	..	4 (36%)	6 (55%)	0	1 (9%)	..	3 (27%)	2 (18%)	6 (55%)	..	..	16 (48%)	10 (30%)	6 (18%)	1 (3%)	..	0.002
Access to hepatitis C treatment
National hepatitis C treatment guidelines	11 (100%)	0	0	..	..	11 (100%)	0	0	..	..	9 (82%)	1 (9%)	1 (9%)	..	..	31 (94%)	1 (3%)	1 (3%)	..	..	0·37
Simplified care algorithm: <2 clinic visits during treatment	5 (45%)	3 (27%)	2 (18%)	1 (9%)	..	4 (36%)	1 (9%)	5 (45%)	1 (9%)	..	6 (55%)	2 (18%)	3 (27%)	..	..	15 (45%)	6 (18%)	10 (30%)	2 (6%)	..	0·704
Simplified care algorithm: non-specialists can prescribe treatment	6 (55%)	1 (9%)	4 (36%)	..	..	8 (73%)	1 (9%)	2 (18%)	..	..	7 (64%)	2 (18%)	2 (18%)	..	..	21 (64%)	4 (12%)	8 (24%)	..	..	0·775
Simplified care algorithm: no patient hepatitis treatment co-payments	7 (64%)	4 (36%)	0	..	..	7 (64%)	3 (27%)	0	1 (9%)	..	3 (27%)	3 (27%)	5 (45%)	..	..	17 (52%)	10 (30%)	5 (15%)	1 (3%)	..	0.029
Simplified care algorithm: no fibrosis restrictions to treatment initiation	9 (82%)	2 (18%)	0	..	..	11 (100%)	0	0	..	..	11 (100%)	0	0	..	..	31 (94%)	2 (6%)	0	..	..	0·12
Simplified care algorithm: no sobriety restrictions to treatment initiation	10 (91%)	1 (9%)	0	..	..	9 (82%)	2 (18%)	0	..	..	6 (55%)	2 (18%)	2 (18%)	1 (9%)	..	25 (76%)	5 (15%)	2 (6%)	1 (3%)	..	0·28
Simplified care algorithm: no genotyping required for treatment initiation	7 (64%)	1 (9%)	3 (27%)	..	..	8 (73%)	1 (9%)	2 (18%)	..	..	8 (73%)	1 (9%)	2 (18%)	..	..	23 (70%)	3 (9%)	7 (21%)	..	..	0·99
Equity in access to hepatitis C care and prevention services among vulnerable populations
National strategy addresses disproportionately affected populations	10 (91%)	1 (9%)	0	..	..	10 (91%)	1 (9%)	0	..	..	10 (91%)	0	0	1 (9%)	..	30 (91%)	2 (6%)	0	1 (3%)	..	0·56
Laws preventing discrimination against people living with hepatitis C	4 (36%)	3 (27%)	2 (18%)	2 (18%)	..	2 (18%)	6 (55%)	2 (18%)	1 (9%)	..	2 (18%)	2 (18%)	7 (64%)	..	..	8 (24%)	11 (33%)	11 (33%)	3 (9%)	..	0·13
Harm reduction for people who inject drugs included in national policy	9 (82%)	0	2 (18%)	..	..	7 (64%)	2 (18%)	0	2 (18%)	..	6 (55%)	2 (18%)	2 (18%)	1 (9%)	..	22 (67%)	4 (12%)	4 (12%)	3 (9%)	..	0·36
National policy for needle and syringe exchange in federal prisons	3 (27%)	1 (9%)	7 (64%)	..	..	..	..	9 (82%)	2 (18%)	..	0	1 (9%)	9 (82%)	1 (9%)	..	3 (9%)	2 (6%)	25 (76%)	3 (9%)	..	0·16
Decriminalisation of possession of syringes and associated paraphernalia	8 (73%)	1 (9%)	2 (18%)	..	..	3 (27%)	0	6 (55%)	2 (18%)	..	4 (36%)	1 (9%)	4 (36%)	2 (18%)	..	15 (45%)	2 (6%)	12 (36%)	4 (12%)	..	0·25
Decriminalisation of drug use	1 (9%)	3 (27%)	7 (64%)	..	..	1 (9%)	2 (18%)	6 (55%)	2 (18%)	..	0	0	10 (91%)	1 (9%)	..	2 (6%)	5 (15%)	23 (70%)	3 (9%)	..	0·33
Hepatitis C financing
Public budget line for hepatitis C testing and treatment	10 (91%)	1 (9%)	0	..	..	8 (73%)	3 (27%)	0	..	..	6 (55%)	1 (9%)	4 (36%)	..	..	24 (73%)	5 (15%)	4 (12%)	..	..	0·031
The Global Fund support used to support prevention, screening, or treatment for patients with co-infections, or harm reduction, as relevant	0	0	0	..	11 (100%)	4 (36%)	2 (18%)	1 (9%)	..	4 (36%)	8 (73%)	1 (9%)	1 (9%)	1 (9%)	..	12 (36%)	3 (9%)	2 (6%)	1 (3%)	15 (45%)	..

Data are n (%), unless otherwise specified. The significance of differences in policy adoption across country income levels was assessed at the 95% confidence level using Pearson’s χ² test. Differences across income categories were assessed based on having any expanded screening policy (age-based, birth-cohort, other special group, or universal screening recommendations). Differences across income categories were not explored for The Global Fund policy as countries are eligible for The Global Fund support based on income classification. HCV=hepatitis C virus. NA=not applicable. *No data on the status of the policy in the country or territory were available.

Hepatitis C strategic information

Mortality and incidence

For national surveillance, only 11 (33%) countries and territories reported availability of an information system to routinely track hepatitis C-related mortality; seven counties or territories shared data for these systems in their profiles. For the remaining countries and territories profiled, data were gathered from epidemiological modelling from the sources given above or from WHO’s Global Hepatitis Report, in which the sources of data are not specified. Hepatitis C-related mortality varied from 0·05 deaths per 100 000 people in Colombia to 15·10 per 100 000 in Taiwan (table 2). 16 (48%) countries and territories reported systems to estimate the number of incident hepatitis C cases (table 1; appendix pp 19-21).

Table 2:

Burden of hepatitis C for countries and territories profiled

	Income category	Prevalence of chronic hepatitis C (year)	Annual number of hepatitis C-related deaths (year)	Hepatitis C-related mortality rate per 100 000 people (year)
Argentina	UMIC	0·66% (2022)9	3656 (2021)17	0·12 (2021)17
Australia	HIC	0·41% (2022)9	500 (2022)18	5·53 (4·51–6·59) (2021)19
Bangladesh	LLMIC	0·70% (2022)20	7640 (2022)20	4·64 (2022)20
Brazil	UMIC	0·30% (2022)9	917 (2022)21	0·50 (2022)21
Canada	HIC	0·34% (2022)9	2692 (2022)9	6·93 (2022)9,22†
China	UMIC	0·40% (2017)23	51 637 (42 246–62 293; 2021)19	3·63 (2·96–4·38; 2021)19
Colombia	UMIC	0·60% (2022)9	27 (2022)9	0·05 (2022)9,22†
Egypt	LLMIC	0·44% (2022)9	7288 (2022)9	7·44 (2021)24
England	HIC	0·14% (2022)25	251 (2022)25	0·44 (2022)25
Ethiopia	LIC	0·55% (2022)9	3465 (2022)9	2·76 (2022)9,22†
Georgia	UMIC	1·8% (2021)26	183 (2022)9	4·82 (2022)9,22†
Ghana	LLMIC	1·31% (2022)9	1659 (2022)9	5·00 (2022)9,22†
Indonesia	UMIC	1·39% (2013)27	6322 (2022)9	2·27 (2022)9,22†
Italy	HIC	0·70% (2022)9	6804 (5882–7463; 2021)19	11·38 (9·83–12·48; 2021)19
Japan	HIC	0·13–0·52% (2020)28	13 630 (2022)29	4·50 (2022)29
Mexico	UMIC	0·54% (2022)9	11 851 (2022)9	9·21 (2022)9,22†
Myanmar	LLMIC	2·65%* (anti-HCV; 2015)30	4497 (3016–6265; 2021)19	7·97 (5·34–11·10; 2021)19
Nigeria	LLMIC	0·60% (2022)9	5652 (2022)9	2·53 (2022) 9,22†
Pakistan	LLMIC	4·10% (2022) 9	20 565 (15 523–26 895; 2021)19	8·73 (6·59–11·42; 2021)19
Peru	UMIC	0·17% (2022)9	310 (2022)9	0·93 (2022)9,22†
Philippines	LLMIC	0·37% (2022)9	3001 (2022)9	2·63 (2022)9,22†
Portugal	HIC	0·39% (2022)9	755 (615–912; 2021)19	7·12 (5·79–8·60; 2021)19
Rwanda	LLMIC	0·48% (2023)31	177 (2022)9	1·30 (2022)9,22†
Senegal	LLMIC	0·75% (2022)9	548 (2022)9	3·10 (2022)9,22†
South Africa	UMIC	0·40% (2022)9	2138 (2022)9	3·43 (2022)9,22†
South Korea	HIC	0·18% (2022)32	931 (2022)9	1·90 (2021)33
Spain	HIC	0·12% (2022)9	4150 (4031–5638; 2021)19	5·90 (2019)34
Switzerland	HIC	0·36% (2022)9	175 (2022)9	2·50 (2015)35
Taiwan	HIC	1·00% (2020)36	3560 (2020)37	15·10 (2020)37
Thailand	UMIC	0·52% (2022)9	2123 (2022)9	2·96 (2022)9,22†
Ukraine	UMIC	3·60% (2020)38	3981 (2762–5394; 2021)19	9·24 (6·41–12·52; 2021)19
USA	HIC	1·00% (0·5–1·4; 2020)39	12 717 (2022)40	2·89 (2·84–2·94; 2022)40
Viet Nam	LLMIC	0·92% (2022)9	3894 (2022)9	3·91 (2022)9,22†

Data are reported according to the most recent year for which data are available. 95% CIs are shown, where available. HCV=hepatitis C virus. HIC=high-income country. LLMIC=low-income and lower-middle-income countries. UMIC=upper-middle-income country. *The prevalence presented for Myanmar is based on a seroprevalence study and does not represent viraemic hepatitis C prevalence. Contributors from Myanmar requested the anti-HCV antibody prevalence be reported as this was based on a national survey. The WHO viraemic prevalence of 0·54% was thought to be low based on the antibody prevalence of 2·65% and available data on the proportion of viraemia among those who are antibody positive. †Death rate per 100 000 calculated based on deaths as reported by the WHO Global Health Observatory⁹ and UN total population estimates.²²

Prevalence

To monitor the burden of HCV infection, 17 (52%) of the 33 countries and territories had conducted a hepatitis C serological survey among the general population or other representative samples in the past 5 years (table 1; appendix pp 19-21). The prevalence of chronic HCV ranged from 0·12% in Spain to 4·1% in Pakistan (table 2). Seven countries and territories reported a chronic hepatitis C prevalence of at least 1%: Georgia, Ghana, Indonesia, Pakistan, Taiwan, Ukraine, and the USA (table 2).

Reporting the number of people tested and treated

Of the 33 countries and territories profiled, 18 (55%) have national hepatitis C registries to track trends in hepatitis C diagnosis and treatment (table 1; appendix pp 19-21). For another ten (30%) countries and territories, hepatitis C registries are in development or are available in a subset of provinces, states, or other subnational geographical area (table 1; appendix pp 19-21). Prior to the release of WHO’s Global Hepatitis Report,¹ hepatitis C diagnosis data were reported for nine (27%) countries and territories, and treatment data were reported for 12 (36%) countries and territories from country-specific sources. With the WHO data and other modelling studies described in the methods, only two (6%) countries and territories did not have data for diagnosis coverage and three (9%) countries and territories did not have data for treatment coverage.¹

Access to hepatitis C screening

To expand access to hepatitis C testing, nine (27%) countries and territories recommend universal hepatitis C testing and five (15%) recommend testing among people of specific ages or birth or other special groups (table 1; appendix pp 22-24). Overall, the estimated proportion of people diagnosed with hepatitis C of those living with hepatitis C ranged from 5% (Ghana, Nigeria, and Peru) to 95% or greater (Japan and Rwanda; appendix pp 31-33). Point-of-care RNA testing was approved in 18 (55%) countries and territories (appendix pp 22-24). Five (15%) countries and territories have partially introduced point-of-care RNA testing through research projects or technology approval for select populations or have registration approval in progress. 17 (52%) countries and territories have adopted universal antenatal hepatitis C screening (appendix pp 19-21). To increase affordability of hepatitis C testing, 16 (48%) countries and territories do not require patients to pay for hepatitis C antibody screening in the public sector (appendix pp 22-24). Another ten (30%) countries and territories have removed co-payments in some states or provinces or for some subpopulations based on income, insurance type, or other factors.

Access to hepatitis C treatment

Many countries and territories described effective models of scaling up hepatitis C treatment in the National Hepatitis Elimination Profiles (panel 3). All countries and territories but one (Senegal) have local guidelines for hepatitis C treatment that are at least partially adopted (appendix pp 22-24). Only two (6%) countries (Ethiopia and the Philippines) reported national restrictions to starting hepatitis C treatment based on sobriety (appendix pp 25-27). No country or territory reported restricting access (nationally) to hepatitis C treatment-based liver fibrosis staging. In Canada and the USA, some provinces and states continue to have restrictions based on sobriety, fibrosis staging, and other criteria.

Panel 3: Innovations in hepatitis C testing and treatment and examples of successful programmes.

Hepatitis C screening

• Task shifting to promote decentralisation: the Brazilian Ministry of Health issued a technical note that provides legal support for nurses to do rapid HCV tests and request additional examinations of those suspected of having HCV.⁴¹ In Canada, the APPROACH study allows community pharmacists in Alberta and Nova Scotia to test people for sexually transmitted infections and blood-borne diseases, including hepatitis C.⁴²

• Integrated screening initiatives: in Rwanda, as part of the well-established health services for HIV, 15 hospitals have the capacity to conduct hepatitis C viral load testing. By use of current systems for HIV viral load testing, blood samples for hepatitis C testing are collected at local health centres and district hospitals, and delivered to one of the testing sites via a centrally organised transport system, which also delivers results back to the health facilities.⁴³ In Mexico, more than 90 000 people living with HIV have been screened for hepatitis C, with more than 1200 people being diagnosed as living with both HIV and hepatitis C and initiating treatment.⁴⁴ During the Egyptian Presidential Initiative, hepatitis C screening was integrated with screening for non-communicable diseases, including diabetes, hypertension, and obesity. Under this programme, more than 240 000 people were screened per day from October 2018 to April 2019. There were 77 PCR testing sites around the country with capacity for 36 000 hepatitis C virus (HCV) RNA tests daily.⁴⁵

• Reflex hepatitis C testing: reflex testing is when a confirmatory HCV RNA test is automatically done if anti-HCV antibody screening is positive, on either the same sample or a second sample collected at the same time, avoiding the need for a repeat visit. In Canada, eleven provinces and territories have reflex hepatitis C testing.⁴⁶ In Spain, many hospital systems have implemented hepatitis C reflex virological testing, reducing the number of clinic visits from screening to hepatitis C treatment initiation. In 2 years, the proportion of Spanish hospitals implementing hepatitis C reflex testing (or diagnosis in one-step) increased from 31% in 2017 to 89% in 2019 according to the Spanish Alliance for the Viral Hepatitis Elimination.⁴⁷

Hepatitis C treatment

• Telementoring for primary care physicians: in Mexico, the Educación, Capacitación y Actualización a Distancia en Salud (EDUCADs) course was created to increase national capacity for hepatitis C testing and treatment with primary care physicians.⁴⁴ In Europe, the HCV Sicily Network is an Italian, web-based, hub-and-spoke model connecting 41 clinical centres and more than 80 specialist physicians (eg, gastroenterologists and hepatologists) managing hepatitis C care. The network’s primary aim is to link specialists with general practitioners.⁴⁸ The HepCare project of Swiss Hepatitis aims to expand capacity for hepatitis C treatment by providing specialist consultations for general practitioners to initiate hepatitis C treatment.⁴⁹

• Care coordinators: the Japanese national programme has established hepatitis medical care coordinators (HMCC) who are specialised personnel expected to support patients and their families in every aspect of care. By 2019, more than 20 000 HMCCs were certified in Japan. In addition, the prefectural government or other authority, after obtaining the consent of the individual, confirms the status of visits to medical institutions and medical treatment by sending a survey sheet once a year, and, if the individual has not yet visited a hospital, recommends that the individual visits a specialist and receives medical consultation by telephone or other means.⁵⁰

Examples of achievements in hepatitis C testing and treatment

• Australia: the National Australian Hepatitis C Point-of-Care Testing Program has partnered with 100 sites in all states and territories and has performed more than 30 000 point-of-care (POC) tests as of October 2024, to assess the effectiveness and feasibility of POC testing and improve access to care. About 10% of all hepatitis C treatment now occurs through this programme. Programme sites include drug-treatment clinics, needle and syringe programmes, prisons, mobile outreach models, homelessness services, Aboriginal community-controlled health organisations, and mental health services.⁵¹

• Indonesia: in 2022 the national hepatitis C treatment programme was expanded to 31 of the country’s 38 provinces.¹⁴

• Japan: in 2007, the Ministry of Health, Labour and Welfare issued the Notice on the Establishment of Liver Disease Care Systems, which initiated the construction of liver disease care systems nationwide, starting with regional core centres and specialised institutions. Currently, at least one regional core centre is designated in each prefecture, with 71 institutions nationwide, all of which have established liver disease consultation and support centres to provide support to patients and their families.⁵²

• Mexico: Diagnosis and treatment are now authorised in the public sector to the entire population at no out-of-pocket cost to any individual, including migrants.⁵³

• Myanmar: in 2017, the Government launched a free treatment programme in eight states and regions, treating more than 10 000 patients.⁵⁴

• Spain: Spain has implemented several successful hepatitis C micro-elimination initiatives. The Hepatitis C Free Balears programme decentralised hepatitis C care to 21 sites serving people who use drugs in the Balearic Islands with a model that involved HCV antibody screening onsite; HCV RNA, HBsAg, and anti-HIV antibody testing via a dried blood spot or phlebotomy; linkage to specialist care and treatment prescription via telemedicine; and onsite monitoring of sustained virological response (SVR). Greater than 80% treatment initiation was achieved and greater than 90% cure rates was achieved in those completing SVR testing.⁵⁵

Despite the availability of pan-genotypic therapies, ten (30%) countries and territories require genotyping to initiate hepatitis C treatment nationally or in some cases. 12 (36%) countries and territories only permit liver or infectious disease specialists to prescribe hepatitis C therapies or place restrictions on when general practitioners can treat hepatitis C for all or some patients. 16 (48%) countries and territories have not fully removed onerous monitoring requirements of at least two clinician visits after initiation of hepatitis C therapy. 15 (45%) countries and territories continue to require some or all patients in the public sector to pay for their hepatitis C treatment (table 1; appendix pp 22-24). The proportion of people diagnosed with hepatitis C who have been treated ranged from 3% in South Africa and the Philippines to 94% in Egypt and Rwanda (appendix pp 34-36). Of people living with hepatitis C, the proportion of people treated ranged from 0% in Ghana to 93% in Egypt (appendix pp 34-36).

Equity in access to hepatitis C care and prevention services among vulnerable populations

In national strategies, 30 (91%) of the 33 countries and territories prioritise hepatitis C prevention and care services for key populations (table 1; appendix pp 25-27). To prevent HCV transmission among people who inject drugs, 22 (67%) countries and territories have harm-reduction programmes. For 22 countries and territories with data, the number of needles and syringes distributed per person who injects drugs per year ranged from zero in the Philippines to 636 in Australia (appendix pp 37-40). Only three (9%) countries and territories have adopted needle and syringe programmes in federal prisons—Canada, Italy, and Spain. Nigeria and Switzerland have ongoing pilot needle and syringe programmes in prisons. 15 (45%) countries and territories have decriminalised the possession of syringes and drug paraphernalia. Two (6%) countries and territories have decriminalised drug use for personal consumption. Eight (24%) countries and territories have adopted national anti-discrimination laws to protect people living with hepatitis C. Innovative strategies have been introduced to expand access to harm-reduction services and reduce stigma (panel 4). For example, in Georgia, hepatitis C screening is available at both stationary needle and syringe programmes and mobile clinics and the Georgian Hepatitis C Cured Patient Association trains elimination ambassadors to serve as peer community workers.

Panel 4: Examples of innovations in improving equity in hepatitis C elimination.

Harm reduction

• The Correctional Service of Canada makes available prison needle and syringe exchange programmes in nine of 43 federal prisons across the country, but needle and syringe exchange is not available in provincial prisons. Also in Canadian federal prisons, hepatitis C testing is universally offered to all entrants and is available on demand. All people in federal prison are eligible for hepatitis C treatment, irrespective of disease stage.⁴⁶

• In Georgia, anti-hepatitis C virus antibody and HBsAg screening is available at 16 needle and syringe programme sites and nine mobile units. Hepatitis B and C screening are provided as part of the pre-enrolment process at all 21 opioid agonist therapy clinics.⁵⁶

• In Nigeria, a three-state pilot needle and syringe programme and feasibility study was implemented in Abia, Gombe, and Oyo states in 2020.⁵⁷

Raising awareness and reducing stigma

• In 2021, the Georgian Hepatitis C Cured Patient Association and their partners identified 20 Elimination Program Ambassadors who participated in a train-the-trainer programme on hepatitis awareness, media communication, and peer-to-peer consulting techniques led by health promotion and strategic communication specialists.⁵⁶

• The Shitte kan-en project in Japan was launched by the Ministry of Health, Labour and Welfare to leverage popular Japanese athletes, actors, and singers as delegates for building public awareness for the early detection and treatment of viral hepatitis.⁵⁸

• In 2019, the Spanish Alliance for Viral Hepatitis Elimination launched a national campaign, Give hepatitis C a happy ending, for which well-known actor Carmelo Gómez lent his image for an awareness commercial that was screened in almost all of Spain’s cinemas.

Financing of hepatitis C testing and treatment

24 (73%) of 33 countries and territories have a national budget supporting hepatitis C testing and treatment. Of the 18 eligible countries and territories, 12 (67%) have accessed funding from The Global Fund to support care for patients with co-infections, harm reduction, or antenatal screening.¹⁷

Policy scores

Of 26 policies with scoring (panel 1), Spain had the highest total score of 23·0, with 23 policies adopted, followed by Egypt and Australia, each with a score of 22·0 (appendix pp 41-42). Bangladesh, the Philippines, Senegal, Ghana, and South Africa had the lowest policy scores, with fewer than 12 policies adopted (panel 1; figure 2; appendix pp 41-42). 13 (39%) countries and territories had a score of 19·5 or higher, 75% of the maximum policy score. The mean policy score across all countries and territories was 17·3 (SD 4·0).

Figure 2: Hepatitis C policy scores by income classification.

(A) Hepatitis C mean policy scores for policy categories. (B) Mean total hepatitis C policy scores by income classification. (C) Country and territory hepatitis C policy scores. HCV=hepatitis C virus.

*Two policies. †Five policies. ‡Four policies. §Seven policies. ¶One policy.

There was a difference in policy score by income levels. The mean policy score for HICs was 20·1 (SD 1·5), compared with 17·0 (SD 3·1) for UMICs and 14·7 (SD 4·7) for LLMICs (figure 2; p=0·007; appendix p 42). There were significant differences across income levels in mean policy scores related to the collection of strategic information (p=0·002) and equity (p=0·014), with HICs having the highest mean scores for each (appendix p 43).

Achievement of WHO 2025 and 2030 targets and tiers on the path to elimination

To date, ten (30%) countries and territories—Australia, Canada, Egypt, Georgia, Japan, South Korea, Rwanda, Spain, Switzerland, and the USA—have achieved the 2025 WHO target of 60% or more people diagnosed with hepatitis C (appendix pp 31-33). Of these ten countries, seven (70%) are HICs, one (10%) is an UMIC, and two (20%) are LLMICs (p=0·028; appendix p 44). Three countries (Canada, Japan, and Rwanda) have met the 2030 WHO Target of 90% or more of people with hepatitis C diagnosed. Five (15%) countries and territories have met the WHO 2025 target of 50% of people who have or had hepatitis C have been treated: Australia, Egypt, Georgia, Japan, and Rwanda. Only Egypt has met the WHO 2030 target of 90% treatment coverage of people who have or had hepatitis C (appendix pp 34-36). Seven (21%) countries and territories have met the WHO 2025 target of 200 needles and syringes distributed per person who injects drugs per year (appendix pp 37-40). No significant differences in the achievement of the 2025 WHO needle and syringe or treatment targets were observed by income category (appendix p 44). The reported hepatitis C-related mortality rates for 14 countries and territories met or were below the WHO 2025 interim mortality target (three deaths per 100 000). Mortality rates for seven countries and territories also met or were below the original WHO 2030 mortality goal (two deaths per 100 000; table 2).

In 2023, Egypt was formally validated by WHO for meeting the gold tier for path to elimination of hepatitis C.⁵⁹ Based on data available for needle and syringes programmes, diagnosis, and treatment, Australia, Georgia, and Spain might be eligible for the silver tier of the WHO path to elimination framework (appendix pp 45-46).⁴³

Local stakeholder recommendations to accelerate hepatitis C elimination

Improvements in hepatitis C testing and treatment were the most frequent recommendations for advancing hepatitis C elimination reported in the profiles (n=31, 94%). The next most common recommendation was strengthening strategic information systems (n=26, 79%), followed by advocacy to engage additional stakeholders (n=21, 64%) and improving prevention of HCV transmission (20, 61%; appendix p 47). There were no significant differences in types of recommendations made across income levels.

Discussion

This Health Policy provides a comprehensive assessment of the key foundational components of hepatitis C elimination programmes described in the National Hepatitis Elimination Profiles for 33 countries and territories, representing an estimated 73% of the global population living with hepatitis C. The policy framework presented in the profiles goes beyond assessing whether a country or territory is on track towards elimination or not, also revealing the drivers or challenges for accelerating progress. The data from the profiles show that most countries and territories have responded to the World Health Assembly and WHO call for hepatitis C elimination. Every country and territory assessed has a current national action plan or is developing one. Only three countries have not adopted hepatitis C elimination goals or are not in the process of doing so. Of the countries and territories that were profiled, 97% have current or upcoming hepatitis C risk-based screening recommendations and 51% have or are in the process of developing expanded screening recommendations. Similarly, 97% of profiled countries and territories have current hepatitis C treatment guidelines in development. To expand access to care, 73% of the countries and territories have established budgets for hepatitis C testing and treatment.

With this recognised progress, the profiles highlight areas needing improvement in policy development and implementation. For example, most countries and territories assessed have limited capacity in hepatitis C surveillance and other strategic information. Public health data are crucial to tracking progress towards the health outcome goals of reductions in hepatitis C incidence and hepatitis C-related mortality, as well as to monitoring access to care. Remarkably, only a third of countries and territories have routine official reports on hepatitis C-related mortality, and slightly less than half of countries and territories have systems to track incidence. Monitoring of mortality related to HCV infection, which is underdiagnosed, is challenging. The absence or incompleteness of crucial records further complicates efforts to understand HCV-related mortality and the attributable fraction of deaths caused by HCV infection. WHO’s consolidated strategic information guidelines for viral hepatitis include guidance for estimating the attributable fraction of deaths in people with sequelae of hepatitis C through data abstraction of routine clinical records at fixed sentinel sites in healthcare facilities caring for people with chronic liver diseases or liver cancer or in cancer registries.⁶⁰ The gold-standard method for assessing incidence through ascertaining new hepatitis C cases prospectively among people at risk of infection can be resource-intensive. Alternative methods have been suggested to improve the feasibility of data collection, including direct estimation of hepatitis C incidence based on retrospective design through the use of health records of people routinely retested or direct estimation based on linked repeated cross-sectional surveys.⁴ To guide and evaluate hepatitis C testing and treatment programmes, the profiles reveal good examples of reliable national systems. In Mexico, the Ambiente para la Administración y Manejo de Atenciones en Salud (AAMATES) information system includes hepatitis C testing and treatment data across all public health institutions.⁶¹ However, only 55% of the countries and territories profiled reported having registries for tracking the number of people diagnosed and treated for hepatitis C.

The profiles reveal multiple clinical practices that add unnecessary complexities to the care of people with hepatitis C. For example, more than half of the profiled countries and territories still require multiple visits during hepatitis C treatment. Studies such as the MINMON trial show that high cure rates of hepatitis C can be achieved with no clinic visits between the start and completion of a hepatitis C course of treatment.⁶² Although pan-genotypic therapies are widely available, seven countries and territories still require genotyping before starting treatment. Around a third of profiled countries and territories do not permit non-specialists to prescribe hepatitis C medications without restrictions. Marshall and colleagues conducted a global analysis of the status of hepatitis C reimbursement and restriction policies and found that, among the 109 countries that reimbursed hepatitis C medicines in the public system, 66 (61%) required specialist prescribing and nearly half of these countries were UMICs or LLMICs.⁶³ Additional restrictions were also reported qualitatively in the profiles. In Japan, patients must apply to the Government’s special hepatitis treatment promotion programme with a referral letter from a designated specialist medical institution to receive financial assistance for co-payments. In the USA, restrictions vary by state but the requirement for prior authorisation for insurance coverage continues to be prevalent.

Through the profiles, local partners shared strategies for expanding access to hepatitis C testing, such as leveraging point-of-care RNA testing to establish models of care offering multiple services at one location, integrating hepatitis C screening with other infectious and non-communicable disease screenings, and introducing microelimination programmes (panel 3).⁶⁴ A systematic review by Cunningham and colleagues showed that point-of-care RNA testing improved HCV RNA testing uptake by 35 times compared with the standard of care, typically laboratory-based RNA testing.^65,66 However, only 55% of countries and territories profiled here have approved point-of-care RNA testing technologies for hepatitis C. Mexico, Thailand, and the USA are the latest to approve point-of-care testing before this data analysis. Only 14 (42%) of 33 countries and territories have moved beyond risk-based screening to recommend age-based, birth cohort-based, other special group, or universal hepatitis C screening. In March 2020, the Italian Government approved the Milleproroghe Decree, allocating €71·5 million for 2020–21 to screen people born from 1969 to 1989 for hepatitis C free of charge.⁶⁷ Pioneering leaders, such as Egypt, Georgia, and Rwanda, have implemented universal screening strategies to scale up hepatitis C screening nationally.

Although 67% of profiled countries and territories reported having harm-reduction programmes for people who inject drugs, only seven (21%) have met the WHO 2025 needle and syringe target. Combined use of opioid agonist therapy with needle and syringe programmes is associated with a 74% risk reduction in HCV infection.⁶⁸ Access to preventive services for people who inject drugs in carceral settings is also limited, as evidenced by only three countries and territories reporting needle and syringe programmes in prisons.

Although progress is being made towards WHO elimination goals across the income spectrum, this progress is most challenging for UMICs and LLMICs. UMICs and LLMICs lag behind HICs in removing financial barriers that restrict access to hepatitis C prevention and care services. 82% of the HICs profiled have removed co-payments for HCV antibody screening, compared with only 36% of UMICs and 27% of LLMICs. To increase affordability of hepatitis C prevention and care, UMICs and LLMICs can include hepatitis C testing and treatment as part of universal health insurance, seek agreements that improve affordability of hepatitis C diagnostics and therapies, and lower costs through integration of hepatitis C care with HIV, primary, and other care services. Only 73% of the UMICs and 55% of the LLMICs reported budgets for hepatitis C testing and treatment, whereas 91% of the HICs reported such budgets, enabled by several innovative financing schemes that could serve as models for LLMICs. The subscription model, whereby payers cap total spending for hepatitis C medicines for a year for an unlimited number of medicines, or at least for a high threshold of treatments pre-agreed on by the government and company, was introduced by Australia at the national level and adopted by state governments in the USA, including Louisiana and Washington.^69-71 The federal Government in Spain has successfully pursued price–volume agreement, where the manufacturer will reduce the price of the drug if the drug’s sales volume exceeds a pre-defined threshold.⁷² For eligible UMICs and LLMICs, leveraging resources from The Global Fund for integration of hepatitis C treatment into HIV treatment platforms is an innovative financing strategy.⁷³

A strength of the profiles is that they are developed in collaboration with key stakeholders in each country or territory, including representation from government, clinical, and civil society sectors. Data for only three countries (the Philippines, Switzerland, and Senegal) were not validated by health officials either directly or via a partner selected by the country’s ministry of health. All profiles were updated in July, 2024, to account for the country-level hepatitis indicators released by WHO for the first time.^1,9 Through participation in WHO’s Data Collaborative for Hepatitis, efforts are ongoing to further align these sources of national data. The profiles also informed the update of The Lancet Gastroenterology & Hepatology Commission on elimination of viral hepatitis, which provided an update on the status of elimination across high-burden countries.¹⁴ Contributors to the profiles (appendix pp 8-18) have reported qualitatively that the profiles have informed government meetings on strategy and policy development, supported advocacy campaigns, provided situational assessments to inform national programme and strategy planning, and provided input to grant applications.⁷⁴

There are limitations to the data reported in the profiles, particularly related to reporting on policy information. The development of a global policy framework must respond to a range of epidemiological and health system contexts. At the national level, some policies might be more important than others. Reported policies can vary by time period and policy development is consistently evolving within countries. To assure the accuracy of this Health Policy, from July to September, 2024, all profile stakeholders were asked to review and update their country’s or territory’s profile. However, additional updates to the reported data are expected. Going forward, profiles will be updated upon request from local contributors and routinely every 2 years; this schedule is expected to keep profiles as current as possible. Policy evaluation can also vary across stakeholders. To standardise assessments, definitions of the policy indicators (appendix pp 2-6) were reviewed by multiple stakeholders from each country or territory (appendix pp 8-18). In some instances, the assessment of policy development varied among national partners, including across perspectives of government and civil society or non-governmental organisation partners. When differing data were presented, the assessment of health ministry officials was selected. For WHO goals and tiers in the path to elimination framework, profile data were not analysed for all criteria, such as incidence and coverage of blood and injection safety in health care. The quality of the incidence data varied, and additional analysis is warranted to further assess the quality of incidence data and suggest recommendations for strengthening incidence data collection systems globally, both among the general population and among people who inject drugs. Data on blood and injection safety were not collected as part of the profiles, although most countries worldwide have met the blood and infection safety criteria WHO targets.⁷⁵ The profiles also did not assess progress towards the 2030 goal of a combined hepatitis B and C mortality rate of at most six deaths per 100 000 people. These data were not collected as part of the profile data collection template given the indicator’s recent introduction in 2023 and the scarcity of available data. New data sources for this indicator are needed to assess criteria for validation of elimination.

Looking forward, the profiles will be revised to reflect the dynamic information to assess hepatitis C policy development and implementation. There are ongoing needs to monitor the status of the care cascade, from screening to diagnosis and initiation of therapy. Data can be enhanced for hepatitis C in pregnancy, children with hepatitis C, people who are incarcerated, and other key populations. Profiles can also present economic data calling attention to the economic losses from HCV infection.⁷⁶ Additional details will improve assessment of strategic information systems. Local coalitions of partners must be empowered to effectively disseminate the profile data to promote advocacy and guide policy change that will improve hepatitis C prevention and care in profiled countries, and others.

In summary, sharing lessons learned will accelerate the adoption of innovations and key policies for hepatitis C by providing proven examples for others to follow. The National Hepatitis Elimination Profiles are a unique resource for comparing and contrasting the strengths and limitations of national hepatitis elimination programmes, which can promote and guide quality improvement. At the national level, the epidemiological and health system context can inform which information in the profile is a priority for policy development. Tracking policy development and essential components assists in identifying priorities for resource mobilisation, operational research, and technical assistance.

National Hepatitis Elimination Profile Collaborators

Angelica Miranda, Brazil; Aya Sugiyama, Japan; Carlos Varaldo, Brazil; Caroline Thomas, Indonesia; Chris Muñoz, the Philippines; Hailemicahel Desalegn, Ethiopia; Hanna Aberra, Ethiopia; Hugo Cheinquer, Brazil; Huma Qureshi, Pakistan; Irina Ivanchuk, Ukraine; Junko Tanaka, Japan; Javier García-Samaniego, Spain; Khin San Tint, Myanmar; Kittiyod Poovorawan, Thailand; María Eugenia de Feo, Argentina; Mark Sonderup, South Africa; Maryna Aleksandrova, Ukraine; Mohammad Ali, Bangladesh; Mohamed Hassany, Egypt; Monica Desai, England; Nishi Prabdial-Sing, South Africa; Rui Marinho, Portugal; Saeed Hamid, Pakistan; Samart Punpetch, Thailand; Thandar Su Naing, Myanmar; Yasu Tanaka-Kumadai, Japan; Young-Suk Lim, South Korea; Yvonne Nartey, Ghana.