Progressing towards global hepatitis C elimination: a systematic review and meta-analysis of care cascades in key populations.

Abstract

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. 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. 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. 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. National Natural Science Foundation of China.