Progress toward hepatitis C elimination among people who inject drugs in San Francisco, 2018 - 2024.

Abstract

Hepatitis C virus (HCV) remains a major cause of liver-related morbidity and mortality, with people who inject drugs (PWID) disproportionately affected. San Francisco has implemented elimination efforts through End Hep C SF since 2016. This study evaluated progress toward HCV elimination among PWID in San Francisco from 2018 to 2024. We analyzed data from the 2018, 2022, and 2024 National HIV Behavioral Surveillance (NHBS) PWID cycles in San Francisco. Respondent-driven sampling was used to recruit PWID aged ≥ 18 years. Participants completed interviewer-administered surveys and underwent HCV antibody testing (2018, 2022, 2024) and RNA testing (2018, 2024). Temporal changes in HCV-related outcomes were examined using Poisson regression with robust variance to estimate prevalence ratios (PRs). A total of 456 participants enrolled in 2018, 527 in 2022, and 512 in 2024. Median age decreased from 48 to 41 years, and stimulant injection increased from 24% to 59%. Active HCV infection (RNA+) declined from 40% in 2018-11% in 2024 (aPR 0.86), while HCV antibody positivity declined from 76% in 2018-43% in 2024 (aPR 0.97). Self-reported HCV positivity decreased from 59% to 39%. Treatment uptake among participants reporting HCV positivity increased from 38% in 2018-60% in 2024 (aPR 1.08), while HCV screening declined over time (aPR 0.96). Black participants had lower HCV prevalence and steeper declines, while Native Americans had persistently elevated risk. San Francisco has made substantial progress toward HCV elimination among PWID, with marked reductions in active infection. Sustaining elimination will require renewed investments in screening, linkage to care, and harm reduction interventions.