The introduction of DAAs has markedly elevated the cure rate for HCV to above 90% [17–19]. This survey found that the HCV RNA positivity rate among diagnosed HCV patients in Chongqing was 37.7%, slightly below the 42.9% observed in a study of patients in hospital visits in Shenyang, Liaoning Province, China in 2018 [20].This variance may reflect a higher ratio of newly diagnosed individuals in clinical settings. Adjusting for duplicate reports, deaths, and foreign cases, Chongqing's recorded hepatitis C cases from 2004 to 2021 were 48,000. According to the positive rate of 37.7%, approximately 18,000 patients were HCV RNA positive that required treatment. Thanks to national health insurance, the cost of DAAs treatment in China decreased to USD 200–1500 for a 12-week course of cure, with out-of-pocket expenditure is within USD 150–450 [21].Thus, the DAAs treatment expense for the 18,000 cases in Chongqing is estimated to be between USD 3.6–27 million, posing a substantial economic burden. The study also noted higher HCV RNA positivity rates among economically disadvantaged groups, farmers or manual laborers, and the unemployed or job-seeking population. Despite insurance coverage for DAAs, the associated costs remain a hurdle for low-income individuals. A study on DAAs usage for Hepatitis C in China highlighted a treatment rate as low as 2.0% [22], with patient affordability and low awareness of the disease as primary barriers to higher treatment uptake. It has been reported that a single Hepatitis C hospitalization can exceed the annual income of rural residents by 117.7% [23]. It is imperative to explore additional financial support for low-income patients to enhance treatment accessibility, such as government subsidies and project funding.
Historically, interferon-based treatments were the sole option therapy for HCV. It was high costs and lengthy treatment duration, but its efficacy rate was only 60–70% [24–25]. This analysis revealed that patients previously treated with interferon had a higher HVC RNA positivity rate of 25.6% compared to 8.1% among those treated with DAAs, suggesting not only focusing on untreated patients but also those treated with interferon to halt the disease's progression. The launch of DAAs in 2013 marked a significant breakthrough in HCV treatment, with DAAs becoming the recommended treatment option by 2015 in China [26]. However, DAAs were not approved in China until 2017, with the very high retail prices, ranging between USD 10,000–17,600 per standard treatment course in the private sector [27]. Finally, the DAAs were included in the national medical insurance list in 2019, with an average price drop of over 85% [28], significantly increased treatment affordability. Cases reported before 2019 had higher HCV RNA positivity rate, due to the high cost and limited accessibility of DAAs, suggesting we need to prioritize earlier-diagnosed cases for treatment.
By 2021, eight DAAs were founded by national health insurance in China [29]. At the same year, Chongqing designated specific hospitals for HCV treatment, promoting systematic case management to improved case management and treatment accessibility. The predominant HCV genotype in Chongqing was genotype 3, followed by 1b and 6, differing from the national distribution [30]. Since different genotypes necessitate specific DAAs, treatments targeting genotype 1b are less costly. Predominantly, Chongqing's hospitals utilize pan-genotypic DAAs effective against genotypes 1, 2, and 6, for genotype 3, advising incorporating ribavirin to improve treatment outcomes [31–32]. Given the prevalence of genotype 3 and genotype 1b in Chongqing, we suggested implement genotype testing and personalized treatment strategies to enhance both cost efficiency and therapeutic effectiveness.
Furthermore, the study identified a higher HCV RNA positivity rate in males than in females, attributed to risk behaviors more common among men and the higher likelihood of women spontaneous clearing HCV infection—approximately double that of men [33, 34]. Higher educational patients showed lower positivity rates. Higher education was associated with greater awareness of Hepatitis C [35], potentially enhancing adherence to treatment following diagnosis. The positivity rate was elevated among individuals aged 40–59, consistent with evidence that spontaneous clearance of HCV is more likely to occur in younger age groups [36]. Additionally, married individuals had lower positivity rate, likely due to a higher inclination towards seeking treatment to prevent intrafamilial transmission.
Our study has some limitations. The subjects were sourced from reported hepatitis C cases within the Chinese Disease Prevention and Control Information System. With some cases had invalid or changed contact information, or had relocated, rendering them untraceable. A portion of the cases, being asymptomatic for extended periods, refused to be surveyed, while some elderly cases were unable to participate due to mobility issues or communication barriers. These factors contributed to a lower survey rate. Therefore, we compared the differences between all reported Hepatitis C cases in Chongqing from 2004 to 2021 and the sample, acknowledging that these differences could have influenced our results (Supplementary Table 1).