A total of 22,000 individuals, both males and females, were offered the HCVAb screening at 24 different Apulia region pharmacies. However, 8128 (36.9%) refused the assay, of which 4204 (51.7%) were males and 3.924 were females. For men, the main reason for not accepting screening was their claim of never having used substances. For women, it was having had only one sexual partner.

Of the remaining 13,042, the minority, 6377 (48.9), were male, while 6665 were female. Overall, 1636 (12.5%) who, according to the result of the accompanying questionnaire, were aware of their spontaneous viral clearance (N = 928), had been successfully treated (N = 167) or were not in the age range of the study (N = 541) were excluded. Of them, 830 (50.7%) were male and 806 female. Thus, among 11.406 individuals correctly screened, the number of males was lower than females, with 5.547 versus 5859 (51.4%) females (p < 0.05). The mean age of screened subjects was 64.9 (± 7.6) years, 65.4 (± 7.6) years for males, and 64.7 (± 7.5) years for females.

Table 1 reports the proportion of subjects undergoing screening by birth cohort. As expected, the screening rate declined with age. More younger females than males agreed to screening, but the proportion declined in those born from 1937 to 1947.

In 70.7% of patients screened, the route of transmission was unknown. Slightly higher percentage of unknown route of transmission (78.1%) was reported by individuals who had been excluded. In up to 21% of those who accepted screening, a raised liver enzyme or a family member with liver disease was the reason for accepting screening; in up to 3% of cases past history of unprotected sex was the reason for accepting the screening. In 5.3% of cases, patients declared a past substance use. All the patients were Caucasian and White.

The distribution of screened patients according to the 6 Apulian provinces was the following: 31.1% from Foggia, 9.2% from Bari, 22.7% from Barletta-Andria Trani, 2.3% from Brindisi, 32.9% from Taranto, 1.8% from Lecce.

Screening outcomes.

Overall, 130 subjects tested HCVAb positive (1.1%) of whom 129 (99.2%) were linked to treatment (Fig. 1). Of 129, 71 (55.0%) were males and 58 females. Seroprevalence was higher in males, at 1.3%, versus 0.98% in females.

Legends: The complete HCV care cascade of patients screened in the 24 street pharmacies involved in the micro-elimination initiative. Data availability statement: The datasets generated and/or analysed during the current study are not publicly available due Privacy restrictions related to data Guarantor Health Authority in our Country but are available from the corresponding author on reasonable request.

The mean age of HCVAb positive subjects was 68.3 (± 10.3) years.

In the youngest birth cohort, the seroprevalence rate was 0.88%, increasing to 1.0% among subjects born between 1946 and 1957 and 2.8% among subjects born from 1937 to 1947.

HCV seroprevalence was higher in males (p < 0.00001) and elderly (p < 0.00001) and in subjects with unknown transmission routes (0.0009).

All the HCV Ab-positive subjects agreed to undergo HCV RNA testing.

Characteristics of patients with active infection.

The prevalence of active infection was 0.8%. HCV RNA was detectable in 87 (67.4%) of 129 HCVAb-positive patients. The complete care cascade is reported in Fig. 1. Patients with active infection were 67.5 (± 10.7) years old and mainly males, 55.1%. Therefore, both HCVAb positivity and active infections were less frequent in women.

HCV RNA positivity increased in older adults.

The rate of active infection peaked at 1.32% in individuals born from 1937 to 1947; by contrast, the prevalence of HCV RNA in the youngest cohort was 0.59%. Epidemiological, clinical and virological characteristics of subjects with active infection are reported in Table 2. The mean liver stiffness measurement (LSM) values of subjects with active infection were 8.8 (± 3.7) KPa.

Gender differences.

Overall, seropositive females were older than males, with a mean age of 70.4 (± 10.3) vs. 66.1 (± 10.3) years.

In the youngest cohort, the majority of HCVAb positive were male (65.4% and ), while in the remaining cohorts, seroprevalence in women was higher than in men, being 54.8% and 60.0%, respectively (p = 0.06) (Table 1).

When HCV-RNA positive results were analysed by gender, rates of 0.9% in 48 men and 0.7% in 39 women were observed. Mean age was 65.7 (± 10.3) years and 69.8 (± 10.7) years for males and females, respectively.

As shown in Table 3, the highest rates of active infection were observed in the youngest and the oldest birth cohorts. In the elderly, the peak was primarily related to a numerically higher active infection rate in females than in men (p = 0.20).

Liver stiffness was higher in women than men (9.2 KPa ± 3.7 vs. 8.6 KPa ± 3.7) (p = 0.04).

Linkage to care and treatment outcomes.

Of the 87 patients HCV-RNA positive, 78 (89.6%) started pan-genotypic, pan-fibrotic treatment; the main reason not to start was “old/too ill from other conditions” (77.7%); other reasons were related to logistics (need to be driven to the DAA distributing center). No gender differences were appreciated in the group of subjects linked to treatment. All the treated patients achieved sustained virological response after 12 weeks of pan-genotypic, pan-fibrotic treatment; one patient experienced reinfection by a different HCV genotype.