HCV poses a significant threat to public health, leading to liver failure and hepatocellular carcinoma. The global distribution of HCV is uneven. HCV infections in mainland China account for one-sixth of all cases worldwide, making it the country with the highest absolute number of infections worldwide⁵. Given the substantial number of HCV-positive individuals in China, the government’s efforts to achieve the WHO’s targets of 90% diagnostic coverage and an 80% treatment rate by 2030 could significantly impact the global burden of HCV-related diseases¹¹. In 2019, reported cases from Kashi accounted for 28.66% of all cases in Xinjiang. From 2015 to 2019, Kashi reported an average of 2,007 hepatitis C cases annually, and there was an uneven distribution across the region⁷. Our investigation retrospectively analysed the HCV-Ab positivity rate, HCV GT distribution, hepatitis C diagnosis status, and treatment status in the Kashi region. Although the HCV-Ab positivity rate and the number of confirmed cases have increased in recent years, the proportion of patients receiving DAA remains relatively low. The results indicate that the hepatitis C epidemic in this area is critical, with suboptimal treatment outcomes, and that local health authorities and medical institutions face considerable challenges.

From 2018 to 2022, the overall HCV-Ab positivity rate in the Kashi region was 2.4% (95% CI: 2.4–2.5%). This positivity rate is significantly higher than the national HCV-Ab prevalence rate of 0.43% reported in 2006 and the prevalence rate of 0.40% reported among populations in western China¹². Additionally, the HCV-Ab positivity rates in Gansu (1.08%) and Chongqing (1.7%) are also higher than the national HCV-Ab prevalence rate reported in 2006^13,14. This evidence suggests that there may have been a certain degree of increase in the HCV-Ab positivity rate in China in recent years, particularly in the western regions. Statistical analysis using the Chi-square test for trend demonstrated that both the HCV-Ab positivity rate (p < 0.001) and HCV RNA positivity rate (p< 0.001) showed significant upward trends. These findings suggest that the burden of HCV infection in the region has been rising steadily over the past several years, indicating a potential increase in the incidence of HCV in this area. This increasing trend may be attributed to several factors. The first factor may be increased screening efforts: China’s “Action Plan for Eliminating the Public Health Hazard of Hepatitis C (2021–2030)” advocates for comprehensive screening in medical institutions, with strategies such as “testing all who should be tested” for key populations and “testing all who wish to be tested” for the general population. With strong support from national policies, public awareness of hepatitis C has gradually increased, leading more people to undergo HCV screening either voluntarily or as a result of medical protocols and thereby identifying more potential cases. Second, there has been increased exposure among high-risk populations. In recent years, due to advancements in medical technology, the frequency of invasive medical procedures in the Kashi region has gradually increased, leading to a corresponding increase in infection risk. Additionally, high-risk groups in this region, such as blood transfusion recipients and intravenous drug users, are more susceptible to infection. Analysis of global trends and regional data suggested that the issue of injection drug use in China has been worsening annually¹⁵. The prevalence of HCV-Ab positivity among intravenous drug users in mainland China is approximately 70.8%¹⁶. Third, socioeconomic factors may play a role in the prevalence of HCV. Kashi is one of China’s impoverished regions and is characterized by poor public sanitation, low individual awareness of self-protection, and a high incidence of risky behaviours, all of which contribute to the spread of HCV. Additionally, the low socioeconomic status in this region may limit access to healthcare services, and inadequate oversight and monitoring mechanisms may further increase the risk of HCV transmission.

Among the 707 HCV-infected individuals, the predominant subtype was 1b (70.7%), which is consistent with the national distribution of HCV GTs¹⁷. However, the proportions of subtypes 3a (9.5%) and 3b (7.1%) were greater than that of subtype 2a (6.7%), in contrast with the findings of a previous study, which indicated that the predominant HCV GTs in Xinjiang were subtypes 1b, 2a, 3a, 3b, and 6a¹⁰. This difference may be related to the demographic composition of the 707 HCV-infected individuals in this study, 90% of whom were from ethnic minority groups. The proportion of HCV GT3 was higher among ethnic minorities than among the Han population¹⁰. However, due to the limitations inherent in retrospective studies, this research lacks detailed demographic information, which restricts the representativeness of the sample and the external validity of the findings.

According to estimates by the Polaris Observatory HCV Collaborators, China’s hepatitis C diagnosis rate increased to 40% in 2022, but it still falls significantly short of the global target of 90%^11,18. Insufficient awareness of the harm of chronic HCV infection, combined with the often asymptomatic nature of the virus, reduces public attention to the dangers of HCV, thereby making it challenging to achieve target diagnosis rates¹⁹. Excluding the incomplete statistics for 2022 (which only include data from January 1 to August 31, 2022), the number of confirmed hepatitis C cases and those receiving DAA in the Kashi region has increased annually, with a particularly significant increase observed in 2021. This encouraging upwards trend may be related to the introduction of LDV/SOF and SOF/VEL at the First People’s Hospital of Kashi in 2021, which improved drug accessibility. The cascade of care for HCV-Ab-positive individuals in the Kashi region, from the screening stage to the diagnosis and treatment stages, highlighted vital issues in this region’s screening and treatment processes. Fewer than half (44%) of the 4,928 HCV-Ab-positive individuals underwent HCV RNA testing, which is consistent with a study conducted in Jiangsu Province, which reported a testing rate of 51.3%¹⁹. An online survey conducted in China revealed that individuals with lower educational attainment, residents of rural or western regions, and current alcohol consumers presented insufficient knowledge about HCV and were less likely to undergo HCV testing²⁰. During the investigation period, HCV RNA testing was not widely available in medical institutions across the Kashi region, with only the First People’s Hospital of Kashi able to perform this test. The Kashi region covers a total area of 162,000 square kilometres. Except for Kashi city, gaining access the First People’s Hospital of Kashi from the surrounding counties involves long distances and inconvenient transportation. Additionally, the two-step diagnostic process, which includes HCV-Ab screening followed by HCV RNA confirmatory testing, is time-consuming. The delayed availability of test results can lead to difficulties in follow-up for patients who initially test positive. The high cost of HCV RNA testing also makes it unaffordable for low-income individuals. Moreover, patients’ lack of awareness about the importance of HCV RNA testing contributed to low testing rates. Many individuals did not fully understand the necessity of confirmatory testing after screening positive for HCV-Ab, which is common in regions with lower levels of public health education regarding viral hepatitis. These factors hinder the timely diagnosis of HCV infection and delay the initiation of prompt antiviral treatment.

In our investigation, only 30% of confirmed patients with chronic HCV infection received treatment with DAA, indicating a low treatment coverage rate. Similarly, a study conducted in Jiangsu reported that only 38.7% of patients received treatment with DAA¹⁹. Both figures fall significantly short of the WHO’s treatment target of 80%¹¹. Among the 483 patients who participated in the follow-up survey in this study, 67.7% received treatment with DAA. The relatively high proportion of patients receiving DAA treatment may be due to a greater willingness to participate in follow-up among those who were treated. In contrast, patients who did not receive treatment may have been less inclined to participate, possibly due to a loss of hope or other reasons. Among the 327 patients who received treatment with DAA, 243 (74%) completed the full course, based on their GTs and the presence or absence of liver cirrhosis. Some patients discontinued treatment after only 28 days of initial DAA treatment, whereas others abandoned further treatment because of the long distances from their places of residence to the hospital. Poor treatment adherence may also be related to economic pressure and limited awareness of hepatitis C. Among the patients who completed the full course of treatment, 73% (177/243) achieved SVR12, and 38% (68/177) achieved SVR24. Patients who did not return for follow-up testing were considered not to have achieved SVR. Aside from two patients who experienced virological breakthrough, all patients who did not achieve SVR12 or SVR24 were lost to follow-up. After completing the DAA treatment course, many patients believed that they were cured and were therefore unwilling to return to the hospital for follow-up testing. While our study did not perform a detailed analysis of specific patient characteristics such as socioeconomic status, distance from the hospital, lack of public awareness, or other factors that may have influenced loss to follow-up. Patients who face financial difficulties, long travel distances, or other logistical barriers may be less likely to complete follow-up appointments, which in turn could affect their treatment outcomes, including achieving SVR12 or SVR24. Despite the fact that follow-up could theoretically be conducted remotely via phone or telemedicine, practical logistical barriers such as difficulties in maintaining consistent patient contact, lack of reliable communication channels, and limited resources for follow-up contributed to the observed loss to follow-up. In addition, time constraints and the need for intensive staff involvement for data collection further limited our ability to perform a comprehensive analysis of these factors.

To enhance follow-up adherence, we propose several approaches. Patient education programs should be strengthened to increase awareness of the importance of SVR monitoring and the risk of reinfection. Telemedicine and remote monitoring can facilitate follow-up consultations, particularly for patients in rural areas, reducing logistical barriers. Integrating post-treatment monitoring into primary healthcare services can improve accessibility and reduce the burden on specialized centers. Additionally, providing incentives, such as cost reductions, transport reimbursement, or mobile clinics, may encourage follow-up adherence. Finally, establishing patient support systems, such as dedicated care coordinators, can help ensure that patients remain engaged in long-term monitoring. These strategies, when tailored to local healthcare infrastructure, may improve retention and optimize treatment outcomes.

An analysis was conducted on the reasons for treatment refusal among the 156 patients who declined DAA therapy. The treatment refusal rate in the Kashi region was 32.3%, which is higher than the 10.5% reported in a study from Taiwan²¹. However, patients in both regions reported similar reasons for refusing treatment. A study in the United States reported that 69% of patients faced barriers when initiating DAA treatment, including issues related to psychosocial factors, healthcare providers, medical systems, and insurance coverage²². The reasons for refusing treatment are varied and often multifactorial, making them difficult to overcome through a single intervention. A research indicated that the majority of patients who did not receive DAA (96.9%) continued to visit hospitals and clinics for other medical care²¹. These findings highlight the need for substantial improvements in public knowledge about hepatitis C prevention and treatment in the Kashi region. There is still much work to be done to raise awareness and ensure better health outcomes.

During the study period, the First People’s Hospital of Kashi was the only medical institution in the region capable of performing HCV RNA testing and providing DAA treatment. However, with the implementation of China’s “Action Plan for Eliminating the Public Health Hazard of Hepatitis C (2021–2030)”, major healthcare institutions in the Kashi region have progressively enhanced their diagnostic capabilities. According to this plan, each district is required to establish a mechanism for eliminating the public health threat of HCV, with at least one healthcare institution per county designated to provide HCV antiviral treatment. Additionally, all secondary and tertiary general hospitals, specialized infectious disease hospitals, and disease control centers are mandated to have the capacity to perform both HCV-Ab and HCV RNA testing. Currently, eight types of DAA are included in the National Health Insurance list in China. The First People’s Hospital of Kashi has introduced five of these DAA, and it is expected that other healthcare institutions in the region may also incorporate additional DAA in the future, further improving accessibility. The inclusion of these DAA in the national health insurance list has significantly alleviated the financial burden on low-income patients. However, further expansion of the insurance coverage is necessary. We recommend expanding the coverage of DAA to include more treatment regimens and implementing national or provincial-level subsidies to further reduce patient out-of-pocket expenses. Such measures will improve treatment accessibility, encourage more patients to seek and complete treatment. In addition to expanding coverage, we suggest drawing from the experiences of countries such as Egypt and Pakistan, which have successfully negotiated lower DAA prices through centralized procurement or national agreements with pharmaceutical companies^23,24. These strategies can help reduce the cost of DAA further. To improve accessibility in remote and rural areas, we recommend implementing mobile clinics that provide screening and treatment services to underserved populations. Increasing public education on HCV and available treatment options is crucial. We propose raising awareness about the importance of HCV RNA testing and DAA treatment through community outreach programs. This can be achieved by collaborating with local media, community health workers, and public health campaigns. Egypt has successfully established a model for managing and treating HCV, which has significantly reduced the national HCV infection rate²³. Egypt’s success has been regarded as a benchmark for other low- and middle-income countries in addressing the HCV epidemic. We believe that applying similar strategies could help improve HCV control in China, particularly in underserved areas such as Kashi region.

This study had several inevitable limitations. First, this was a retrospective investigation, which might be subject to selection bias and incomplete data collection. Second, the investigation population was limited to those who sought care at the First People’s Hospital of Kashi, potentially excluding a broader representation of HCV-infected individuals in this region. Third, the reliance on telephone-based follow-up surveys may have produced response bias, as those who were more compliant or engaged with the healthcare system were more likely to participate.