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Approximately 4.1 million individuals in the United States have a history of hepatitis C virus (HCV) exposure, including 2.5 million with chronic infection. Screening guidelines recommend one-time, routine, opt out HCV screening for all individuals 18 years or older. Risk-based testing is recommended for specific individuals. Although many patients with chronic hepatitis C may progress to cirrhosis, end-stage liver disease, and hepatocellular carcinoma, early treatment can prevent development of these sequelae. Management of hepatitis C has simplified significantly, and primary care physicians now can monitor and provide treatment for most patients. Adults with chronic hepatitis C who do not have cirrhosis and have not received hepatitis C treatment previously are eligible for primary care-based treatment. These patients should undergo a comprehensive pretreatment evaluation to guide treatment planning. Patients typically are treated with one of two pangenotypic regimens: glecaprevir-pibrentasvir for 8 weeks or sofosbuvir-velpatasvir for 12 weeks. Virologic cure, defined as sustained virologic response (SVR) at 12 weeks after treatment completion, should be confirmed by an undetectable quantitative HCV RNA via polymerase chain reaction test performed 12 weeks or later after treatment completion. Management results in rates of virologic cure of greater than 95% across genotypes. Patients who do not achieve SVR at 12 weeks should be referred to a subspecialist experienced in management of treatment failure.

Case 2. BT is a 36-year-old man with a history of hepatitis C (genotype 1a) and opioid use disorder managed with buprenorphine-naloxone. He comes to your office to ask about treatment for hepatitis C. He has received no previous treatment.

The national burden of hepatitis C in the United States is remarkably high considering the relatively short time since identification of the virus in 1989.22 Although the epidemiology before 1989 primarily is unknown, demographic trends suggest an explosive outbreak of hepatitis C from the 1960s through 1980s that primarily was mediated by blood transfusions and injection drug use.23

According to data from the 2013-2016 National Health and Nutrition Examination Survey (NHANES), approximately 4.1 million individuals in the United States have a history of hepatitis C virus (HCV) exposure, including 2.5 million with chronic infection.24 Because the NHANES data exclude some groups at high risk of chronic hepatitis C (notably individuals who are incarcerated, institutionalized, or unsheltered), these numbers underestimate the true total by as many as 800,000 cases.25 Furthermore, these numbers do not account for the increase in cases related to the current opioid epidemic.

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