The burden of chronic HCV infection based on NHANES data was estimated at 2.7 million persons in the United States, however a recent study suggests at least 3.5 million when accounting for groups not included in survey such as homeless, incarcerated, etc. This burden of disease makes eradication unrealistic in the near future, even with highly effective treatments. However, elimination, or reduction in the incidence of new infections, through the combination of prevention efforts and treatment remains a worthy goal. Tremendous progress has been made in anti-HCV drug discovery, with multiple classes of antivirals that act directly on the viral life cycle. Well-tolerated direct acting antiviral (DAA) combinations cure the vast majority of people treated. With such effective DAA options available, it is time to evaluate the approach of HCV treatment as prevention. Treatment as prevention requires reaching groups at high risk of transmitting HCV to others such as active drug users and HIV/HCV co-infected MSM with high-risk behaviors. In people who inject drugs, modeling data suggests that scaling up treatment in active drug users in addition to harm reduction interventions such as needle exchange and opiate substitution therapy has potential to dramatically reduce HCV prevalence over time. The impact of treatment on prevention with respect to the epidemic in MSM remains less clear. In the real world, limited data suggests DAA are effective in active drug users and HIV-infected MSM. Reinfection rates remain an important consideration as does the theoretical risk of transmission of DAA-resistant virus strains. Lastly because of cost, those with the most immediate clinical need have been prioritized for DAA treatment, while those at highest risk of transmitting virus are often specifically denied (because of mild disease and/or concern for reinfection). For treatment as prevention to be feasible, linkage to care and access to medications must also improve.
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