A silent liver-destroying virus continues to spread across the United States at an accelerating pace, even though the drugs that cure it have been on pharmacy shelves for nearly a decade. In a perspective article published in the Journal of General Internal Medicine, two University of California, Los Angeles physicians argue that the nation’s faltering response to hepatitis C could be rescued by borrowing the playbook that transformed the HIV epidemic, from community-based testing and rapid “test and treat” initiation to federally funded safety nets and a fundamental reframing of what treatment nonadherence actually means.
The paper, written by Dr. Anna C. Scialli of UCLA’s Division of General Internal Medicine and Dr. Tara Vijayan of the Division of Infectious Diseases, opens with a clinical vignette that captures the paradox of modern hepatitis C care. A 34-year-old man with a history of injection drug use and unstable housing arrived at a hospital with fever, fatigue, and shortness of breath, and was found to have Staphylococcus aureus endocarditis with septic emboli. Screening revealed chronic hepatitis C virus infection. He was eager to begin treatment, and during a 39-day admission that included respiratory failure management and tricuspid valve replacement, clinicians started him on glecaprevir-pibrentasvir, obtained through the institution’s specialty pharmacy because the drug was not on the hospital formulary. It is precisely this kind of opportunistic, in-hospital treatment that the authors want to make routine.
The numbers they cite are stark. Between 2015 and 2022, the United States saw an estimated twofold increase in acute hepatitis C infections, yet only about a third of insured individuals diagnosed with the virus receive treatment within a year of diagnosis. Up to four million Americans are believed to carry the virus. By contrast, in HIV care, where the “care cascade” framework originally took root, roughly 76 percent of people diagnosed with HIV receive care and 65 percent are virally suppressed. The cascade framework, which tracks patients through sequential steps of diagnosis, linkage to care, receipt of direct-acting antivirals, and achievement of sustained virologic response, has been adopted by hepatitis C elimination strategies, but outcomes at every step have persistently lagged behind HIV milestones.
On the surface, the two viruses could hardly be more different biologically. Untreated HIV progressively depletes CD4 lymphocyte counts, producing the opportunistic infections and malignancies that define AIDS, a disease that is fatal within years for all but a rare fraction, less than half a percent, of “long-term non-progressors.” Chronic hepatitis C, meanwhile, may smolder asymptomatically for decades, gradually driving liver inflammation and fibrosis, with an estimated 5 to 10 percent of patients developing cirrhosis after twenty years and a 1 to 3 percent cumulative rate of hepatocellular carcinoma after thirty years. But the authors emphasize that the two epidemics share a critical social anatomy: both concentrate in the most marginalized communities, among people with limited access to prevention and treatment and distinct socioeconomic disparities. Their public health histories, they argue, overlap enough to yield forty years of transferable lessons.
The parallels run deep from the very beginning. HIV was first observed in New York as early as 1978 but was not formally reported until 1981, when Los Angeles physicians described Pneumocystis pneumonia in five men who have sex with men in the CDC’s Morbidity and Mortality Weekly Report. By 1990, more than 100,000 Americans had died of AIDS, and the disease, pejoratively labeled a “gay cancer,” became a vehicle for stigma and the marginalization of sexual minorities. Hepatitis C followed an eerily similar timeline. First described in 1975 as “non-A, non-B hepatitis” among transfusion recipients, accounting for up to 90 percent of transfusion-associated hepatitis, it was not definitively identified until 1989, when researchers isolated HCV RNA and developed an antibody test. Widespread blood-supply screening followed by 1992, and screening recommendations evolved from risk-based targeting to universal one-time screening of all adults by 2020, as rising infection rates among younger people shifted the epidemic’s demographics.
Treatment histories also rhyme. HIV therapy evolved from poorly tolerated early regimens to the 1996 introduction of combination antiretroviral therapy, then single-tablet regimens in the 2000s that improved adherence and reduced toxicity, and most recently long-acting injectables such as cabotegravir and rilpivirine, which maintain viral suppression with dramatically reduced adherence barriers. Hepatitis C treatment traveled its own arc, from interferon-alpha with cure rates low enough and durations long enough, up to 72 weeks, to be nearly prohibitive, through pegylated interferon plus ribavirin combinations marked by flu-like symptoms, depression, and hemolytic anemia, to the revolutionary direct-acting antivirals of the 2010s. The pan-genotypic regimens first approved by the FDA in 2016, including glecaprevir-pibrentasvir and sofosbuvir-velpatasvir, now offer eight-to-twelve-week, once-daily courses with rare side effects, no laboratory monitoring, and cure in over 95 percent of those treated. Because the cure is short, simple, and complete, the authors note, the technical barriers to hepatitis C eradication should be far lower than for HIV. That they are not is the central problem.
The first lesson concerns testing. Only an estimated 55 percent of people with hepatitis C are aware of their diagnosis, compared with an estimated 87 percent of people living with HIV. In the HIV epidemic, the shift from risk-based testing toward universal opt-out screening, launched by the CDC in 2006 when 21 percent of infections were undiagnosed, helped reduce undiagnosed infections to 15 percent by 2015. Crucially, that progress was driven by low-barrier testing outside traditional health facilities: mobile clinics, emergency rooms, community health fairs, and inpatient units. For hepatitis C, the settings with the highest testing yields today are syringe service programs and clinics treating substance use disorder, but the authors insist these cannot be the only option, particularly since syringe service programs lack federal support. They advocate a broad test-and-treat strategy, including initiating direct-acting antivirals during hospital admission. Because most hospitals will not stock the drugs, they propose a practical mechanism: prescribing through a contracted specialty pharmacy that purchases medications at 340B pricing and delivers them to the bedside, stored securely on the ward much like an unavailable home medication.
The second lesson concerns insurance and funding. Many state Medicaid programs still impose sobriety requirements and fibrosis-stage restrictions on hepatitis C treatment, and states with such restrictions treat fewer patients, despite explicit recommendations from the Infectious Diseases Society of America and the American Association for the Study of Liver Diseases to remove them. Private insurers are even less transparent, denying more than half of hepatitis C treatment claims in one national specialty pharmacy cohort study. HIV care took a different path: the Ryan White CARE Act of 1990 created a federally funded safety net covering antiretroviral therapy for uninsured and underinsured patients, now supporting 82 percent of uninsured people living with HIV. Early hospital initiation of antiretroviral therapy has been shown to improve linkage to care, especially for patients with substance use disorder. No equivalent exists for hepatitis C, even though an estimated 60 percent of people with the virus are covered by public insurance, and the 2025 One Big Beautiful Bill cut nearly one trillion dollars from Medicaid over the coming decade. Meanwhile, budget pressures threaten HIV’s own safety net: as of February 2026, twenty states were tightening AIDS Drug Assistance Program eligibility, and models estimate up to a 73 percent increase in new HIV infections across thirty states if that funding disappears.
The third lesson is the most philosophical. Provider hesitancy, particularly toward people who use drugs, remains a powerful barrier to hepatitis C treatment, with physicians frequently citing concerns about nonadherence. Yet studies show people who use drugs complete hepatitis C treatment more than 96 percent of the time. HIV advocacy movements, notably ACT UP, forced a reframing: nonadherence was reinterpreted not as a moral failing of the patient but as a failure of systems in which marginalized groups face enormous barriers. Current CDC guidelines now explicitly state that homelessness, substance use, and mental health conditions are not justifiable reasons to defer antiretroviral therapy, and federally funded supports, from Ryan White case management and patient navigation to the Housing Opportunities for Persons with AIDS program, address the social determinants that undermine adherence. Peer navigation programs and drug user unions are emerging as hepatitis C analogs, but without matching federal investment.
The Norway-based OPPORTUNI-C trial provides the empirical anchor for the authors’ central proposal: among people who inject drugs, 68 percent of those who began hepatitis C treatment while hospitalized completed it, compared with just 35 percent of those referred to outpatient care. For a population with frequent admissions and siloed inpatient care, the hospital bedside may be the single best opportunity to deliver a cure. As antiretroviral therapy became simpler and its community-level benefits clear, the authors write, reducing time to treatment initiation became not merely a public health measure but a moral imperative. With a twelve-week cure available, they argue, hepatitis C elimination now depends on treating patients where they are.
Subject of Research: Applying lessons from the HIV epidemic’s care cascade, testing, treatment funding, and adherence policies to improve hepatitis C treatment uptake and elimination in the USA
Subject of Research: Medicine
Article Title: Meeting Patients with Hepatitis C Where They Are: Lessons from the HIV Epidemic in the USA
Article References: Scialli, A. C., & Vijayan, T. (2026). Meeting Patients with Hepatitis C Where They Are: Lessons from the HIV Epidemic in the USA. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10629-7
Image Credits: AI Generated
DOI: 10.1007/s11606-026-10629-7
Keywords: hepatitis C, HIV, direct-acting antivirals, care cascade, people who use drugs, health equity, test and treat, inpatient treatment initiation, Ryan White program, Medicaid restrictions, sustained virologic response
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Kristina Jarvis. (September 10, 2026). Hepatitis C Care Can Learn Key Lessons from the US HIV Epidemic. Scienmag. https://scienmag.com/hepatitis-c-care-can-learn-key-lessons-from-the-us-hiv-epidemic/
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Tags: clinical management of hepatitis Ccommunity-based testing for hepatitis Ccomparison of hepatitis C and HIV responsefederally funded hepatitis C safety netshepatitis C and injection drug usehepatitis C care in homeless populationshepatitis C in homeless populationshepatitis C treatment adherenceHepatitis C treatment strategieshepatitis C virus cure availabilityhepatitis C virus elimination effortsimproving hepatitis C diagnosis and linkage to careintegrated care models for hepatitis Clessons from HIV epidemic responsepublic health approaches to viral hepatitisrapid test and treat approachrapid test and treat for viral hepatitistreatment adherence in hepatitis CUS HIV epidemic lessons
