Introduction
According to the World Health Organization (WHO), an estimated 50 million people were living with hepatitis C worldwide in 2022, with approximately 1 million new infections occurring that year [
1]. In the Republic of Korea, data from the Korea Disease Control and Prevention Agency (KDCA) estimated that 327,432 individuals were seropositive for hepatitis C virus (HCV) antibodies, and 102,970 were positive for HCV RNA as of 2020 [
2]. The national incidence rate reported through the KDCA surveillance system in 2020 was 22.86 per 100,000 population [
3].
Hepatitis C is the second most common cause of chronic viral hepatitis in the Republic of Korea after hepatitis B virus infection and accounts for approximately 10% of hepatocellular carcinoma cases [
4]. According to data published by the Korean Association for the Study of the Liver (KASL), the nationwide hepatitis C management rate in 2019 was 78.2%, and the treatment rate was 58.1% [
5]. The management rate refers to the proportion of patients who either visited medical institutions at least twice for hepatitis C–related care or received antiviral therapy within 18 months after diagnosis, whereas the treatment rate refers to the proportion of patients who received at least 1 antiviral prescription within 18 months. In Jeonbuk, the management rate was 75.8% and the treatment rate was 54.9%, ranking as the 4th lowest in the country [
5].
In the Republic of Korea, hepatitis C transmission is not primarily driven by key populations such as people who inject drugs but is largely concentrated among older age cohorts in the general population [
6]. This epidemiological pattern suggests that broad linkage-to-care strategies, rather than narrowly targeted interventions, may be required to achieve hepatitis C elimination targets.
To support the WHO elimination goal, Jeonbuk State, in collaboration with KASL, implemented a regional campaign to enhance awareness and evaluate the hepatitis C treatment cascade. This study analyzed provincial surveillance and survey data to assess the current treatment status of patients with hepatitis C and to identify reasons for non-treatment, thereby providing evidence to guide strategies for improving care engagement and treatment uptake.
Materials and Methods
All individuals newly diagnosed with hepatitis C and reported to the National Notifiable Infectious Disease Surveillance (NNIDS) system in Jeonbuk between January 2023 and June 2024 were included in the study. Age, sex, and date of notification were extracted from the surveillance data. As part of a regional awareness improvement campaign, a survey was conducted from July to September 2024 to investigate treatment status, treatment type, and reasons for non-treatment among untreated individuals. Individuals confirmed to have died before contact or those who could not be reached were excluded from the final analysis.
For statistical analysis, the chi-square test and the Cochran-Armitage test for trend were used. Logistic regression analysis was also performed, and statistical significance was assessed at the 0.05 level using 2-tailed tests. All analyses were conducted using IBM SPSS Statistics for Windows, ver. 28.0 (IBM Corp.).
Ethics Statement
This study was approved by the Institutional Review Board (IRB) of Jeonbuk National University Hospital (IRB No: 2025-07-019). The informed consent was waived because of the retrospective nature of this study.
Results
A total of 311 patients were identified during the study period. Of these, 208 (66.9%) completed the survey (
Table S1). Among respondents, 139 (66.8%) were female (
Table 1). The mean age was 71.4 years, and the largest proportion of respondents was aged ≥80 years (32.7%).
Overall, 116 of 208 respondents (55.8%) reported having received antiviral therapy. Treatment uptake did not differ significantly by sex (50.7% in males vs. 58.3% in females;
χ² test,
p=0.302). In contrast, treatment uptake decreased significantly with increasing age (Cochran-Armitage test for trend,
p=0.014). The proportion receiving treatment ranged from 85.0% among those aged ≤49 years to 42.6% among those aged ≥80 years (
Table 1).
Among the 116 patients who received antiviral treatment, treatment outcomes were as follows: 97 (83.6%) reported being cured, 4 (3.4%) were still undergoing treatment, 3 (2.6%) reported treatment failure or relapse, and 12 (10.4%) had an unknown treatment response.
Among the 92 individuals who had not undergone antiviral therapy, the most commonly reported reasons for non-treatment were being asymptomatic and concerns about medication costs (
Table 2). Lack of awareness regarding the need for treatment and the presence of comorbidities were also frequently cited.
Reported barriers showed some variation by sex and age. Men more frequently reported a lack of awareness regarding the need for treatment, whereas women more commonly cited asymptomatic status and financial concerns (
Table 2). By age group, lack of awareness was more common among those aged 60–79 years, whereas asymptomatic status was frequently reported in both the youngest and oldest groups (data not shown).
Discussion
Understanding the Republic of Korea’s unique HCV epidemic is essential for interpreting these findings and formulating effective elimination strategies. Unlike in countries where HCV prevalence is 1%–2% or higher, the Republic of Korea has a relatively low anti-HCV seroprevalence of 0.6%–0.7% in the general population and approximately 100,000 HCV RNA-positive individuals requiring treatment [
2]. However, the epidemiological profile is distinct: rather than being driven by young people who inject drugs, HCV infection in the Republic of Korea predominantly affects older age cohorts who were exposed through iatrogenic routes, including blood transfusions before 1992, when routine HCV screening of donated blood was introduced, and invasive procedures or interventions [
6]. Prevalence rises sharply with age, from 0.32% in those aged 10–19 years to 1.93% in those aged ≥70 years [
7]. Genotypes 1b and 2a/2c account for more than 90% of infections in the Republic of Korea [
8], making pan-genotypic direct-acting antiviral (DAA) regimens highly suitable. Despite the availability of highly effective DAAs, awareness of HCV infection remains low: only 30.5% of HCV RNA-positive individuals are aware of their infection status [
7]. This low awareness, combined with the Republic of Korea’s aging HCV-infected population and historical iatrogenic transmission patterns, suggests that targeted patient education, management, and linkage-to-care strategies for diagnosed cases—rather than broad mass-media public awareness campaigns—may be the most efficient approach to achieving elimination targets in the Republic of Korea.
The WHO has set a goal of eliminating viral hepatitis, including hepatitis C, as a public health threat by 2030. To achieve this goal, the WHO aims to reduce the incidence of new hepatitis infections to fewer than 5 cases per 100,000 population and hepatitis-related mortality to fewer than 2 deaths per 100,000 population. Other key targets include diagnosing 90% of people with hepatitis C and treating 80% of those eligible for therapy.
Among strategies used for hepatitis C elimination in other countries, Canada pursued price negotiations in 2017 to reduce the cost of DAA agents, increasing the number of treatment initiators by approximately 2.3-fold, from 5,127 in 2014 to about 12,000 in 2017. In addition, rapid linkage-to-treatment policies were implemented after diagnosis, and in 2017, 83% of HCV antibody-seropositive individuals in the province of British Columbia completed HCV RNA testing, with 38% initiating treatment [
9]. In Georgia, approximately 150,000 people—about 5.4% of the adult population—were infected with hepatitis C. In response, the country launched a national hepatitis C elimination program in 2015 and, with support from Gilead Sciences, established an integrated system connecting screening, laboratory diagnosis, and treatment services. Subsequently, between 2015 and 2019, around 60,000 individuals initiated treatment nationwide, achieving a high success rate of 96.1% [
10]. In Egypt, a DAA-based program was implemented on a large scale in 2014, and more patients were able to receive treatment after support for treatment costs was introduced [
11]. In 2018, the national screening program showed a cure rate of more than 98% among adults and 100% among adolescents [
12]. In Taiwan, DAA treatment has been covered by health insurance since 2017, along with targeted screening programs and improved diagnostic-to-treatment linkage through government intervention. Through these comprehensive policies, the number of treated patients increased dramatically from 9,500 in 2017 to 46,000 in 2019 [
13].
As illustrated by these international examples, strengthening patient management through government-led programs that link diagnosis and treatment, while improving treatment accessibility, appears necessary. In addition, strategies are needed to ensure a seamless process from identifying candidates for screening to confirmatory testing and subsequent treatment.
In line with the WHO goal of eliminating hepatitis C, KASL and the Korean Liver Foundation are conducting various awareness campaigns to increase the hepatitis C awareness rate to 90% by 2030 in the Republic of Korea. In addition, a portion of treatment costs has been covered by the National Health Insurance Service since November 2022, and hepatitis C antibody screening for 56-year-old adults has been a component of the national health checkup program since 2025. The KDCA is also implementing a program to support the costs of confirmatory RNA testing.
In this survey, the treatment rate among reported patients with hepatitis C in Jeonbuk State was 55.8%, which remains below the WHO target of 80% for hepatitis C elimination. When reasons for non-treatment were examined, many untreated patients reported being asymptomatic, not knowing whether treatment was necessary, or believing that cure was not possible. These findings suggest a need for improved patient information and awareness regarding hepatitis C and its treatment. In addition, 21 respondents (22.8%) reported that they did not receive treatment because of the burden of medication costs, making this the second most common reason for non-treatment and an important consideration for future policy development. Although DAA agents are reimbursed under the National Health Insurance system in the Republic of Korea, the estimated out-of-pocket cost for a full course of treatment is approximately 3 million Korean won (approximately 2,000 United States dollars). This level of copayment may still pose a meaningful financial barrier for some patients. Individuals who had not received treatment because of insufficient disease-related information accounted for 58.7% of untreated respondents, suggesting that awareness campaigns about hepatitis C treatment may have substantial potential to improve outcomes with relatively limited effort and thereby increase treatment uptake. In addition, strengthening provider-level education and clinical guidance may help ensure appropriate counseling and timely linkage to antiviral therapy after diagnosis.
This study is meaningful in that it identified reasons for non-treatment by using community public health personnel and the existing infectious disease epidemiological investigation system, encouraged and promoted treatment, and contributed to efforts to improve treatment rates. However, because the investigation relied on participants’ recollections and statements, misclassification may have occurred due to the inability to review the medical records of the included patients. In addition, because no information was available on income level or probable route of infection, treatment rates and reasons for non-treatment could not be evaluated according to socioeconomic status or risk category. Geographic variation in treatment uptake may exist even within the same province; however, this study did not examine such differences in detail, and further research is needed to better understand potential regional disparities. Finally, it should be noted that the treatment rate was assessed only among individuals reported through the NNIDS and therefore may not reflect undiagnosed prevalent cases.
This study investigated hepatitis C treatment rates and reasons for non-treatment in a province of the Republic of Korea, with the aim of providing a basis for policy development to improve treatment uptake. To our knowledge, it is the first study conducted in the Republic of Korea to examine reasons for untreated hepatitis C and includes survey data that reflect characteristics of local community population composition and medical resource utilization. Existing programs, such as those promoting hepatitis C prevention guidelines and conducting epidemiological investigations, should be continued. However, new initiatives—such as expanding hepatitis C screening within the national health checkup program and providing financial support for confirmatory testing—are also needed to identify undiagnosed hepatitis C cases and link diagnosis to treatment under the leadership of national and local governments.
, You Jeong Moon2
