Hepatitis C care cascade using direct-acting antivirals in rural new York State from 2013 to 2023: a retrospective observational study

Background: Hepatitis C virus (HCV) infection rates are higher in rural areas than in urban areas, yet rural HCV care remains understudied. We evaluated the HCV care cascade using direct-acting antivirals (DAAs) in rural New York State. Methods: Electronic health record data from 2013 to 2023 were retrospectively collected from active Bassett Health Network primary care patients aged 18–79 years, consistent with the most recent US screening recommendations. We constructed 11 annual testing cohorts based upon the date of HCV serological testing. Annual care cascades were summarized using frequencies and percentages. We used chi-square to compare outcomes pre- and post-implementation of HCV RNA reflex testing and universal screening and to assess differences by opioid use disorder status. Results: The average annualized patient population was 72,615, White (96.45%) and male (44.58%). HCV seropositivity was highest (4.17%) among those aged 20–39 years. Annual HCV RNA positivity in HCV seropositive patients ranged from 18.27 to 76.60%. DAA initiation ranged from 26.32 to 56.52% in HCV RNA-positive patients. HCV antibody testing increased significantly after implementation of universal screening (p < 0.0001). Patients with opioid use disorder had higher RNA positivity (51.32% vs. 32.07%, p < 0.0001) and lower DAA initiation (35.65% vs. 57.71%, p < 0.0001) than those without opioid use disorder. Conclusions: While HCV diagnosis improved after universal screening implementation, DAA treatment remains suboptimal in rural New York State, especially among people with OUD. Expanding DAA treatment in people with opioid use disorder is critical to improving rural HCV care and HCV elimination.