Progress and Challenges in a Pioneering Hepatitis C Elimination Program in the Country of Georgia, 2015-2018.

Georgia, with a high prevalence of hepatitis C virus (HCV) infection, launched the world's first national hepatitis C elimination program in April 2015. A key strategy is the identification, treatment, and cure of the estimated 150,000 HCV infected persons living in the country. We report on progress and key challenges from Georgia's experience.We constructed a care cascade by analyzing linked data from the national hepatitis C screening registry and treatment databases during 2015-2018. We assessed the impact of reflex hepatitis C core antigen (HCVcAg) testing on rates of viremia testing and treatment initiation (i.e. linkage to care).As of December 31, 2018, 1,101,530 adults (39.6% of the adult population) were screened for HCV antibody, of whom 98,430 (8.9%) tested positive, 78,484 (79.7%) received viremia testing, of these, 66,916 persons (85.3%) tested positive for active HCV infection. A total of 52,576 persons with active HCV infection initiated treatment, 48,879 completed their course of treatment. Of the 35,035 who were tested for cure (i.e., sustained virologic response [SVR]), 34,513 (98.5%) achieved SVR. Reflex HCVcAg testing, implemented in March 2018, increased rates of monthly viremia testing among persons screening positive for anti-HCV by 97.5%, however, rates of treatment initiation decreased by 60.7% among diagnosed viremic patients.Over one-third of persons living with HCV in Georgia have been detected and linked to care and treatment, however, identification and linkage to care of the remaining persons with HCV infection is challenging. Novel interventions, such as reflex testing with HCVcAg can improve rates of viremia testing, but may result in unintended consequences, such as decreased rates of treatment initiation. Linked data systems allow for regular review of the care cascade, allowing for identification of deficiencies and development of corrective actions.