Does antiviral treatment (Direct-acting antivirals) cure Hepatitis C (HCV) and eliminate the need for surveillance?

Direct-Acting Antivirals Cure Hepatitis C, But Surveillance Remains Essential for Patients with Advanced Fibrosis or Cirrhosis

Antiviral treatment with direct-acting antivirals (DAAs) does cure hepatitis C in over 95-97% of patients, but surveillance is still required for those with cirrhosis or advanced fibrosis (F3-F4) due to persistent hepatocellular carcinoma risk even after achieving sustained virologic response. 1, 2, 3

What "Cure" Means in Hepatitis C

• Sustained virologic response (SVR12)—defined as undetectable HCV RNA 12 weeks after treatment completion—represents a virologic cure in more than 99% of patients. 4, 1, 2
• Fewer than 1% of patients relapse after achieving SVR12, making this endpoint tantamount to permanent viral eradication. 4
• Modern DAA regimens achieve cure rates exceeding 95-97% across all patient populations, including those historically difficult to treat. 1, 2, 3, 5

Clinical Benefits of Achieving Cure

• Curing HCV infection prevents the complications of chronic liver disease, including cirrhosis progression, hepatic decompensation, and death. 2, 3
• Patients without advanced fibrosis who achieve SVR generally have excellent outcomes with resolution of liver disease and no need for ongoing HCC surveillance. 1
• Quality of life improves and the stigma associated with chronic viral hepatitis is removed. 3

The Critical Exception: Patients with Cirrhosis or Advanced Fibrosis

Despite achieving virologic cure, patients with established cirrhosis (F4) or advanced fibrosis (F3) remain at reduced but ongoing risk for hepatocellular carcinoma and require indefinite surveillance. 1, 2, 3

Why Surveillance Remains Necessary

• The risk of HCC is significantly reduced but not eliminated in cirrhotic patients who achieve SVR. 4, 1
• Meta-analyses of interferon-based therapies showed more than 70% reduction in HCC incidence after SVR, but patients with liver cirrhosis still retain a relevant residual risk of 0.3–2.4% annually. 4
• Patients with complete response to prior HCC therapy who achieve SVR require indefinite post-SVR HCC surveillance. 1

Surveillance Protocol for High-Risk Patients

• Lifelong HCC surveillance with ultrasound every 6 months is recommended for all patients with advanced fibrosis or cirrhosis (F3-F4) even after achieving SVR. 1, 2, 3
• This recommendation comes from the American Association for the Study of Liver Diseases and European Association for the Study of the Liver. 1, 3
• Fibrosis reassessment and monitoring for reinfection in at-risk patients (such as people who inject drugs) is also recommended. 3

Post-Treatment Confirmation of Cure

• SVR should be confirmed by undetectable HCV RNA at 12 weeks after completion of DAA treatment. 4
• Routine confirmation of SVR at 48 weeks post-treatment is recommended, though testing at 24 weeks should be considered on an individual basis. 4
• For most patients on DAA regimens with expected high SVR rates, checking SVR is optional except in patients at risk of reinfection. 1
• Routine testing for HCV RNA beyond 48 weeks after end of treatment to evaluate for late virologic relapse is not supported by available evidence. 4

Common Pitfall to Avoid

The most critical error is discontinuing HCC surveillance in patients with cirrhosis or advanced fibrosis after they achieve SVR. While the virus is cured, the underlying liver damage and cirrhotic architecture persist, maintaining elevated HCC risk that requires lifelong monitoring. 1, 2, 3