The Republic of Korea ranks among the top 20 countries most heavily burdened by viral hepatitis but has shown little progress in hepatitis C control policies over the last five years [2]. Although HCV is not endemic here, with an anti-HCV prevalence of 0.7% [3], many cases of HCV-associated liver disease are detected at advanced stages [4] due to the absence of universal screening—unlike hepatitis B, which can be aware early through universal screening programs. According to a previous nationwide study [5], a linkage-to-care rate was 65.5%, and the treatment rate was 56.7% in chronic hepatitis C patients from 2018 to 2020, meaning that 87% of eligible individuals received antiviral treatment. This treatment uptake rate has been expected to improve with the widespread availability of pan-genotypic direct-acting antivirals covered by National Health Insurance since late 2022. Thus, the most essential step to enhance linkage-to-care in the Republic of Korea is detecting more HCV-infected individuals, similar to the other high-income countries [6]. Previous studies have already proven the cost-effectiveness of one-time universal screening using blood anti-HCV tests [7,8]. Nonetheless, limited accessibility to the blood test is an obstacle to making this universal screening program successful.

In this issue of Clinical and Molecular Hepatology, Shin et al. [9] suggested anti-HCV self-testing using oral fluid as an alternative tool for universal screening in the Republic of Korea, demonstrating its cost-effectiveness. Their study found that universal lifetime screening is more cost-effective in terms of incremental cost-effectiveness ratios (ICERs) per disability-adjusted life year (DALY) than birth cohort screening compared to no screening strategy, assuming 28% yearly screening acceptability and 70% referral and 72.8% treatment initiation rates. Despite the higher ICERs per quality-adjusted life year (QALY) for universal screening compared to birth cohort screening, these ICERs are still within the Republic of Korea’s willingness-to-pay threshold. This universal self-testing may be less cost-effective than blood testing because its ICERs/QALY were higher than those in the previous study, which assumed the use of blood tests as a screening method [8]. However, a direct comparison is not feasible because the detailed assumptions and models were not the same.

While universal self-testing might incur higher costs than blood testing, self-testing offers unique advantages in reaching high-risk populations who might otherwise never undergo screening. These populations include drug users, incarcerated individuals, men who have sex with men, sex workers, and those infected with human immunodeficiency virus – populations that might prefer self-testing to avoid stigma. Once aware of their infection, these groups have treatment uptake and success rates comparable to the general population [10]. Shin et al.’s study [9] represents a pioneering effort in demonstrating the cost-effectiveness of screening high-risk populations in the Republic of Korea. Although this approach was cost-saving, it did not substantially improve clinical outcomes, resulting in negative ICERs per DALY. This finding emphasizes the need for universal HCV screening, extending beyond high-risk groups.

Encouragingly, the Government of the Republic of Korea has resolved to start birth cohort screening for HCV using blood tests next year. As a possible next step, universal self-testing screening could improve liver-related health outcomes in this country, alongside WHO’s recent prequalification of the first self-test kit for HCV [11]. Ongoing research into prevalence and linkage-to-care in special high-risk groups will be crucial to refining these cost-effective strategies in Korea.