Universal self-testing as a cost-effective weapon to eliminate hepatitis C virus in the Republic of Korea: Editorial on “Self-testing strategy to eliminate hepatitis C as per World Health Organization’s goal: Analysis of disease burden and cost-effectiveness”

Article information

Clin Mol Hepatol. 2025;31(2):596-598

Publication date (electronic) : 2024 November 11

doi : https://doi.org/10.3350/cmh.2024.0992

Eun Sun Jang

Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea

Corresponding author : Eun Sun Jang Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam 13620, Korea Tel: +82-31-787-7067, Fax: +82-31-787-4051, E-mail: janges@snubh.org

Editor: Han Ah Lee, Chung-Ang University College of Medicine, Korea

Received 2024 November 5; Accepted 2024 November 7.

In the era of potent direct-acting antiviral drugs, hepatitis C virus (HCV) infection can be cured in over 98% of cases within a few months. Nevertheless, despite these advancements, HCV remains a significant global health burden and is far from being eliminated in most countries because asymptomatic individuals often miss the opportunity to benefit from these “magic pills” due to a lack of screening. The World Health Organization (WHO) estimates that, without adequate efforts, hepatitis virus infections could result in approximately 20 million deaths globally by 2030—a particularly alarming figure given the preventability of these deaths with effective treatment [1].

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.