Micro-elimination of hepatitis C in patients with chronic kidney disease and diabetes in Taiwan

 

Meaning

Micro-elimination is a focused public-health strategy that aims to eliminate hepatitis C virus (HCV) within a defined subpopulation, setting, or geographic area (for example, dialysis units, patients with diabetes, an occupational group, or a district) rather than attempting to eliminate the disease across the whole population at once. Micro-elimination breaks a large national goal into manageable, high-yield projects to accelerate progress, demonstrate feasibility, and produce measurable public-health gains quickly. PMC+1

Introduction

Hepatitis C remains a major public-health problem worldwide and has important extrahepatic consequences — including associations with diabetes and renal disease. Taiwan has committed to aggressive HCV elimination policies (screening and broad DAA access), and high-risk groups such as people with chronic kidney disease (especially those on hemodialysis) and people with diabetes are attractive targets for micro-elimination because they: (1) have higher HCV prevalence than the general population in many settings, (2) are heavily linked into regular healthcare systems (which simplifies screening and follow-up), and (3) gain substantial clinical benefit from viral clearance. Taiwan’s national programs and local pilot projects have already used micro-elimination approaches successfully in dialysis populations and other targeted groups. ScienceDirect+2AJKD+2

Advantages (Benefits)

1. High yield for case finding – CKD/dialysis units historically have higher HCV prevalence than the general community, so targeted screening finds more cases per test. AJKD+1

2. Easier linkage to care – Patients with CKD or diabetes have regular clinic contacts (dialysis sessions, diabetes clinics), allowing easy on-site testing, reflex confirmatory testing, and rapid DAA initiation. PMC+1

3. Reduces nosocomial transmission risk – Treating and curing HCV among dialysis patients lowers the pool of infectious patients within units and lowers risk of iatrogenic outbreaks. PMC+1

4. Clinical extrahepatic benefits – Evidence links chronic HCV infection with higher risk of insulin resistance and type-2 diabetes and with renal dysfunction markers; curing HCV can improve liver and extrahepatic outcomes (some studies show improvement in glycemic control and proteinuria after cure). PubMed+1

5. Policy alignment & financial feasibility – Taiwan’s National Health Insurance (NHI) provides broad screening and reimburses DAA treatment; recent policy moves have loosened prescribing restrictions and expanded screening reimbursements, making micro-elimination feasible and cost-effective. National Health Institute+2National Health Institute+2

Disadvantages (Limitations / Potential downsides)

1. Narrow scope may miss transmission sources – Micro-elimination in a single group reduces HCV in that population quickly but may not prevent reintroduction from other reservoirs (e.g., people who inject drugs, incarcerated populations, community reservoirs) unless broader measures continue. PMC

2. Resource shifting – Intensive focus (staff, budget, lab capacity) on one population may divert resources temporarily from other public-health priorities if not budgeted separately.

3. Surveillance burden – High-quality micro-elimination requires good registries, follow-up for SVR12, and reinfection monitoring — which increases data-management needs. Global Hepatitis Initiative

4. Potential complacency – Success in a target group can create political or operational complacency that slows wider population efforts if the micro-wins are perceived as “enough.”

Challenges (Practical barriers to success)

1. Diagnostic cascade losses — Without reflex RNA/core antigen testing, patients who test anti-HCV positive can be lost between antibody screening and confirmatory viral testing. Reflex testing and same-sample RNA/Ag testing reduce this gap. PMC+1

2. Coordination across specialties — Dialysis, nephrology, hepatology, and primary care must coordinate prescribing, pre-treatment assessment and timing of therapy in CKD/dialysis patients; institutional inertia or unclear roles can slow treatment starts. KDIGO

3. Infection-control adherence — Iatrogenic transmission in dialysis units has historically driven HCV spread; sustained infection-control vigilance (training, audits, incident investigation) is required even after micro-elimination. PMC+1

4. Reinfection risk and reintegration — Patients cured in a micro-elimination program can be reinfected if underlying transmission drivers persist in the community; monitoring and harm-reduction linkages are needed for durable success. PMC

5. Equitable outreach — Some diabetes patients (rural, lower-income, indigenous communities) may have less access to screening unless active outreach is built into the program. Taiwan’s age-based free screening is helpful, but targeted outreach is still required. National Health Institute+1

In-depth analysis

Epidemiologic rationale

• Prevalence and risk: Dialysis populations frequently show higher anti-HCV prevalence due to historical blood-transfusion and nosocomial pathways. Taiwan also has a higher burden of end-stage renal disease and a known HCV burden that the national program targets. Targeting dialysis and CKD care settings therefore captures a disproportionate share of untreated HCV infections. AJKD+1

• HCV–diabetes bidirectional link: Multiple cohort and mechanistic studies indicate HCV infection increases insulin resistance and incidence of type 2 diabetes, while diabetes worsens liver outcomes in chronic HCV. That two-way relationship makes diabetes clinics both a high-value screening point and a place where curing HCV may improve metabolic outcomes. PubMed+1

Program design elements that work (evidence from Taiwan and international guidance)

1. Reflex testing (anti-HCV → automatic RNA/core antigen on same sample) dramatically reduces diagnostic drop-off. Automated electronic reminders and “standing orders” in outpatient clinics increase screening coverage among CKD patients. Taiwanese pilot projects using reminders and integrated ordering achieved higher testing rates. PMC+1

2. On-site dialysis initiatives — Collaborative care models that integrated screening, in-unit blood draws, nurse navigators and streamlined DAA prescribing in dialysis centers achieved near-complete diagnosis and treatment coverage in published Taiwanese experiences. These models emphasize local ownership, simplified algorithms, and close nephrology-hepatology collaboration. ResearchGate+1

3. DAA selection and safety in CKD — Modern pangenotypic DAAs are safe and highly effective (SVR >95% in most cohorts). KDIGO and local consensus recommend selecting regimens appropriate for advanced CKD or dialysis and coordinating with nephrology. Taiwan’s NHI supports DAA reimbursement broadly, removing a major access barrier. KDIGO+2PMC+2

4. Infection control plus treat-and-cure — Infection prevention measures remain essential; however, a treat-and-cure approach in dialysis units simultaneously reduces reservoirs and the risk of transmission — the two strategies are complementary, not substitutes. PMC+1

Outcomes & impact metrics

• Individual outcomes: High SVR rates, potential improvements in glycemic control, and stabilization or slower decline of renal function in some observational studies after HCV cure. Nature+1

• Program outcomes: Rapid rise in case-finding, shorter time from diagnosis to treatment initiation, near-elimination within treated dialysis cohorts in demonstrated pilot programs, and reduction of facility-associated seroconversions. ResearchGate+1

Cost & sustainability considerations

• Cost per cured patient is heavily influenced by screening/test strategy (reflex RNA vs multi-visit testing), local staff costs (nurse navigators), and DAA prices. In Taiwan, NHI coverage and expanding screening reimbursement improve financial feasibility; upfront investments in data systems and navigators increase efficiency and sustainability long term. HPA+1

Conclusion

Micro-elimination of hepatitis C among people with CKD (especially dialysis patients) and people with diabetes in Taiwan is a strategic, evidence-based approach that can rapidly reduce HCV prevalence in high-yield settings, prevent iatrogenic transmission, and deliver direct clinical benefits to patients (including possible positive effects on glycemic control and renal outcomes). Taiwan is well positioned for this approach because of NHI reimbursement for DAAs, national screening programs, and successful pilot experiences in dialysis units. The main requirements for success are reflex confirmatory testing to minimize diagnostic losses, coordinated clinical pathways between nephrology/hepatology/primary care, strict infection-control practices in dialysis units, and monitoring systems to measure screening coverage, treatment uptake, SVR12, and reinfection. Sustained community-level efforts remain necessary to prevent reinfection and to complement micro-elimination gains. ResearchGate+2National Health Institute+2

Summary 

Micro-elimination targets high-risk, health-system-connected groups (CKD/dialysis and diabetes) to rapidly identify and cure hepatitis C, reduce nosocomial transmission, and deliver extrahepatic health benefits. Taiwan’s policy environment, NHI DAA access, and successful dialysis unit programs make this an actionable, high-impact strategy — provided reflex testing, coordination across specialties, infection control, and reinfection surveillance are implemented.