| Summary: | Background & Aims: Timely HCV care is essential to prevent liver disease progression. The aim of this study was to evaluate trends in late HCV diagnosis and treatment in people diagnosed with end-stage liver disease (ESLD) in New South Wales (NSW), Australia. Methods: HCV notifications in NSW, Australia (1995-2022) were linked to hospital admissions (2010-2021) and treatment records (2002-2022). Descriptive analyses and logistic regression were used to examine trends and factors associated with late diagnosis and missed treatment opportunities. Late diagnosis and treatment were defined as the absence of HCV notification and treatment within 2 years prior to or following the first hospitalisation for ESLD. Results: Among 4,419 people with an HCV notification and ESLD diagnosis, late HCV diagnoses decreased from 24% in 2010-2012 to 16% in 2019-2021. The proportion receiving no or late treatment declined from 98% (85% no, 13% late) to 70% (48% no, 22% late). Residing in rural or regional areas was linked with late HCV diagnosis (adjusted odds ratio [aOR] 1.44, 95% CI 1.05-1.97, p = 0.024). Recent injecting drug use (aOR 0.78, 95% CI 0.60-0.99, p = 0.041), incarceration (distant [aOR 0.55, 95% CI 0.38–0.78, p = 0.001], recent [aOR 0.51, 95% CI 0.28–0.96, p = 0.037]), government assistance (aOR 0.57, 95% CI 0.39-0.82, p = 0.002), and older age (born ≤1944 [aOR 0.31, 95% CI 0.15-0.66, p = 0.002], born 1945-1959 [aOR 0.47, 95 CI% 0.29-0.77, p = 0.003]), were associated with lower odds of a late HCV diagnosis. Recent alcohol use disorder was associated with increased odds of no or late treatment (aOR 1.80, 95% CI 1.40-2.32, p = 0.001). Conclusion: Encouragingly, factors associated with social marginalisation predict earlier HCV diagnosis, while rural/regional residence predicts late HCV diagnosis among people with ESLD. Missed HCV treatment opportunity, defined by no or late treatment is associated with alcohol use disorder, but not with indicators of social marginalisation. Impact and implications: Timely HCV care is essential to prevent liver disease progression. Significant improvements in HCV diagnosis and treatment timing in New South Wales over the past decade highlight the success of Australia's universal provision of direct-acting antiviral therapy and targeted screening initiatives, particularly for people who inject drugs and those recently incarcerated. Persistent barriers to timely care remain for rural communities and people with alcohol use disorder, suggesting the need for enhanced integration of HCV services with alcohol treatment programs and expanded rural outreach. Achieving World Health Organization elimination targets by 2030 requires strengthened efforts to reach underserved populations and better integrate HCV care.
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