Hepatitis C prevalence and key population size estimate updates in San Francisco: 2015 to 2019
Authors: Facente Shelley N. , Grinstein Rachel , Bruhn Roberta , Kaidarova Zhanna , Wilson Erin , Hecht Jennifer , Burk Katie , Grebe Eduard , Morris Meghan D. 
Published: May 2022

Background
In 2017, San Francisco’s initiative to locally eliminate hepatitis C virus (HCV) as a public health threat, End Hep C SF, generated an estimate of city-wide HCV prevalence in 2015, but only incorporated limited information about population HCV treatment. Using additional data and updated methods, we aimed to update the 2015 estimate to 2019 and provide a more accurate estimate of the number of people with untreated, active HCV infection overall and in key subgroups–people who inject drugs (PWID), men who have sex with men (MSM), and low socioeconomic status transgender women (low SES TW).

Methods
Our estimates are based on triangulation of data from blood bank testing records, cross-sectional and longitudinal observational studies, and published literature. We calculated subpopulation estimates based on biological sex, age and/or HCV risk group. When multiple sources of data were available for subpopulation estimates, we calculated an average using inverse variance weighting. Plausible ranges (PRs) were conservatively estimated to convey uncertainty.

Results
The total number of people estimated to have anti-HCV antibodies in San Francisco in 2019 was 22,585 (PR:12,014–44,152), with a citywide seroprevalence of 2.6% (PR:1.4%–5.0%)–similar to the 2015 estimate of 21,758 (PR:10,274–42,067). Of all people with evidence of past or present infection, an estimated 11,582 (PR:4,864–35,094) still had untreated, active HCV infection, representing 51.3% (PR:40.5%–79.5%) of all people with anti-HCV antibodies, and 1.3% (PR:0.6%–4.0%) of all San Franciscans. PWID comprised an estimated 2.8% of the total population of San Francisco, yet 73.1% of people with anti-HCV antibodies and 90.4% (n = 10,468, PR:4,690–17,628) of untreated, active HCV infections were among PWID. MSM comprised 7.8% of the total population, yet 11.7% of people with anti-HCV antibodies and 1.0% (n = 119, PR:0–423) of those with untreated active infections. Low SES TW comprised an estimated 0.1% of the total population, yet 1.4% of people with HCV antibodies and 1.6% (n = 183, PR:130–252) of people with untreated active infections.

Conclusions
Despite the above-average number (2.6%) of people with anti-HCV antibodies, we estimate that only 1.3% (PR:0.6%–4.0%) of all San Francisco residents have untreated, active HCV infection–likely a reflection of San Francisco’s robust efforts to diagnose infection among high-risk groups and initiate curative treatment with as many people as possible. While plausible ranges of infections are wide, these findings indicate that while the overall number of people with anti-HCV antibodies may have increased slightly, the number of people with active HCV infection may have decreased slightly since 2015. This estimate improves upon the 2015 calculations by directly estimating the impact of curative treatment citywide and in subgroups. However, more research is needed to better understand the burden of HCV disease among other subgroups at high risk, such as Blacks/African Americans, people with a history of injection drug use (but not injecting drugs in the last 12 months), people who are currently or formerly incarcerated, and people who are currently or formerly unhoused.