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Viral Hepatitis


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Veteran Data Reports on Viral Hepatitis

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State of Care for Veterans with Chronic
Hepatitis C

Executive Summary

The Department of Veterans Affairs (VA), Veterans Health Administration (VHA) is the largest single provider of hepatitis C (HCV) care in the United States. According to Clinical Case Registry data, between 2000 and 2008, 287,410 Veterans in VHA care screened positive for antibodies to HCV and 189,065 (65%) were identified with chronic HCV infection. In 2008, VHA clinicians cared for over 147,000 Veterans with chronic HCV; these Veterans were cared for in every one of VHA.s 21 Veterans Integrated Service Networks (VISNs) and at every one of the 128 VHA local healthcare systems across the United States. Of the 5.6 million Veterans in VHA care in 2008, one of every 38 (2.6%) had a diagnosis of chronic HCV. The number of Veterans with chronic HCV in VHA care has been relatively stable over the past 5 years with approximately 8% entering VHA care and approximately 8% leaving (including deaths) VHA care each year. In 2008, caseloads of Veterans with chronic HCV ranged from 2,480 to 14,019 across VISNs and from 26 to 4,476 across local VHA healthcare systems. In 2008, the typical Veteran with chronic HCV was White (49%), 56 years old, male (97%), with a history of co-morbidities including hypertension (63%) and depression (56%). This group has a significant history of tobacco use (62%) and alcohol use (54%), complicating the management of chronic HCV. More than one in eight had a history of cirrhosis and over 900 new cases of hepatocellular carcinoma (HCC) were diagnosed in 2008. The proportion of those in care with advanced liver disease, including cirrhosis and liver cancer, has grown significantly over the past 8 years.

Nationally, Veterans with chronic HCV receive high quality care at the VHA as reflected in rates of guideline-concordant HCV-specific care, recommended prophylaxis, screening for conditions important to public health, and outcomes measures; however room for improvement exists. National VHA rates of providing guideline-recommended clinical preventive services for Veterans with chronic HCV receiving care in 2008 included: confirmation of hepatitis B immunity or vaccination 70%, confirmation of hepatitis A immunity or vaccination 65%, HIV testing 56%, influenza vaccination 46%, and screening for HCC in Veterans with chronic HCV and cirrhosis 45%. By 2008, over 31,000 had received antiviral therapy for HCV; they represent one-fifth of the Veterans with chronic HCV in VHA care in 2008. Attainment of a successful HCV antiviral treatment outcome, referred to as sustained virologic response (SVR), was lower in VHA compared to drug registry trials, as might be expected due to differences in patient population.

As the report shows, VHA has made significant improvements over the past 8 years in many areas of HCV population management including patient identification, testing, and in quality of care indicators. These improvements coincide with the establishment of a National Hepatitis Clinical Program Office and the Hepatitis C Resource Centers. Programmatic efforts have included the development of educational materials, development and dissemination of successful models of care, various training programs and quality improvement initiatives. This document provides a descriptive report; it is not meant to be exhaustive nor is it to provide the type of statistical analyses that allow inferences to be drawn. The PHSHG uses these data to understand HCV prevalence, burden of disease, and care outcomes regionally and locally in order to design targeted interventions and identify topics requiring additional investigation, thus assisting in improving care for our nation.s Veterans. Geographic variability across VISNs and local healthcare systems exists on all the quality indicators covered in this report, providing an opportunity for the PHSHG, administrators, local champions, and VHA researchers to identify gaps, barriers, and best practices to improve care.