Barriers across the hepatitis B and C care cascade in India: a narrative review of recent evidence

INTRODUCTION

Chronic infection with HBV or HCV is a major cause of chronic liver disease, cirrhosis, and hepatocellular carcinoma worldwide. The WHO has set 2030 elimination targets for viral hepatitis, including a 90% reduction in new chronic infections and a 65% reduction in mortality.^1,2 Progress in low- and middle-income countries (LMICs), including India, remains insufficient.

India is estimated to have 29.8 million people living with chronic HBV infection and 5.5 million people living with chronic HCV infection, accounting for a substantial share of the global viral hepatitis burden.^3-6 In 2018, the Government of India launched the NVHCP to provide free testing and treatment and to drive elimination.⁷ Nonetheless, substantial gaps persist across the care cascade-testing, linkage to confirmatory diagnosis and treatment, long-term retention, surveillance, and prevention.

Since the scale-up of NVHCP implementation, particularly from 2020 onward, several programmatic and implementation studies have evaluated performance at state and district levels, highlighting both progress and persistent bottlenecks.^8-11 This review synthesises recent evidence to identify the principal barriers across the HBV and HCV care cascade in India and to highlight promising strategies for improvement.

RATIONALE FOR A NARRATIVE APPROACH

A narrative review was selected because the relevant evidence is methodologically heterogeneous-spanning implementation studies, economic evaluations, programme reports, and policy documents-and is therefore not amenable to the quantitative pooling of a systematic review or meta-analysis. To reduce selection bias, we nevertheless adopted a structured, reproducible search strategy, as recommended for high-quality narrative reviews.

Data sources and search strategy

We searched PubMed and Scopus for records published between January 2020 and May 2026, using combinations of the terms: "hepatitis B," "hepatitis C," "viral hepatitis," "India," "care cascade," "continuum of care," "screening," "diagnosis," "linkage to care," "treatment," "retention," "follow-up," "vaccination," and "National Viral Hepatitis Control Programme" / "NVHCP." Searches were limited to English-language publications. We supplemented database searches by hand-screening reference lists of relevant articles and by reviewing operational guidelines, surveillance reports, and policy documents from the Ministry of Health and Family Welfare (MoHFW), the NVHCP, and the WHO. Foundational documents predating 2020 were included where necessary for context.

Eligibility and study selection

We included original research, implementation studies, and programme evaluations conducted in India; reviews and commentaries offering relevant insight into cascade barriers and facilitators; and policy, operational, and surveillance documents. Eligible records addressed at least one cascade stage-screening/testing, linkage to confirmatory diagnosis, treatment initiation, retention, surveillance/data systems, or prevention (notably HBV vaccination). Studies addressing only clinical management without reference to cascade outcomes or system-level barriers were excluded unless they provided essential context. Evidence was synthesised thematically by cascade stage.

BARRIERS TO HEPATITIS B AND C TESTING

Barriers at health-system, provider, and community levels contribute to low testing uptake in India.

Limited integration of routine screening

Testing is not comprehensively integrated into routine services. Missed opportunities occur in antenatal, primary, and general outpatient care, where systematic HBV/HCV screening is often not offered. At a tertiary centre in Puducherry, nearly one-quarter of outpatients offered hepatitis B surface antigen (HBsAg) testing declined, with disproportionately higher refusal among men-suggesting low perceived risk, stigma, and inadequate awareness.¹²

Diagnostic infrastructure gaps and geographic inequities

Situational analyses of the NVHCP document limited availability of screening and confirmatory tests, including HCV RNA testing, at peripheral facilities.⁷ Decentralized care with generic direct-acting antivirals in the management of chronic hepatitis C in a public health care setting.^13,14

Provider-level barriers

Provider factors include limited awareness and training among primary-care providers on who to screen and how to act on results, and inconsistent implementation of NVHCP training across states.^15-17 Consequently, opportunities to test at-risk individuals-or those with abnormal liver function tests-are frequently missed.

Community-level barriers

Limited awareness, misconceptions about transmission, and stigma reduce testing demand.¹⁵ Because chronic HBV and HCV are often asymptomatic for years, perceived need for testing is low among otherwise healthy adults, contributing to late presentation.

TESTING-STRATEGY INNOVATIONS

Self-testing and point-of-care approaches

HCV self-testing piloted in urban slums encountered challenges with blood-sample collection, instruction interpretation, and absence of integrated counselling, limiting current feasibility and usability. Economic evaluations from Tamil Nadu (HCV) and Punjab (HBV) indicate that rapid point-of-care testing can be cost-effective under specific conditions, though budget impact and scalability depend on local capacity.^18,19

Reaching high-risk and marginalised populations

Migrants, prisoners, and people who inject drugs (PWID) face structural barriers including criminalisation, stigma, and poor service access.²⁰ In Manipur, a community-led, same-day HCV test-and-treat model for PWID achieved high uptake and rapid linkage when delivered in accessible, non-stigmatising settings, illustrating the potential of peer-led models.^21,22

LINKAGE TO CONFIRMATORY TESTING AND TREATMENT

Cascade losses after initial screening

Substantial attrition occurs between screening and confirmatory diagnosis or treatment. In one apex NVHCP treatment centre, only 27.7% of HBV-positive and 8.9% of HCV-positive blood donors-already identified as reactive-attended clinics for confirmatory testing and care, exposing the weakness of passive referral and the need for active linkage. ²³

Service-delivery models and outcomes

The integrated district-hospital models-co-locating screening, viral-load testing, and treatment-achieved higher confirmatory-testing uptake, faster turnaround, and better treatment initiation and retention than referral-based models.²⁴ Fragmented pathways introduce travel costs, long waits, reporting delays, and counselling/follow-up shortfalls. Punjab's systematically developed hub-and-spoke model offers a replicable template.¹³

Financial barriers despite free treatment

Although antiviral therapy is free under the NVHCP, patients incur out-of-pocket costs for travel, uncovered investigations, and monitoring visits,²⁵contributing to documented cascade losses even after diagnosis and linkage.²⁶

RETENTION IN CARE AND LONG-TERM FOLLOW-UP

Chronic HBV management

HBV typically requires long-term monitoring and, in some cases, prolonged therapy. Low perceived need for care among asymptomatic individuals and socioeconomic constraints undermine follow-up.

HCV adherence and discontinuation

Punjab's programmatic experience identified early discontinuation of direct-acting antiviral (DAA) therapy linked to supply-chain disruptions and adherence challenges, underscoring the need for reliable supply, counselling, and simplified, decentralised delivery.

Models of successful retention

Micro-elimination initiatives demonstrate that high retention and cure are achievable: Punjab's expanded hub-and-spoke model reported cure rates exceeding 90% among PWID and other marginalised groups.²⁷ Real-world NVHCP data suggest an overall sustained virologic response (SVR) of 92%, although outcomes are poorer in decompensated cirrhosis owing to higher mortality.²⁸

Mobility and system constraints

Internal labour migration disrupts continuity, as patients may relocate mid-treatment. Weak patient-tracking, limited record interoperability, inadequate active follow-up, insufficient counselling time, and overburdened clinics compound attrition.

DATA REPORTING AND SURVEILLANCE CHALLENGES

Incomplete, heterogeneous reporting

Despite an established NVHCP reporting system, gaps persist in completeness, timeliness, and quality.²⁹ Under-reporting from the large private sector is a major limitation, and standardised cascade metrics are lacking across states. Implementation reports highlight incomplete screening capture, absent indicators for reflex testing (automatic viral-load testing after a positive screen), and the limited linkage/retention reporting within routine health management information systems (HMIS).

Fragmented digital infrastructure

Poor interoperability between laboratories, treatment centres, and national databases, together with parallel reporting systems across vertical programmes (immunisation, HIV, hepatitis), creates duplication and gaps.³⁰While individual studies such as HEAD-Start (>37,000 screened) report detailed cascade outcomes, consolidated national cascade metrics (screened → confirmed → treated → retained) are not routinely published, impeding progress assessment.²⁴

HEPATITIS B BIRTH DOSE AND HIGH-RISK VACCINATION

Timely birth dose

India includes a hepatitis B birth dose in the Universal Immunization Programme (UIP), yet timely coverage (within 24 hours) remains suboptimal (77.6%) despite high institutional-delivery rates (NFHS-6).³¹ Operational barriers include home births and delayed postnatal contact; labour-room workflow and staffing gaps; supply- and cold-chain challenges in high-fertility, hard-to-reach areas; limited caregiver awareness; and provider under-emphasis on the 24-hour window. Targeted operational improvements at labour-room and provider levels are needed.³²

High-risk groups

Coverage among high-risk adults-healthcare workers, PWID, and household contacts of HBV/HCV-infected persons-is inconsistent India.³³ Stigma, low risk perception, and poor integration with HIV, harm-reduction, and occupational-health services impede uptake. Community-led integration of HBV vaccination with HCV treatment has increased uptake among marginalised groups but remains localised.

DISCUSSION

Barriers to HBV and HCV elimination in India are multifactorial and span every cascade stage. At the community level, inadequate awareness, low perceived risk, stigma, and asymptomatic infection suppress demand until advanced disease develops.⁹

At health-system level, deficiencies in infrastructure, diagnostics, workforce and service integration delay care; fragmented models incur substantial losses and financial and logistical barriers persist despite free therapy. At programme and policy level, incomplete surveillance and integration with other national programs, private-sector under-reporting, inconsistent cascade metrics, and fragmented digital systems constrain monitoring. Challenges in reaching high-risk populations, including people who inject drugs, together with persistent gaps in organised screening, a substantial pool of undiagnosed infections, and the need for coordinated public health action, continue to hinder progress towards viral hepatitis elimination in India (Table 1).^21,34-36

Promising models. Integrated "one-stop" district services improve linkage and retention; decentralised hub-and-spoke delivery with capacity-building and political commitment achieves high coverage as well as the cure (Punjab); community-led, same-day test-and-treat reaches marginalised groups (Manipur); and state-specific economic evaluations guide rational scale-up.²¹ These models, however, are not yet institutionalised nationally.

Limitations

As a narrative review, this synthesis is subject to selection bias despite a structured search, and was restricted to English-language records indexed in two databases, potentially omitting regional-language or grey literature. The heterogeneity of included sources precluded quantitative synthesis, and several recent programme outcomes derive from single-state experiences (notably Punjab and Manipur) that may not generalise nationally. Findings should therefore be interpreted as a thematic mapping of barriers and facilitators rather than a definitive quantitative assessment.

CONCLUSION

Barriers across testing, linkage, treatment, retention, reporting, and vaccination impede HBV and HCV elimination in India. Evidence from 2020-2026 clarifies these bottlenecks and identifies scalable models.

Priority actions are: Strengthen active linkage-implement active recall, patient navigation, and structured pathways from blood banks, antenatal clinics, and outpatient departments to NVHCP centres. Scale integrated "one-stop" services-co-locate screening, confirmatory testing, and treatment. Expand decentralised hub-and-spoke delivery-replicate Punjab's model with peripheral capacity-building and robust supply chains. Embed diagnostics and digital linkage in NVHCP guidelines-incorporate reflex testing, simplified algorithms, and electronic tracking.

Institutionalise national cascade reporting-standardised, WHO-aligned metrics across public and private sectors. Improve birth-dose delivery-address labour-room workflows, cold chain, and provider training, prioritising high-fertility and hard-to-reach areas. Integrate hepatitis services into harm-reduction and community programmes-for PWID, migrants, prisoners, and other marginalised groups. Strengthening primary-care platforms, integrating services, leveraging digital health, and prioritising high-risk populations will be critical to closing cascade gaps and accelerating elimination in India. Implementing targeted interventions and ensuring equitable access across regions will be essential to overcome existing barriers and achieve comprehensive hepatitis elimination goals.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. World Health Organization. Global health sector strategies on HIV, viral hepatitis and sexually transmitted infections for the period 2022-2030. Available at: https://www.who.int/publications/i/item/9789240053779. Accessed on 1 March 2026.
2. 2. World Health Organization. Global hepatitis report 2026. Available at: https://www.who.int/publications/i/item/9789240122383. Accessed on 1 March 2026.
3. 3. Blach S, Weis N, Lavanchy D. Global change in hepatitis C virus prevalence and cascade of care between 2015 and 2020: a modelling study. Lancet Gastroenterol Hepatol. 2022;7(5):396-415.
4. 4. Razavi-Shearer D, Gamkrelidze I, Nurmatov Z. Global prevalence, treatment, and prevention of hepatitis B virus infection in 2016: a modelling study. Lancet Gastroenterol Hepatol. 2018;3(6):383-403.
5. 5. Premkumar M, Chawla YK. Chronic hepatitis B: challenges and successes in India. Clin Liver Dis (Hoboken). 2021;18(3):111-6.
6. 6. Mahalakshmi PA, Gowtham RR, Mudhigeti N. Seroprevalence and Trend of Hepatitis B and C Viral Infections in Patients at a Tertiary Care Hospital in Southern India: A Retrospective Study. J Clin Diagn Res. 2020;14(6):DC01-5.
7. 7. Ministry of Health and Family Welfare, Government of India. National Viral Hepatitis Control Programme (NVHCP): Operational Guidelines. New Delhi: Ministry of Health and Family Welfare. 2018.
8. 8. Shanmugam V, Ward J, Vijayakumar S, Giten K, Cary J, Lokesh S, et al. Challenges and opportunities in combating viral hepatitis in India: insights from the Indian Hepatitis Summit 2025. BMC Proc. 2026;20(4):4.
9. 9. Daniel R, Das S, Ramadass S, Surya BN. Preventive strategies for chronic liver disease: a critical review of awareness, vaccine and screening programmes. Indian J Gastroenterol. 2026;NA.
10. 10. Pandey P, Gupta R, Badola M. Evaluation of the National Viral Hepatitis Control Program in Uttarakhand: a mixed-method approach. J Family Med Prim Care. 2026;15(3):1194-201.
11. 11. Pandey P, Bhadoria AS. Capacity building efforts on viral hepatitis under National Viral Hepatitis Control Program. J Epidemiol Fam Community Health India. 2023;1(1):1-4.
12. 12. Kumar SS, Chinnakali P, Dhodapkar R, Mohan P, Olickal JJ, Hamide A. Willingness and yield of screening for hepatitis B among outpatients of a tertiary care centre, Puducherry, South India. Trop Doct. 2021;51(2):197-202.
13. 13. Bhadoria AS, Pathak VK, Bhattacharya P, Roy P, Grover G, Pandey P. Efforts towards elimination of viral hepatitis in India. In: Wai CT, Lim SG, editors. Viral Hepatitis in Asia and the Pacific: Towards Elimination as a Public Health Threat. Cambridge (MA): Academic Press. 2025;87-110.
14. 14. Dhiman RK, Grover GS, Premkumar M. Decentralized care with generic direct-acting antivirals in the management of chronic hepatitis C in a public health care setting. J Hepatol. 2019;71(6):1076-85.
15. 15. Goel A, Seguy N, Aggarwal R. Burden of hepatitis C virus infection in India: a systematic review and meta-analysis. J Gastroenterol Hepatol. 2019;34(2):321-9.
16. 16. Bhadoria AS, Gawande KB, Kedarisetty CK, Rewari BB, Pathak VK, Pandey P, et al. Prevalence of Hepatitis B and C Among Prison Inmates in India: A Systematic Review and Meta-Analysis. Cureus. 2021;13(11):e19672.
17. 17. Shrivastava M, Agrawal A, Das S, Mishra S. Burden of hepatitis B in asymptomatic blood donor population of India: a systematic review and meta-analysis. Indian J Med Res. 2024;160(2):155-64.
18. 18. Chugh Y, Premkumar M, Grover GS, Dhiman RK, Teerawattananon Y, Prinja S. Cost-effectiveness and budget impact analysis of facility-based screening and treatment of hepatitis C in Punjab state of India. BMJ Open. 2021;11(2):e042280.
19. 19. Malaisamy M, Nagarajan K, Kirti T. Economic evaluation of implementing a rapid point-of-care screening test for the identification of hepatitis C virus under National Viral Hepatitis Control Programme in Tamil Nadu, South India. J Glob Infect Dis. 2021;13(3):126-32.
20. 20. Shukla L, Shivaprakash P, Kumar MS. HIV, hepatitis B and C in people who inject drugs in India: a systematic review of regional heterogeneity and overview of opioid substitution treatment. Indian J Med Res. 2023;158(5-6):522-34.
21. 21. Rajkumar N, Khumukcham LS, Thangjam D, et al. Decentralised same-day test and treatment of hepatitis C leveraging existing peer support networks among men who inject drugs: feasibility and effectiveness. Harm Reduct J. 2024;21(1):98.
22. 22. Kermode M, Nuken A, Medhi GK, Akoijam BS, Sharma HU, Mahanta J. High burden of hepatitis C and HIV co-infection among people who inject drugs in Manipur, Northeast India. Indian J Med Res. 2016;143(3):348-56.
23. 23. Ahammed SM, Singh BM, Saren S, Dey P, Roy R, Chowdhury A. Linkage to care of people with chronic hepatitis B virus and hepatitis C virus infection among blood donors: experience from an apex treatment centre under National Viral Hepatitis Control Program, India. JGH Open. 2024;8(12):e70085.
24. 24. Markby J, Gupta E, Soni D, Sarin S, Murya M, Katapur P, et al. Feasibility, effectiveness and cost of a decentralized HCV care model among the general population in Delhi, India. Liver Int. 2022;42(3):532-40.
25. 25. Iyengar S, Tay-Teo K, Vogler S, Beyer P, Wiktor S, de Joncheere K, et al. Prices, costs, and affordability of new medicines for hepatitis C in 30 countries: an economic analysis. PLoS Med. 2016;13(5):e1002032.
26. 26. Rai SK, Oberoi S, Singh A, Singh H. Understanding the cascade of care and predictors of treatment success among patients with hepatitis C: a prospective study at a tertiary care center in India. IJID Reg. 2025;17:100783.
27. 27. Dhiman RK, Grover GS, Premkumar M. Outcomes of real-world integrated HCV microelimination for people who inject drugs: an expansion of the Punjab Model. EClinicalMedicine. 2021;41:101148.
28. 28. Dutta S, Nath S, Das R. Assessment of direct-acting antiviral treatment outcomes in patients with chronic hepatitis C infected with various HCV genotypes: insights from a real-world cohort in West Bengal, India. BMC Infect Dis. 2025;25(1):1180.
29. 29. Pandey P, Roy A, Bhadoria AS. National Viral Hepatitis Control Program in India: call for update. J Family Med Prim Care. 2023;12(9):1755-8.
30. 30. World Health Organization. Monitoring and evaluation for viral hepatitis B and C: recommended indicators and framework. Available at: https://www.who.int/publications/i/item/978924151028. Accessed on 1 March 2026.
31. 31. International Institute for Population Sciences (IIPS). National Family Health Survey (NFHS-6), 2023-24: India and State/UT Fact Sheets. Mumbai: IIPS. 2026.
32. 32. Lahariya C, Subramanya BP, Sosler S. An assessment of hepatitis B vaccine introduction in India: lessons for roll out and scale up of new vaccines in immunization programs. Indian J Public Health. 2013;57(1):8-14.
33. 33. Ramesh P. Hepatitis B vaccination coverage and its determinants among healthcare personnel in Chengalpattu District: a cross-sectional study. Cureus. 2026;18(4):e106638.
34. 34. Chauhan V, Raina S, Thakur S. State of the Globe: hepatitis C—opportunistic versus organized screening. J Glob Infect Dis. 2017;9(2):39-40.
35. 35. Beig MA, Singh P, Sharma R, Roy A, Alghamdi AS, et al. Tackling the burden of viral hepatitis in India: a call for collaborative efforts. J Hepat Res. 2023;8(1):1049.
36. 36. Jain RK, Jain A, Jain SK, Chaurasia D, Agarwal A, Maan HS, et al. Unravelling the hidden and undiagnosed cases of hepatitis B and C viruses among patients seeking health care for other viral illness: a cross-sectional study from Central India. Indian J Community Med. 2025;50(6):1016-20.