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Ruihong Wu,1 Dongfeng Geng,2 Xiumei Chi,1 Xiaomei Wang,1 Xiuzhu Gao,1 Hongqin Xu,1 Ying Shi,1 Yazhe Guan,1 Yang Wang,1 Jinglan Jin,1 Yanhua Ding,3 Junqi Niu1 1Department of Hepatology, First Hospital of Jilin University, Changchun, Jilin Province 130021, People’s Republic of China; 2Centre for Reproductive Medicine, Centre for Prenatal Diagnosis, First Hospital of Jilin University, Changchun, Jilin Province 130021, People’s Republic of China; 3Phase I Clinical Research Center, The First Hospital of Jilin University, Changchun, Jilin Province 130021, People’s Republic of ChinaCorrespondence: Yanhua DingPhase I Clinical Research Center, The First Hospital of Jilin University, Changchun, Jilin Province 130021, People’s Republic of ChinaTel +86 4 318 878 2168Email dingyanhua2003@126.comJunqi NiuDepartment of Hepatology, The First Hospital of Jilin University, Changchun, Jilin Province 130021, People’s Republic of ChinaTel +86 4 318 187 5101Email junqiniu@aliyun.comBackground and objective: Direct-acting antivirals (DAA) facing resistance continue to be used in some areas worldwide. Thus, identifying hepatitis C virus (HCV) genotypes/subtypes and loci with certain prevalent resistance-associated substitutions (RASs) deserves attention. We investigated the global and regional frequencies of naturally occurring RASs among all confirmed HCV subtypes (n=86) and explored co-occurring and mutually exclusive RAS pairs within and between genes NS3, NS5A, and NS5B.Methods: A total of 213,908 HCV sequences available as of July 10, 2019 were retrieved from the NCBI nucleotide database. After curation, 17,312 NS3, 8,478 NS5A, and 25,991 NS5B sequence fragments from DAA-naïve patients were screened for RASs. MEGA 6.0 was used to translate aligned nucleotide sequences into amino acid sequences, and RAS pairs were identified by hypergeometric analysis.Results: RAS prevalence varied significantly among HCV subtypes. For example, D168E, highly resistanct to all protease inhibitors except voxilaprevir, was nearly absent in all subtypes except in 43.48% of GT5a sequences. RASs in NS3 exhibiting significantly different global distribution included Q80K in GT1a with the highest frequency in North America (54.49%), followed by in Europe (22.66%), Asia (6.98%), Oceania (6.62%), and South America (1.03%). The prevalence of NS3 S122G in GT1b was highest in Asia (26.6%) and lowest in Europe (2.64%). NS5A L28M, R30Q, and Y93H in GT1b, L31M in GT2b, and NS5B C316N in GT1b was most prevalent in Asia. A150V in GT3a, associated with sofosbuvir treatment failure, was most prevalent in Asia (44.09%), followed by Europe (31.19%), Oceania (24.29%), and North America (19.05%). Multiple mutually exclusive or co-occurring RAS pairs were identified, including Q80K+R155K and R155K+D168G in GT1a and L159F+C316N and R30Q (NS5A)+C316N (NS5B) in GT1b.Conclusion: Our data may be of special relevance for those countries where highly effective antivirals might not be available. Considering the specific RASs prevalence will help the clinicians to make optimal treatment choices. The RASs pairs would benefit anti-HCV drug development.Keywords: hepatitis C virus, direct-acting antiviral, resistance-associated substitution, subtype