Heat a large pot over medium heat. Add the onions and ground beef. Cook and stir until beef is cooked through and onions have softened, about 12 minutes. Add the garlic and cook until fragrant, about 1 minute.
Add the water, Worcestershire sauce, tomato sauce, heavy cream, hot sauce, salt, pepper, paprika, and cayenne. Stir and bring to a simmer. Add the macaroni and cook until al dente, about 8 minutes.
Reduce the heat to low and stir in the cheese. Garnish with parsley and enjoy!