Direct acting antiviral uptake disparities in HIV/HCV-coinfected populations

Background: Direct acting antivirals (DAAs) have revolutionized hepatitis C (HCV) treatment with nearly 100% cure rates even in real-world studies, giving hope that HCV can be eliminated. Historically, HCV treatment initiation rates have been low, particularly among people who inject drugs (PWID) an important group to target if the goal is to reduce incident HCV infections. In a publically funded health care setting, we investigated DAA treatment uptake disparities among HIV-HCV co-infected subpopulations. Methods: The Canadian Co-Infection Cohort Study prospectively follows 1625 HIV/HCV co-infected participants from 19 centers, representing approximately a quarter of the total Canadian co-infected population in care. Among HCV RNA+ participants, we determined the incidence of HCV treatment initiation per year and stratified by different risk profiles (Aboriginals, women, PWID and men who have sex with men (MSM)). Multivariate Cox models were used to estimate adjusted hazard ratios (aHR) for DAA initiation accounting for age, sex, Aboriginal status, active (within 6 months) and past PWID, MSM, alcohol use, advanced fibrosis, HCV genotype, undetectable HIV RNA, province and income (a priori predictors of treatment initiation). Results: Overall, HCV treatment initiations rose more than five times between 2013 and 2015, from 8 (95% CI: 5-11) to 46 (95% CI: 39-55) per 100 person-years. After stratifying initiation, by risk profiles, uptake was markedly lower among Aboriginals, women and active PWID (Figure 1). Among 854 HCV RNA+ participants, 195 initiated DAAs [128=ledipasvir/sofosbuvir (SOF); 28=SOF/ribavirin; 19=SOF/simeprevir; 13=SOF/ribavirin/interferon; 7=other all-oral regimens]. After adjustment (aHR, 95% CI), Aboriginals (0.56, 0.34-0.94), active PWID (0.54, 0.36-0.84) remained less likely to initiate HCV treatment. Women and past PWID tended to have lower treatment rates (0.80, 0.55, 1.15) and (0.73, 0.53, 1.02). Conversely, MSM were more likely to initiate DAAs (1.89, 1.41- 2.46). SVR rates were high in all sub-groups regardless of uptake: 100% in women and Aboriginals, 95% in active PWID and 91% in MSM compared to 93% for the cohort overall. Conclusion: Treatment uptake has increased dramatically with the availability of all oral DAAs, but marginalized populations are still failing to access treatment. Barriers to treating these subgroups, who can obtain high SVR rates, need to be addressed if DAAs are to impact HCV incidence and the overall burden of chronic liver disease. (Figure Presented).