Background
People with HIV (PWH) are at increased risk of coinfection with worse outcomes from hepatitis C virus (HCV) and are a key group targeted for treatment with direct-acting antivirals (DAA). Not all PWH eligible for DAA receive it. We estimated DAA uptake among PWH with HCV coinfection in the NA-ACCORD to identify factors associated with DAA initiation.
Methods
U.S. and Canadian PWH 18-years or older with untreated HCV in NA-ACCORD clinical cohorts were followed from their latest date of: 1) detectable HCV viremia, 2) ART initiation, 3) enrollment date, or 4) 1/1/2014 until the first of: 1) DAA prescription (event), 2) clearance of HCV viremia (ineligible for DAA), 3) loss to follow-up, 4) death or 5) 12/31/2021. A competing risk approach estimated the cumulative incidence of DAA initiation while accounting for both death and HCV clearance. Cox proportional hazard models estimated crude and adjusted hazard ratios (aHR) and 95% confidence intervals to identify factors associated with DAA initiation including sex, age, HIV risk group, race/ethnicity, FIB-4 score, HBV coinfection, alcohol use, smoking status, HIV viral load and a history of AIDS, hypertension, diabetes, and chronic kidney disease.
Results
Among 6,300 PWH with HCV, 3,672 initiated DAA. The 8-year cumulative incidence of DAA initiation was 65% [63%-66%]. Accounting for the competing risks of death and HCV clearance, 6% of eligible PWH did not initiate DAA (Figure). PWH reporting heterosexual (aHR=0.79 [0.68, 1.92]) or injection drug use (aHR=0.84 [0.75, 0.95] HIV risks initiated DAA at a lower rate compared with men who have sex with men. A reduced rate of DAA initiation was identified among non-Hispanic Black (aHR=0.83 [0.76, 0.90]) and Hispanic (aHR=0.88 [0.77, 1.00]) PWH compared with non-Hispanic white PWH. DAA initiation was significantly lower among PWH with at-risk alcohol use, smoking, detectable HIV viremia, and a history of AIDS. A higher FIB-4 score was associated with increased DAA initiation. Other assessed factors were not associated with differences in DAA initiation in multivariable models.
Conclusions
Accounting for death and HCV clearance the treatment gap among PWH eligible for, and those initiating DAA has narrowed over time. We identified factors associated with disparities in DAA uptake including HIV risk, race/ethnicity, smoking, alcohol use and HIV viremia. Targeted approaches are needed to increase equity in DAA initiation by addressing these disparities to achieve the goal of HCV elimination among PWH.
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