Parenteral drug use as the main barrier to hepatitis C treatment uptake in HIV‐infected patients

Abstract

ObjectivesOur objective was to identify patient factors associated with being untreated for hepatitis C virus (HCV) infection in HIV-coinfected patients. MethodsA prospective longitudinal study was carried out. HIV-infected patients with active chronic HCV infection included in the HERACLES cohort (NCT02511496) constituted the study population. The main study outcome was receipt of HCV direct-acting antiviral (DAA) treatment from 1 May 2015 to 1 May 2017. The population was divided into patients who were receiving HCV treatment during follow-up and those who were not. ResultsOf the 15 556 HIV-infected patients in care, 3075 (19.7%) presented with chronic HCV infection and constituted the study population. At the end of the follow-up, 1957 patients initiated HCV therapy (63.6%). Age < 50 years, absence of or minimal liver fibrosis, being treatment-na€ ıve, HCV genotype 3 infection, being in the category of people who inject drugs using opioid substitutive therapy (OST-PWID), and being in the category of recent PWID were identified as significant independent risk factors associated with low odds of DAA implementation. When a multivariate analysis was performed including only the PWID population, both OST-PWID [odds ratio (OR) 0.552; 95% confidence interval (CI) 0.409-0.746) and recent PWID (OR 0.019; 95% CI 0.004-0.087) were identified as independent factors associated with low odds of treatment implementation.We identified factors, which did not include prioritization of a DAA uptake strategy, that limited access to HCV therapy. The low treatment uptake in several populations seriously jeopardizes the elimination of HCV infection in the coming years.

Increased case‐finding and uptake of direct‐acting antiviral treatment essential for micro‐elimination of hepatitis C among people living with HIV: a national record linkage study

“…A study of HCV screening of patients in HIV care in the United States found that 77.9% were not tested for HCV and that only 17.8% were initiated onto treatment [31]. A prospective cohort in Spain found that while more than 60% were started on HCV treatment, recent PWID and those on opioid substitution therapy had lower rates compared with other groups, which is consistent with our results [32]. An Australian cohort of co‐infected patients also found that rapid scale‐up of DAA treatment was possible in a short time and these results demonstrate that micro‐elimination in this population is possible [33].…”

Low hepatitis C virus-viremia prevalence yet continued barriers to direct-acting antiviral treatment in people living with HIV in the Netherlands

“…Among studies conducted in settings without universal DAA-access, individuals with frequently missed visits and PWID were less likely to receive DAA [8–11], similar to our findings. Additionally, those with advanced fibrosis or cirrhosis more often received DAAs, likely owing to the specific restrictions put in place in these settings [8–11]. Regarding alcohol use, similar to what we observed, severe alcohol use was associated with a lower DAA-uptake in a study in HCV-infected individuals receiving opioid agonist therapy [21], which was not confirmed in a smaller study among HIV-positive PWID [22].…”

“…Among studies conducted in settings without universal DAA-access, individuals with frequently missed visits and PWID were less likely to receive DAA [8][9][10][11], similar to our findings. Additionally, those with advanced fibrosis or cirrhosis more often received DAAs, likely owing to the specific restrictions put in place in these settings [8][9][10][11].…”

“…Coupled with newly occurring acute HCV infections and re-infections [6], treatment of these remaining HCV-viremic individuals is essential to reduce ongoing HCV transmission and thus achieve micro-elimination. Several studies have examined the reasons why HCV-infected individuals remain untreated [8][9][10][11]. However, in those studies DAA treatment was partly restricted or recently unrestricted, making inference to settings with prolonged unrestricted access difficult.…”

What barriers delay treatment in patients with hepatitis C?

“…1 A multicenter, observational prospective cohort study (N = 3075) evaluated receipt of HCV treatment for patients co-infected with HCV and HIV. 2 The primary outcome was initiation of HCV treatment with DAAs; 1957 patients initiated therapy, while 1118 did not. Significant independent risk factors for noninitiation of treatment included age younger than 50 years, a history of IV drug use, and use of opioid substitution therapy (OST).…”