Background: Direct-acting antivirals (DAAs) achieve high sustained virologic response (SVR) in hepatitis C virus (HCV) patients with cirrhosis, yet the risk of hepatic decompensation or hepatocellular carcinoma (HCC) persists. Fibrosis-4 (FIB-4), a pre-treatment index that predicts advanced fibrosis, is linked to HCC risk post SVR. We compared post-SVR outcomes and care engagement, and determined the optimal pre-treatment FIB-4 index to predict the risk of HCC or decompensation in HCV patients with cirrhosis treated at the Department of Corrections (DOC) and non-DOC clinics. Methods: HCV patients with cirrhosis treated with DAAs since 2014 in the HCV Treatment Registry were included. Cirrhosis was defined by elastography, imaging, or clinical criteria. Patients with prior decompensation or HCC were excluded. Outcomes (HCC, decompensation) were collected from records. The FIB-4 index was compared between DOC and non-DOC groups. Results: Among 2104 cirrhotic patients (mean age 54; 76% male), 53% were treated in DOC via telemedicine and 47% in non-DOC clinics. HCC developed in 4.8% and decompensation in 8.1%. DOC patients had lower FIB-4 scores and SVR, partly from higher loss to follow-up (9% vs. 1%). Of 1581 with follow-up, surveillance was more common in non-DOC, which also had higher HCC and decompensation. A higher baseline FIB-4 index independently predicted HCC and decompensation (cutoffs: 3.24, 3.7; AUROC 0.79, 0.75, respectively). Conclusions: Despite SVR, cirrhotic patients—especially with a high FIB-4 index—remain at risk for HCC and decompensation. Outcomes differ by care setting, highlighting the need for continued AASLD-recommended surveillance post-SVR.
Mikati et al. (Mon,) studied this question.