Direct Acting Antiviral Initiation among People with HCV and HIV who are on Antiretroviral Therapy in the US and Canada: Factors Driving the HCV Treatment Gap

Background People with HIV (PWH) are at increased risk of hepatitis C virus (HCV) coinfection and experiencing negative clinical outcomes. We evaluated direct-acting antiviral (DAA) initiation among PWH with HCV to identify factors associated with initiation. Methods U.S. and Canadian PWH ≥ 18 years with a detectable HCV RNA in NA-ACCORD were followed from the latest of first detectable HCV viremia, ART initiation, enrollment date, or 1/1/2014; until the first of DAA prescription, clearance of HCV viremia, loss-to-follow-up, death or 12/31/2021. We estimated the cumulative incidence of DAA initiation accounting for the competing risks of death and HCV viral clearance. Cox proportional hazard models estimated crude and adjusted hazard ratios (aHR) and 95% confidence intervals to identify factors associated with DAA initiation. Results Among 6,300 PWH with a detectable HCV RNA, 3,672 (58%) initiated DAA. Accounting for the competing risks of death and HCV clearance, by 8 years after study entry 6% of eligible PWH had not initiated DAA. A lower rate of DAA initiation was identified among non-Hispanic Black and Hispanic PWH compared with non-Hispanic white PWH. DAA initiation was lower among PWH reporting injection drug use as their HIV acquisition risk, at-risk alcohol use, smoking, detectable HIV viremia, and a history of AIDS. A higher FIB-4 score was associated with increased DAA initiation. Conclusions The DAA initiation gap among PWH engaged in care and eligible for treatment has greatly narrowed over time. Targeted approaches to increase equity in DAA initiation are needed to eliminate HCV among PWH.