Increasing HCV Diagnosis and Treatment Uptake Among Community‐Recruited People Who Inject Drugs in Athens, Greece, During the Transition to Unrestricted Access to Direct‐Acting Antivirals

Eliminating hepatitis C requires focusing efforts on people who inject drugs (PWID). The ARISTOTLE HCV-HIV program aimed to increase HCV and HIV diagnosis and linkage to care among PWID, particularly those currently injecting and not linked to opioid agonist treatment (OAT). This study evaluated HCV diagnosis and linkage to direct-acting antiviral (DAA) treatment before and after removal of fibrosis-based treatment restrictions. ARISTOTLE HCV-HIV (April 2018-February 2020) was conducted in a community setting at a fixed site in central Athens. Two respondent-driven sampling rounds recruited PWID. Single-visit procedures included interviews, blood collection, and liver fibrosis assessment. Reflex HCV-RNA/HCV genotype testing was performed. Participants were linked to collaborating clinicians for DAA treatment. We estimated program reach by exploratory two-source capture-recapture and constructed HCV care cascades. DAA initiation was assessed from the first visit documenting HCV monoinfection through 180 days after the last such visit. Among 1634 unique participants, 75.0% reported past-30-day injecting (exploratory model-based reach among this population in Athens: 73.2%), 22.9% were currently receiving OAT, and 26.8% were currently homeless. Anti-HCV prevalence was 76.9% (95% CI: 74.8-78.9), 83.3% (95% CI: 80.8-85.6) of anti-HCV-positive individuals had viremia. Of 587 monoinfected individuals eligible for treatment, 43.4% initiated DAA. Lifting fibrosis restrictions boosted DAA utilization by 19.2 treatment courses/100 anti-HCV-positive PWID. DAA access increased substantially after lifting liver fibrosis restrictions. Peer-driven, community-based interventions can achieve substantial program reach among underserved PWID and contribute to HCV elimination.