Background: People with HIV are disproportionately co-infected with the Hepatitis C virus (HCV) and experience accelerated liver-related morbidity and mortality. Direct-acting antivirals (DAAs) are well-tolerated and yield high sustained virologic response (SVR) rates. However, DAA uptake is low. This study characterizes the DAA-era HCV treatment cascade among US men and women with and without HIV and identifies treatment barriers.
Methods: We constructed HCV treatment cascades using data from two observational cohorts: Women''s Interagency HIV Study (women, six semiannual visits, 2015-2018, n=2,447) and Multicenter AIDS Cohort Study (men, one visit, 2016-2017, n=2221). Cascades included HCV treatment-eligible individuals, defined as HCV RNA+ or reported DAAs. Surveys captured clinical (e.g., CD4/viral load, poor health), patient (e.g., missed visits), system (e.g., appointment access), and financial (e.g., insurance) barriers.
Results: 323 women and 92 men were HCV RNA+ or reported DAAs. Most women/men had HIV (77%/70%) and were Black (69%/63%); median age (interquartile range) was 56 (51-60) and 58 (55-63), respectively. Despite similar treatment interest, HIV+ women were more likely to attain cascade outcomes than HIV- women (82% vs. 61% recommended, 69% vs. 43% initiated, with 63% of HIV+ vs. 37% of HIV- women achieving SVR); similar discrepancies were noted for men (Figure). Men were less likely to progress through the cascade. Individuals reporting substance use and Black men were less often treated. Women initiating treatment (vs. those not) differed in proportions of visits with reported patient (14%/33%) and system barriers (34%/17%), but not clinical (32%/35%) or financial barriers (26%/24%). Among men not treated, clinical barriers were most often reported (53%), compared to patient (1%), system (2%), and financial (2%) barriers.
Conclusions: In our cohorts, people with HIV were more likely to receive treatment for HCV and attain SVR. HIV-related care may facilitate navigation of HCV treatment barriers. HIV- individuals, Black men, and substance users may need additional support.

Direct-acting antiviral Hepatitis C treatment cascade among US men and women, by HIV status (n=415)
[Direct-acting antiviral Hepatitis C treatment cascade among US men and women, by HIV status (n=415)]

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