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Reaching HCV micro-elimination in HIV/HCV co-infected individuals in the Netherlands: exploring remaining barriers to HCV treatment

Title
Reaching HCV micro-elimination in HIV/HCV co-infected individuals in the Netherlands: exploring remaining barriers to HCV treatment
Presenter
Cas Isfordink
Authors
C. Isfordink * (1,2), C. Smit (3), A. Boyd (3,4), M. de Regt (5), B. Rijnders (6), R. van Crevel (7), R. Ackens (8), P. Reiss (1,3), J. Arends (2), M. van der Valk (1), on behalf of the ATHENA observational cohort
Institutions
(1) Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Centers, Department of Internal Medicine, Division of Infectious Diseases, Amsterdam, Netherlands, (2) UMC Utrecht, Department of Internal Medicine and Infectious Diseases, Utrecht, Netherlands, (3) Stichting HIV Monitoring, Amsterdam, Netherlands, (4) Public Health Service of Amsterdam, Department of Infectious Diseases, Research and Prevention, Amsterdam, Netherlands, (5) Onze Lieve Vrouwe Gasthuis, Department of Internal Medicine and Infectious Diseases, Amsterdam, Netherlands, (6) Erasmus MC, University Medical Center, Department of Internal Medicine, Section Infectious Diseases, Rotterdam, Netherlands, (7) Radboud University Medical Center, Department of Internal Medicine and Radboud Center for Infectious Diseases, Nijmegen, Netherlands, (8) Maastricht University Medical Center, Department of Internal Medicine, Division of Infectious Diseases, Maastricht, Netherlands

BACKGROUND: With universal access to direct-acting antivirals (DAA) since November 2015, the Netherlands is progressing towards micro-elimination of hepatitis C virus (HCV) in people living with HIV (PLWH). However, some HCV-viremic PLWH have yet to receive DAA-treatment. We described the barriers for DAA-uptake in these individuals.
METHODS: We included HCV-viremic individuals from a nationwide cohort of PLWH in the Netherlands with '¥1 visit during universal DAA-access (database lock=31 December 2019). Based on their last visit, these individuals were grouped as DAA-treated or -untreated. We identified variables associated with being DAA-untreated using multivariable logistic regression. In December 2020, physicians of DAA-untreated PLWH were asked to complete an in-depth questionnaire on barriers to DAA-uptake and risk of onward HCV-transmission.
RESULTS: Of the 25,196 PLWH ever screened for HCV, roughly 5% were HCV-viremic between 2003-2014, decreasing to 1.6% in 2016 and 0.7% in 2019. 983 PLWH were HCV-viremic during the universal DAA-access era; 76/983 remained DAA-untreated at the time of database lock. Being DAA-untreated was associated with belonging to a key population other than men who have sex with men (OR=10.6, 95%CI=5.5-22.0), older age (OR/10 years=1.6, 95%CI=1.3-1.9), infrequent follow-up (OR=17.1, 95%CI=8.3-36.6) and excessive alcohol use (OR=1.7, 95%CI=1.4-5.3). Of the 76 persons known to be DAA-untreated at database lock, 41 were no longer in care (deceased, n=23; lost to follow up, n=12; moved abroad, n=6), while six initiated DAA since database lock. The remaining 29 were still DAA-untreated and in care in December 2020 (29/983, 3%), in whom the most common barriers to DAA-uptake were patient-related concerns (Table 1).

Physician-reported barriers to DAA-treatment and risk of onward transmission in HCV-viremic persons living with HIV in the Netherlands (n=29)
Barrier to DAA-treatment uptake*
Patient refusal9 (31%)
No liver fibrosis7 (24%)
Infrequent visit attendance6 (21%)
Severe comorbidity5 (17%)
Insufficient adherence expected3 (10%)
Physician-reported risk of onward HCV transmission#1 (3%)
Additional data collection form not returned9 (31%)
Data obtained via questionnaire by the treating physician (December 2020). *Five most frequent barriers mentioned. Multiple barriers per individual are possible. #Risk of onward sexual transmission and/or onward transmission through drug use.
Abbreviations: DAA: direct-acting antivirals. HCV: hepatitis C virus

CONCLUSIONS: The current prevalence of HCV-viremic PLWH in care is low in the Netherlands, coinciding with widespread DAA-uptake since 2016. Patient refusal is the main barrier to DAA-uptake in the remaining DAA-untreated. Few of these individuals appear to engage in activities associated with risk of onward HCV-transmission.