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


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.