Increasing numbers of people co-infected with HIV and hepatitis C (HCV) are accessing treatment for HCV as antivirals become more effective – but challenges beyond increasing access, remain.
A new study shows that despite new direct-acting antiviral (DAA) medication for hepatitis C (HCV) – which leads to high cure rates and increased linkages to care – HCV incidence remains stubbornly high. Results from a recent study in the Journal of the International AIDS Society (JIAS) reveal high rates of re-infection, thought to be driven by social and cultural factors, such as stigma and discrimination.
HCV treatment was transformed in 2011 with the introduction of direct-acting antiviral medication, which can cure HCV within two to three months in 90% of cases. The introduction of these new medicines was particularly good news for those living with HIV, as over two million are thought to also be co-infected with HCV. Furthermore, chronic viral hepatitis accounts for around 10% of deaths among people living with HIV.
But there’s a lack of data on the effectiveness of DAA treatment in eliminating HCV among people living with HIV in the real world.
To address this, the study assessed cascade of care data from seven HCV elimination initiatives and studies among people with HIV/HCV co-infection. These were carried out in Australia, Canada, France, Georgia, the Netherlands and Switzerland.
Of the seven studies, four focused on HCV elimination in gay and bisexual men living with HIV, while three included a combination of people who inject drugs, gay and bisexual men, and other people living with HIV.
The authors found encouraging evidence that DAAs led to better linkage to care, with around 50% of patients diagnosed with HIV/HCV being linked to treatment. They also found higher retention rates; some 96% of participants finished their DAA treatment, while 93% of people with co-infection being cured of HCV.
Treatment uptake varied substantially between studies, from 21% in some cases to 91% in others. Nevertheless, the results showed that the introduction of DAAs has led to a substantially higher treatment uptake overall. In the Swiss studies, for example, treatment uptake increased four-fold after the introduction of second-generation DAAs.
However, this wide variation in uptake indicates that barriers to care go beyond a simple question of availability, and may arise from a number of social and structural factors. These include HIV and HCV-related stigma; discrimination on the basis of sexual and gender identities or drug use; and the criminalisation of certain groups such as people who inject drugs. This is despite each of the countries having effective harm reduction programmes in place, as well as laws that prohibit discrimination on the basis of sexual orientation.
Although DAAs have led to an impressive increase in uptake over a relatively short time period, half of those living with HIV/HCV are still not accessing DAAs.
To change this, the researchers suggest training healthcare workers in the identification and treatment of re-infection cases. At the moment, high rates of re-infection mean that even very high treatment success rates will not result in reductions in HCV incidence. Behavioural interventions to reduce risk behaviours are needed to reduce the incidence of HCV.
The authors note that further research is needed to quantify the number of undiagnosed infections and to evaluate the effectiveness of elimination programmes in other countries, particularly those with more hostile environments towards people who inject drugs and people who are LGBT.