Shift in Disparities in Hepatitis C Treatment From Interferon to DAA Era

A Population-based Cohort Study

N. Z. Janjua; N. Islam; J. Wong; E. M. Yoshida; A. Ramji; H. Samji; Z. A. Butt; M. Chong; D. Cook; M. Alvarez; M. Darvishian; M. Tyndall; M. Krajden


J Viral Hepat. 2017;24(8):624-630. 

In This Article

Abstract and Introduction


We evaluated the shift in the characteristics of people who received interferon-based hepatitis C virus (HCV) treatments and those who received recently introduced direct-acting antivirals (DAAs) in British Columbia (BC), Canada. The BC Hepatitis Testers Cohort includes 1.5 million individuals tested for HCV or HIV, or reported cases of hepatitis B and active tuberculosis in BC from 1990 to 2013 linked to medical visits, hospitalization, cancer, prescription drugs and mortality data. This analysis included all patients who filled at least one prescription for HCV treatment until 31 July 2015. HCV treatments were classified as older interferon-based treatments including pegylated interferon/ribavirin (PegIFN/RBV) with/without boceprevir or telaprevir, DAAs with RBV or PegIFN/RBV, and newer interferon-free DAAs. Of 11 886 people treated for HCV between 2000 and 2015, 1164 (9.8%) received interferon-free DAAs (ledipasvir/sofosbuvir: n=1075; 92.4%), while 452 (3.8%) received a combination of DAAs and RBV or PegIFN/RBV. Compared to those receiving interferon-based treatment, people with HIV co-infection (adjusted odds ratio [aOR]: 2.96, 95% CI: 2.31–3.81), cirrhosis (aOR: 1.77, 95% CI: 1.45–2.15), decompensated cirrhosis (aOR: 1.72, 95% CI: 1.31–2.28), diabetes (aOR: 1.30, 95% CI: 1.10–1.54), a history of injection drug use (aOR: 1.34, 95% CI: 1.09–1.65) and opioid substitution therapy (aOR: 1.30, 95% CI: 1.01–1.67) were more likely to receive interferon-free DAAs. Socio-economically marginalized individuals were significantly less likely (most deprived vs most privileged: aOR: 0.71, 95% CI: 0.58–0.87) to receive DAAs. In conclusion, there is a shift in prescription of new HCV treatments to previously excluded groups (eg HIV-co-infected), although gaps remain for the socio-economically marginalized populations.


Hepatitis C virus (HCV) infection is a major global health concern with about 184 million people infected worldwide.[1] In North America, large numbers of people acquired the virus decades ago and are now increasingly being diagnosed with serious liver-related illnesses including decompensated cirrhosis and hepatocellular carcinoma (HCC).[2–4] Interferon-based treatments have been available since early 2000, but due to low uptake and effectiveness (~50% cured), these treatments have resulted in limited population-level impact.[5,6] As a result, HCV-associated liver-related morbidity and mortality have been increasing across the world.[7–10]

Although overall treatment rates were low in the interferon-based era (<15%), rates were especially low for certain population groups including people who inject drugs (PWIDs) and people co-infected with HIV.[6,11] Some of the barriers to treatment included higher toxicity and perceived lack of compliance among PWIDs and HIV-co-infected individuals.[12]

Short course, highly effective and well-tolerated direct-acting antiviral (DAA) agents are expected to reduce barriers related to toxicity and compliance, and increase treatment rates. However, the higher cost of DAAs and lack of sufficient treatment capacity are hampering treatment uptake.[13] Potential for re-infection among PWIDs following treatment with expensive DAAs is an additional concern.[14–16] Monitoring uptake of DAAs across various high-burden groups will allow us to understand the disparities in treatment uptake and the impact on health outcomes. As DAA uptake is being scaled up, we assessed the characteristics of people who received interferon-based treatments, compared them with those who received recently introduced DAAs and identified characteristics associated with receiving DAAs compared to interferon-based treatments in British Columbia (BC), Canada.