Parenteral Drug Use as the Main Barrier to Hepatitis C Treatment Uptake in HIV-Infected Patients

A Rivero-Juarez; F Tellez; M Castaño-Carracedo; D Merino; N Espinosa; J Santos; J Macias; M Paniagua-García; A Zapata-Lopez; A Collado; MA Gómez-Vidal; J Perez-Stachowski; L Muñoz-Medina; E Fernandez-Fuertes; A Rivero on behalf of the Grupo de estudio de Hepatitis virales (HEPAVIR) of the Sociedad Andaluza de Enfermedades Infecciosas (SAEI)


HIV Medicine. 2019;20(6):359-367. 

In This Article

Abstract and Introduction


Objectives: Our objective was to identify patient factors associated with being untreated for hepatitis C virus (HCV) infection in HIV-coinfected patients.

Methods: A prospective longitudinal study was carried out. HIV-infected patients with active chronic HCV infection included in the HERACLES cohort (NCT02511496) constituted the study population. The main study outcome was receipt of HCV direct-acting antiviral (DAA) treatment from 1 May 2015 to 1 May 2017. The population was divided into patients who were receiving HCV treatment during follow-up and those who were not.

Results: Of the 15 556 HIV-infected patients in care, 3075 (19.7%) presented with chronic HCV infection and constituted the study population. At the end of the follow-up, 1957 patients initiated HCV therapy (63.6%). Age < 50 years, absence of or minimal liver fibrosis, being treatment-naïve, HCV genotype 3 infection, being in the category of people who inject drugs using opioid substitutive therapy (OST-PWID), and being in the category of recent PWID were identified as significant independent risk factors associated with low odds of DAA implementation. When a multivariate analysis was performed including only the PWID population, both OST-PWID [odds ratio (OR) 0.552; 95% confidence interval (CI) 0.409–0.746) and recent PWID (OR 0.019; 95% CI 0.004–0.087) were identified as independent factors associated with low odds of treatment implementation.

Conclusions: We identified factors, which did not include prioritization of a DAA uptake strategy, that limited access to HCV therapy. The low treatment uptake in several populations seriously jeopardizes the elimination of HCV infection in the coming years.


Hepatitis C virus (HCV) infection has a global prevalence of 1% (71 million individuals).[1] As HCV shares a common route of transmission with HIV, coinfection with both viruses is common.[2,3] The high prevalence of HCV-related comorbidities is one of the main causes of death among HIV-infected patients,[4] as a consequence of accelerated liver fibrosis progression, even in patients on highly active antiretroviral therapy (HAART).[5] Thus, the suppression of HCV viral load in the coinfected population is a priority. Nevertheless, low rates of cure [defined as a sustained virological response (SVR)] achieved with pegylated interferon (Peg-IFN) and ribavirin (RBV) are further limited by the long duration of treatment, complicated dosing and schedules, and other side effects.[6] The use of direct-acting antiviral (DAA) drugs with simple combination therapy and posology, which can be used without Peg-IFN and RBV, has resulted in significantly enhanced SVR rates.[7,8] For this reason, institutions such as the World Health Organization (WHO) and the United States Centers for Disease Control and Prevention (CDC) have drawn up strategic plans to eradicate this infection.[9,10] However, the success of these plans is heavily dependent on treatment uptake in patients.

In April 2015, Spain, which provides universal and free health care access, established criteria for the initiation and prioritization of HCV treatment, known as the Spanish National Strategy for HCV treatment. This strategy recognized different scenarios based on disease severity (such as liver fibrosis stage and extrahepatic manifestations), comorbidities, epidemiology (such as population transmission risk and women wanting to become pregnant), and so on.[11] The application of this strategy has had an obvious beneficial impact on short-term treatment uptake.[12] Nevertheless, clinical, epidemiological and geographical factors associated with lower treatment odds have not been evaluated in a public and universal health care system. Understanding patient factors associated with HCV being left untreated would help support extra efforts in those patients in order to eliminate HCV infection in the coming years. Here, we evaluated HCV treatment uptake after 2 years of universal access and the barriers to lower rates of treatment implementation among HIV-coinfected subjects.