Increased Case-Finding and Uptake of Direct-Acting Antiviral Treatment Essential for Micro-elimination of Hepatitis C Among People Living With HIV

A National Record Linkage Study

A McLeod; SJ Hutchinson; S Smith; C Leen; S Clifford; A McAuley; LA Wallace; ST Barclay; P Bramley; JF Dillon; A Fraser; RN Gunson; PC Hayes; N Kennedy; E Peters; K Templeton; DJ Goldberg


HIV Medicine. 2021;22(5):334-345. 

In This Article

Abstract and Introduction


Objectives: Micro-elimination of hepatitis C virus (HCV) in people living with HIV (PLHIV) and co-infected with HCV has been proposed as a key contribution to the overall goal of HCV elimination. While other studies have examined micro-elimination in HIV-treated cohorts, few have considered HCV micro-elimination among those not treated for HIV or at a national level.

Methods: Through data linkage of national and sentinel surveillance data, we examined the extent of HCV testing, diagnosis and treatment among a cohort of PLHIV in Scotland identified through the national database of HIV-diagnosed individuals, up to the end of 2017.

Results: Of 5018 PLHIV, an estimated 797 (15%) had never been tested for HCV and 70 (9%) of these had undiagnosed chronic HCV. The odds of never having been tested for HCV were the highest in those not on HIV treatment [adjusted odds ratio (aOR) = 7.21, 95% confidence interval (CI): 5.15–10.10). Overall HCV antibody positivity was 11%, and it was at its highest among people who inject drugs (49%). Most of those with chronic HCV (91%) had attended an HCV treatment clinic but only half had been successfully treated (54% for those on HIV treatment, 12% for those not) by the end of 2017. The odds of never having been treated for HCV were the highest in those not on HIV treatment (aOR = 3.60, 95% CI: 1.59–8.15).

Conclusions: Our data demonstrate that micro-elimination of HCV in PLHIV is achievable but progress will require increased effort to engage and treat those co-infected, including those not being treated for their HIV.


Since the introduction of direct-acting antiviral (DAA) treatment for hepatitis C virus (HCV) infection, with shorter treatment duration and cure rates exceeding 95%, elimination of the virus is now possible.[1,2] The World Health Organization (WHO) has set the goal of reducing HCV mortality by 65% and new chronic HCV infections by 80% by 2030.[3] Micro-elimination of HCV in key populations has been proposed as a pragmatic approach to the overall elimination goal.[4] Where health systems may not be prepared for the scale-up of prevention, testing and screening required for full-scale elimination, micro-elimination provides a mechanism for incremental progress towards elimination.[5] This involves the elimination of HCV in a defined population, e.g. people in specific settings, risk groups or those with co-infections, in the recognition that different populations may need different services. A key population for micro-elimination is people living with HIV (PLHIV) and co-infected with HCV.[6]

Of the estimated 36.9 million PLHIV worldwide, 2.3 million (6.2%) are also HCV antibody-positive. The prevalence of HCV antibody positivity varies significantly by risk group, ranging from 4.0% among pregnant or heterosexually exposed HIV patients to 82.4% among HIV-infected people who inject drugs (PWID).[7] The 2015 European Association for the Study of the Liver (EASL) recommendations on treatment of HCV prioritized DAA therapy for HCV/HIV co-infected individuals, regardless of fibrosis stage, due to drug interactions between antiretroviral therapy and interferon-based HCV treatments.[8] Treatment of co-infected PLHIV with DAA therapy has now been shown to be as highly effective as for HCV mono-infected patients.[9] More recently, the British HIV Association (BHIVA) has called for an accelerated effort to eliminate HCV among PLHIV with targets to cure 80% of all patients diagnosed with HIV and HCV co-infection by 2019, increasing to 100% by 2021.[10]

Scotland is uniquely placed to monitor progress towards micro-elimination of HCV among PLHIV targets through national surveillance of HIV diagnoses linked to HCV testing, diagnoses and treatment data. Here we demonstrate an approach to monitor progress towards elimination of HCV among PLHIV, using a combination of surveillance data and prediction modelling. These data are important to inform what progress has been made and where further effort is required to reach HCV elimination in this population.