Evaluation of the Hepatitis C Cascade of Care Among People Living With HIV in New South Wales, Australia

A Data Linkage Study

Samira Hosseini-Hooshyar; Maryam Alavi; Marianne Martinello; Heather Valerio; Shane Tillakeratne; Gail V. Matthews; Gregory J. Dore


J Viral Hepat. 2022;29(4):271-279. 

In This Article


This study provides state-level data on HCV care cascade among PLHIV in NSW, Australia, demonstrating the favourable impact of unrestricted access to DAA therapy on HCV testing and linkage to care. People living with HIV/HCV coinfection were highly engaged in the HCV testing continuum with the vast majority of the population receiving HCV RNA testing since 2010. HCV treatment uptake varied from suboptimal levels in pre-DAA era to high levels post-availability of DAAs, with a nearly 10-fold increase in proportion of treatment uptake. These findings have important implications for HCV elimination efforts in Australia and elsewhere and highlight the success of the Australian public health approach to HCV: Broad testing and unrestricted DAA therapy access for all adults with chronic HCV infection.[23,24]

The present study is one of the few population-level studies that describes and evaluates both testing and treatment components of the HCV cascade of care among PLHIV. During eight years from 2010 to 2018, among those who ever had an HCV notification, 91% had HCV RNA testing and among those with an indicator of chronic HCV infection, 74% received HCV treatment, a transformation from the 7% treated in the pre-DAA era. These findings are comparable with what was observed during six years in the British Columbia Hepatitis Testers Cohort (BC-HTC) study among PLHIV: 90% HCV RNA testing among all HCV diagnosed individuals, and a 62% HCV treatment uptake among HCV RNA positive people.[14]

In the DAA era (2016–2018), both overall HCV treatment uptake and time from HCV diagnosis to treatment uptake substantially improved. A recent systematic review[24] has reported variable levels of DAA treatment uptake among people living with HIV/HCV coinfection from 18% in the United States[25,26] and 21% in Switzerland,[27] to 44% in the Netherlands,[28] and 62% in British Columbia, Canada.[14] Although DAA treatment uptake among people living with HIV/HCV coinfection was considered to be relatively high in three of these four studies, they are lower than what we have observed in Australia. Along with the great impact of rapid DAA scale-up, the higher levels of treatment uptake in NSW compared with other settings can be explained by the fact that a high proportion of PLHIV (85%) are linked to and retained in care in Australia.[17]

This study further confirms that DAA treatment uptake in a population-level linkage study is similar to those found in HIV/HCV coinfection clinic-based cohort studies in Australia. CEASE (The Control and Elimination of HCV from HIV-infected individuals within Australia)[11] was an Australian study among HIV/HCV coinfected populations. Following universal access to DAA therapies, treatment uptake increased from 7% and 11% in 2014 and 2015, respectively, to 80% in 2016 in CEASE study.[11] This resulted in a substantial decline in HCV viremic prevalence from 82% in 2014 to 8% in 2018 among this study population.[11]

We also identified the characteristics of people living with HIV/HCV coinfection in NSW who did not progress to testing or treatment, that could be used to optimize interventions to further improve the gaps in the continuum. Although HCV RNA testing has been high among PLHIV in the care cascade in NSW and has further improved in DAA era, there remain small but important gaps. Younger people were more likely to have HCV RNA testing meaning that older cohorts of PLHIV are left behind in the testing continuum, and therefore, less likely to be aware of their HCV infection status. We further observed that women and those who were HCV notified in rural regions are less likely to have HCV RNA testing. No factor was observed to be associated with not receiving DAA therapy among PLHIV in NSW; however, given the small number of untreated people in DAA era (n = 68), the sample size may have been under powered to draw any meaningful conclusion. The data was also limited by the relatively small number of demographic and behavioural characteristics collected, especially related to injecting drug use. Larger studies with more detailed information may be better able to tease out potential reasons for not receiving DAA therapy among PLHIV. Strategies aiming to reduce vulnerabilities among women living with HIV such as scaling up HCV testing in settings where women seek care for sexual and reproductive health can help health providers close the gap from HCV diagnosis to HCV RNA testing among women. Further, barriers to HCV screening and testing in rural regions need to be addressed. Strategies like point-of-care technologies along with continuous education for care providers can improve progression to HCV RNA testing.

This study has several limitations. First, our findings may not be nationally representative as the study has been carried out in one jurisdiction in Australia. However, NSW has been reported to have the highest proportion of people with chronic HCV (36%) in Australia by the end of 2017.[17] Further, the proportion of people with chronic HCV infection initiating DAA therapy in 2017 in NSW (12%) has been reported to be similar to overall DAA uptake at the national level (12%) in Australia.[17] Second, HCV treatment uptake was estimated among people with an indicator of chronic HCV infection (i.e. those with records of genotype testing or those who were dispensed HCV treatment). This may have potentially underestimated the denominator of chronically infected population as some people who were chronically infected might have never received genotype testing or treatment. However, this limitation is balanced against the high proportion of HCV RNA testing among our study population. Third, information on the proportion of individuals that completed HCV treatment as well as adherence and treatment outcomes were unavailable. This information provides insight into whether patients are transitioning through the stages of care or not, which would inform need for interventions to enhance treatment completion. Fourth, information on additional covariates such as HIV/HCV transmission patterns, fibrosis stage, etc. was not available. Including these factors could have allowed a better characterization of people living with HIV/HCV coinfection.

In conclusion, people living with HIV/HCV coinfection have progressed well through the testing continuum in NSW with nearly 10-fold increase in HCV treatment uptake following the unrestricted availability of DAAs. Further efforts to reach those who have been lost to care after HCV diagnosis and those who are hardly reached are needed to close the remained gap in the treatment uptake among this population. In order to achieve the WHO HCV elimination targets, NSW needs to work on removing barriers to HCV testing, expanding treatment to a variety of settings and ensure that continuous education alongside harm reduction services is in place to prevent new HCV infections or reinfection after treatment among PLHIV.