Direct-Acting Antiviral Initiation Among People With Hepatitis C Virus (HCV) and HIV on Antiretroviral Therapy in the United States and Canada: Factors Driving the HCV Treatment Gap.

Background: People with human immunodeficiency virus (HIV; PWH) are at increased risk of hepatitis C virus (HCV) coinfection and experiencing negative clinical outcomes. We evaluated direct-acting antiviral (DAA) initiation among PWH with HCV to identify factors associated with initiation. Methods: US and Canadian PWH ≥18 years with a detectable HCV RNA in the North American AIDS Cohort Collaboration on Research and Design were followed up from the latest of first detectable HCV viremia, antiretroviral therapy initiation, enrollment date, or 1 January 2014 until the first of DAA prescription, clearance of HCV viremia, loss to follow-up, death, or 31 December 2021. We estimated the cumulative incidence of DAA initiation accounting for the competing risks of death and HCV viral clearance. Cox proportional hazard models estimated crude and adjusted hazard ratios and 95% confidence intervals to identify factors associated with DAA initiation. Results: Among 6300 PWH with a detectable HCV RNA, 3672 (58%) initiated DAA. Accounting for the competing risks of death and HCV clearance, by 8 years after study entry 6% of eligible PWH had not initiated DAA. A lower rate of DAA initiation was identified among non-Hispanic black and Hispanic PWH compared with non-Hispanic white PWH. DAA initiation was lower among PWH reporting injection drug use as their HIV acquisition risk, at-risk alcohol use, smoking, detectable HIV viremia, or a history of AIDS. A higher Fibrosis-4 score was associated with increased DAA initiation. Conclusions: The DAA initiation gap among PWH engaged in care and eligible for treatment has greatly narrowed over time. Targeted approaches to increase equity in DAA initiation are needed to eliminate HCV among PWH.