Time to direct-acting antiviral initiation and liver-related events in people with HIV and hepatitis C virus
Within the HepCAUSAL collaboration, Chalouni et al investigated how quickly people living with both HIV and hepatitis C virus (HCV) begin direct-acting antiviral (DAA) treatment after achieving HIV viral suppression, and whether treatment timing affects their risk of liver-related events. Using a target trial emulation approach, they compared DAA initiation within six months of HIV suppression with initiation after six months including data from 12 cohorts in Europe and North America, The primary outcome was the occurrence of liver decompensation or hepatocellular carcinoma within 3 years.
Among the 862 individuals included, median time from HIV viral suppression to DAA initiation was 8 months, but 1 in 4 has not started DAA therapy after 3 years. Younger participants, people with lower CD4 cell counts and those with a history of injecting drug use were more likely to not start DAA therapy. During follow-up, 14 liver-related events occurred. The estimated cumulative incidence of liver-related events was 1.1% with early DAA initiation and 1.7% with delayed DAA initiation, with largely overlapping confidence intervals between the two groups.
These findings reveal an important gap in hepatitis C care: A substantial proportion of people with successful ART initiation did not start DAA therapy within 3 years. The low number of liver-related events may reflect the relatively small proportion of participants with advanced liver disease at baseline and the limited observation period of 3 years. Therefore, the results should not be interpreted as evidence that delaying treatment is safe. Prompt DAA initiation remains important to prevent progressive liver disease and reduce HCV transmission. Addressing barriers to treatment will be essential for achieving hepatitis C elimination targets.