Isfordink Cas J, Boyd Anders, Sacks-Davis Rachel, van Santen Daniela K, Smit Colette, Martinello Marianne, Stoove Mark, Berenguer Juan, Wittkop Linda, Klein Marina B, Rauch Andri, Salmon Dominique, Lacombe Karine, Stewart Ashleigh, Schinkel Janke, Doyle Joseph S, Hellard Margaret, van der Valk Marc, Matthews Gail V
Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Institute for Infection and Immunity, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands.
Stichting HIV Monitoring, Amsterdam, Netherlands; Department of Infectious Diseases, Research, and Prevention, Public Health Service of Amsterdam, Amsterdam, Netherlands.
Lancet Public Health. 2023 Apr;8(4):e294-e304. doi: 10.1016/S2468-2667(23)00056-7.
Individuals with HIV and hepatitis C virus (HCV) who remain untreated with direct-acting antivirals can contribute to HCV transmission and HCV-related mortality. We aimed to compare rates of uptake of direct-acting antivirals following unrestricted access to this treatment in high-income countries and examine factors associated with remaining untreated.
This multinational, prospective cohort study used data from the International Collaboration on Hepatitis C Elimination in HIV Cohorts (InCHEHC). We analysed data from nine observational cohorts participating in the InCHEHC, including data from six high-income countries (Australia, Canada, France, the Netherlands, Spain, and Switzerland). We included individuals aged 18 years and older, with HIV and HCV (ie, HCV-RNA positive without evidence of spontaneous clearance) during unrestricted access to interferon-free direct-acting antiviral treatment in each country. We calculated the cumulative proportion of participants who remained untreated with direct-acting antivirals, with follow-up starting after the date of unrestricted access or cohort inclusion, whichever occurred most recently. Factors associated with the commencement rate of direct-acting antiviral treatment were assessed using competing-risks regression with the Fine-Gray method.
The date of unrestricted access to direct-acting antiviral treatment for people with HIV ranged from Nov 1, 2014, in France to Nov 1, 2017, in Switzerland. We included 4552 individuals with HIV-HCV, mainly men who have sex with men (MSM; n=2156 [47%]) and people who inject or have injected drugs (n=1453 [32%]). 1365 (30%) of 4552 participants remained untreated with direct-acting antivirals. For individuals treated with direct-acting antivirals, median time from start of follow-up to treatment was 5 months (IQR 2-12). For individuals who were not treated with direct-acting antivirals, median follow-up was 22 months (8-30). Being linked to care in Australia, France, or the Netherlands, on antiretroviral therapy, having undetectable HIV RNA, and shorter duration since first positive HCV test were independently associated with higher commencement rate of direct-acting antiviral treatment. Compared with MSM, male heterosexuals and females with unknown or other routes of HIV transmission (ie, neither injection drug use nor heterosexual transmission) had lower rates of commencement.
Despite unrestricted access, almost a third of individuals with HIV-HCV remained untreated with direct-acting antivirals during follow-up, with variation in commencement rate of HCV treatment between countries and key populations. Increased efforts are required to reach the remaining individuals with HIV who are HCV-viraemic to achieve HIV-HCV micro-elimination.
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未接受直接抗病毒药物治疗的艾滋病毒和丙型肝炎病毒（HCV）感染者可能会导致HCV传播及与HCV相关的死亡。我们旨在比较高收入国家在可无限制获得此类治疗后直接抗病毒药物的使用比例，并研究与仍未接受治疗相关的因素。
这项跨国前瞻性队列研究使用了来自艾滋病毒队列丙型肝炎消除国际协作组（InCHEHC）的数据。我们分析了参与InCHEHC的9个观察性队列的数据，包括来自6个高收入国家（澳大利亚、加拿大、法国、荷兰、西班牙和瑞士）的数据。我们纳入了18岁及以上、在各国可无限制获得无干扰素直接抗病毒治疗期间感染艾滋病毒和HCV（即HCV-RNA阳性且无自发清除证据）的个体。我们计算了未接受直接抗病毒药物治疗的参与者的累积比例，随访从无限制获得治疗日期或队列纳入日期（以较晚者为准）之后开始。使用Fine-Gray方法的竞争风险回归评估与直接抗病毒治疗开始率相关的因素。
艾滋病毒感染者可无限制获得直接抗病毒治疗的日期从2014年11月1日（法国）到2017年11月1日（瑞士）不等。我们纳入了4552名艾滋病毒-HCV感染者，主要是男男性行为者（MSM；n = 2156 [47%]）以及注射或曾注射毒品者（n = 1453 [32%]）。4552名参与者中有1365名（30%）未接受直接抗病毒药物治疗。对于接受直接抗病毒药物治疗的个体，从随访开始到治疗的中位时间为5个月（IQR 2 - 12）。对于未接受直接抗病毒药物治疗的个体，中位随访时间为22个月（8 - 30）。在澳大利亚、法国或荷兰与医疗保健机构建立联系、接受抗逆转录病毒治疗、HIV RNA检测不到以及自首次HCV检测呈阳性以来的时间较短与直接抗病毒治疗的较高开始率独立相关。与MSM相比，男性异性恋者以及HIV传播途径未知或为其他途径（即既非注射毒品传播也非异性传播）的女性开始治疗的比例较低。
尽管可无限制获得治疗，但在随访期间，近三分之一的艾滋病毒-HCV感染者未接受直接抗病毒药物治疗，各国和关键人群之间HCV治疗的开始率存在差异。需要加大努力，使其余HCV病毒血症的艾滋病毒感染者接受治疗，以实现艾滋病毒-HCV的微观消除。
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