The Effects of Hepatitis C Treatment Eligibility Criteria on All-cause Mortality Among People With Human Immunodeficiency Virus

Abstract

Background: The cost of direct-acting antivirals (DAAs) for hepatitis C virus (HCV) prompted many payers to restrict treatment to patients who met non-evidence-based criteria. These restrictions have implications for survival of people with HCV, especially for people with human immunodeficiency virus (HIV)/HCV coinfection who are at high risk for liver disease progression. The goal of this work was to estimate the effects of DAA access policies on 10-year all-cause mortality among people with HIV.

Methods: The study population included 3056 adults with HIV in the Women's Interagency HIV Study and Multicenter AIDS Cohort Study from 1 October 1994 through 30 September 2015. We used the parametric g-formula to estimate 10-year all-cause mortality under DAA access policies that included treating (i) all people with HCV; (ii) only people with suppressed HIV; (iii) only people with severe fibrosis; and (iv) only people with HIV suppression and severe fibrosis.

Results: The 10-year risk difference of treating all coinfected persons with DAAs compared with no treatment was -3.7% (95% confidence interval [CI], -9.1% to .6%). Treating only those with suppressed HIV and severe fibrosis yielded a risk difference of -1.1% (95% CI, -2.8% to .6%), with 51% (95% CI, 38%-59%) of coinfected persons receiving DAAs. Treating a random selection of 51% of coinfected persons at baseline decreased the risk by 1.9% (95% CI, -4.7% to .3%).

Conclusions: Restrictive DAA access policies may decrease survival compared to treating similar proportions of people with HIV/HCV coinfection with DAAs at random. These findings suggest that lives could be saved by thoughtfully revising access policies.

Keywords: antiretroviral therapy; direct-acting antivirals; hepatitis C virus; human immunodeficiency virus; population intervention effects.

Figure 1.

Ten-year risk of all-cause mortality under direct-acting antiviral treatment criteria among people with human immunodeficiency virus (HIV) and hepatitis C virus in the Women’s Interagency HIV Study and Multicenter AIDS Cohort Study, 1994–2015. A, Treat none at baseline (solid line) vs treat all at baseline (dotted line). B, Treat once HIV virally suppressed (solid line) vs treat same percentage of people at random at baseline (dotted line). C, Treat once progressed to severe fibrosis or cirrhosis (solid line) vs treat same percentage of people at random at baseline (dotted line). D, Treat once HIV virally suppressed and progressed to severe fibrosis or cirrhosis (solid line) vs treat same percentage of people at random at baseline (dotted line). Note that in all 4 panels, a lower curve indicates lower mortality, and thus in panels (B–D), treating people at random at baseline is generally superior to treating based on the stated criteria.