Hepatitis C Virus Continuum of Care in the Interferon and Direct-Acting Agent Eras Among HIV-Coinfected Patients

To better understand the impact of the rapidly changing hepatitis C virus (HCV) treatment landscape on HCV/HIV-coinfected patients, a modified HCV continuum of care (CoC) ¹ was assessed at the Washington DC Veterans Affairs Medical Center (DC-VAMC) using the previously described HCV Clinical Case Registry (HCV CCR). ² Our CoC stages included: HCV Diagnosis, Engagement in Medical Care, HCV Treatment, and HCV Suppression. The HCV CCR provided data for DC-VAMC numbers of known HCV/HIV-coinfected patients during 2008–2015. Engagement in care was defined as receipt of any outpatient, inpatient, laboratory, radiology, and pharmacy service(s) during 2008–2015. HCV treatment was defined as any prescription for pegylated interferon-based therapy during 2008–2013 and for simeprevir, sofosbuvir, ledipasvir–sofosbuvir, and ombitasvir–paritaprevir–ritonavir with dasabuvir with or without ribavirin during 2014–2015. Patients were treated within our Infectious Diseases Clinic, which has multidisciplinary integrated care coordination with hepatology support. Viral suppression was defined by one or more HIV RNA or HCV RNA levels below the lower limit of detection at 40 copies/ml and 12 IU/ml, respectively, using the Abbott RealTime m2000 platform (Abbott Laboratories, Inc., Abbott Park, IL). We hypothesized that direct-acting agents (DAAs) during 2014–2015 compared with interferon-based regimens during 2008–2013 would increase HCV treatment and thus HCV suppression among HCV/HIV-coinfected patients.

There were 408 coinfected patients with median CD4 = 422 [interquartile range (IQR) = 261.5–630.5] cells/mm³ during 2008–2013 and 300 coinfected patients with median CD4 = 478 (IQR: 307–682.75) cells/mm³ during 2014–2015. While HIV suppression was similar between 2014–2015 and 2008–2013 (78% vs. 75%, p = .42 by two-tailed Fisher's exact test), log₁₀-transformed HIV RNA levels among viremic patients were significantly lower (mean = 3.02 vs. 3.26, p = .0015 by two-tailed unpaired t-tests) during 2014–2015.

As shown in Table 1, our coinfected patients were well engaged (>99%) in their medical care. During 2014–2015, there were significant increases in both HCV treatment and HCV suppression compared with the period 2008–2013.

Our study had several limitations. We used the local HCV CCR for all study data without individual chart review. Our definition of engagement in care may have been falsely elevated by including any service utilization at DC-VAMC. We assessed the earliest results of HCV suppression using DAAs during 2014–2015 and, therefore, did not use sustained virologic response at 12 weeks as the metric of treatment success.

At the DC-VAMC, more HCV/HIV-coinfected patients were treated and achieved HCV suppression with the availability of DAAs. Our findings support the relationship between expanded access to DAA HCV treatment and suppression among HCV/HIV-coinfected patients. The increase in number of individuals who achieved HCV suppression is likely related to the reported greater tolerability and efficacy of DAAs among those with HIV coinfection. ³ Preexisting strong provider–patient relationship within our Infectious Disease Clinic likely enhanced HCV treatment outcomes through better adherence to DAAs. HCV suppression will likely mitigate the increased risk of liver decompensation and mortality among HCV/HIV-coinfected individuals. ⁴ Our early success portends improved health outcomes for veterans, as the VA healthcare network has made a commitment to expand access to DAAs for all with chronic HCV infection.