1 Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada.
2 Research Institute of the McGill University Health Centre, Montreal, Canada.
3 Department of Economics, McGill University, Montreal, Canada.
4 University Health Network, University of Toronto, Toronto, Canada.
5 CIHR Canadian HIV Trials Network, Vancouver, Canada.
6 British Columbia Centre for Disease Control, University of British Columbia, Vancouver, Canada.
7 Ottawa Hospital Research Institute, Ottawa, Canada.
8 Vancouver Infectious Diseases Centre, Vancouver, Canada.
9 BC Centre of Excellence, St. Paul's Hospital, Vancouver, Canada.
10 Departement de Microbiologie et Infectiologie, Centre Hospitalier de l'Université de Montréal, Montreal, Canada.
11 Southern Alberta HIV Clinic, Calgary, Canada.
12 Regina Qu'Appelle Health Region, Regina, Canada.
13 Division of Infectious Diseases, Laval University, Québec City, Canada.
High costs of direct acting antivirals (DAAs) led healthcare insurers to limit access worldwide. Using a natural experiment, we evaluated the impact of removing fibrosis stage restrictions on hepatitis C (HCV) treatment initiation rates among people living with HIV and then examined who was left to be treated.
Using data from the Canadian HIV-HCV Co-Infection Cohort, we applied a difference-in-differences approach. Changes in treatment initiation rates following the removal of fibrosis stage restrictions was assessed using a negative binomial regression with generalized estimating equations. The policy change was then specifically assessed among people who inject drugs (PWID). We then identified characteristics of participants who remained to be treated using a modified Poisson regression.
Between 2010-2018, there were a total of 585 HCV initiations among 1130 eligible participants. After removing fibrosis stage restrictions, DAA initiations increased by 1.8-fold (95% CI 1.3, 2.4) controlling for time-invariant differences and secular trends. Among PWID the impact appeared even stronger; adjusted incidence rate ratios (aIRR) (95% CI), 3.6 (1.8, 7.4). However, this increased treatment uptake was not sustained. One year following universal access, treatment rates declined, 0.8 (0.5, 1.1). Marginalized participants (PWID and Indigenous ethnicity) and those disengaged from care were more likely to remain HCV RNA positive.
After the removal of fibrosis restrictions HCV treatment initiations nearly doubled immediately but this treatment rate was not sustained. To meet the WHO elimination targets, minimization of structural barriers and adoption of tailored interventions are needed to engage and treat all vulnerable populations.