1 The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia.
2 Centre for Social Research in Health, UNSW Sydney, Sydney, New South Wales, Australia.
3 NSW Users and AIDS Association, Sydney, New South Wales, Australia.
4 Australian Injecting and Illicit Drug Users League, Canberra, ACT, Australia.
5 Kirketon Road Centre, Sydney, New South Wales, Australia.
6 South Western Sydney Local Health District Drug Health Services, Sydney, NSW, Australia.
7 Cairns Sexual Health Service, Cairns, Queensland, Australia.
8 Alcohol and Drug Service, Metro North Mental Health, Metro North Hospital and Health Service, Brisbane, Queensland, Australia.
9 Drug and Alcohol Services of South Australia, Adelaide, South Australia, Australia.
10 Orange Aboriginal Medical Service, Orange, NSW, Australia.
11 Bayside Alcohol and Drug Services, Cleveland, QLD, Australia.
12 Gateway Clinic Nepean Hospital, Sydney, NSW, Australia.
13 Western Sydney Local Health District, Sydney, NSW, Australia.
14 Sydney Medically Supervised Injecting Centre, Sydney, NSW, Australia.
15 Royal Prince Alfred Hospital, Sydney, NSW, Australia.
16 Alcohol and Drug Service, St Vincent's Hospital, Sydney, New South Wales, Australia.
17 Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia.
18 Burnet Institute, Melbourne, Victoria, Australia.
Gaps in hepatitis C virus (HCV) testing, diagnosis, liver disease assessment and treatment uptake among people who inject drugs (PWID) persist. We aimed to describe the cascade of HCV care among PWID in Australia, prior to and following unrestricted access to direct-acting antiviral (DAA) treatment. Participants enrolled in an observational cohort study between 2014 and 2018 provided finger-stick whole-blood samples for dried blood spot and Xpert HCV Viral Load, and venepuncture samples. Participants underwent transient elastography and clinical assessment by a nurse or general practitioner. Among 839 participants (mean age 43 years), 66% were male (n=550), 64% (n=537) injected drugs in the previous month, and 67% (n=560) reported currently receiving opioid substitution therapy. Overall, 45% (n=380) had detectable HCV RNA, of whom 23% (n=86) received HCV treatment within 12 months of enrolment. HCV treatment uptake increased from 2% in the pre-DAA era to 38% in the DAA era. Significant liver fibrosis (F2-F4) was more common in participants with HCV infection (38%) than those without (19%). Age 50 years or older (aOR, 2.88; 95% CI, 1.18-7.04) and attending a clinical follow-up with nurse (aOR, 3.19; 95% CI, 1.61-6.32) or physician (aOR, 11.83; 95% CI, 4.89-28.59) were associated with HCV treatment uptake. Recent injection drug use and unstable housing were not associated with HCV treatment uptake. HCV treatment uptake among PWID has increased markedly in the DAA era. Evaluation of innovative and simplified models of care is required to further enhance treatment uptake.