Direct-Acting Antiviral Initiation Among People With Hepatitis C Virus (HCV) and HIV on Antiretroviral Therapy in the United States and Canada: Factors Driving the HCV Treatment Gap

By
Raynell Lang
Elizabeth Humes
Asya Lyass
Leila H Borowsky
Brenna Hogan
Arthur Kim
Michael LaValley
Michael J Silverberg
H Nina Kim
Sonia Napravnik
Richard D Moore
Michael A Horberg
Frank J Palella
Greg D Kirk
Edward Cachay
George A Yendewa
Seble Kassaye
Kathleen McGinnis
Sally B Coburn
Timothy R Sterling
Marina B Klein
Mari M Kitahata
Catherine Lesko
Virginia A Triant
Keri N Althoff
on behalf the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) of the International Epidemiologic Databases to Evaluate AIDS (IeDEA)
August 4, 2025
0 min

Category	Detail
Condition	Hepatitis C virus (HCV) coinfection in people with human immunodeficiency virus (HIV)
Key Mechanisms	Direct-acting antivirals (DAAs) achieve >95% cure rates by targeting HCV; treatment initiation influenced by demographic, behavioral, and clinical factors
Target Population	People with HIV (PWH) aged ≥18 years with detectable HCV RNA in the US and Canada
Care Setting	HIV clinical care cohorts with linkage to antiretroviral therapy and HCV monitoring

Among 6300 PWH with detectable HCV RNA, 58% initiated DAA treatment by study end (2014–2021).
Lower DAA initiation rates observed in non-Hispanic Black and Hispanic PWH compared to non-Hispanic White PWH.
Factors associated with lower DAA initiation include injection drug use, at-risk alcohol use, smoking, detectable HIV viremia, and history of AIDS.

Identify HCV coinfection via detectable HCV RNA testing in PWH.
Exclude individuals with spontaneous or prior HCV clearance (undetectable HCV RNA after detectable).

Initiate DAA therapy promptly in eligible PWH to achieve cure and reduce liver-related morbidity.
Use simplified HCV treatment algorithms with minimal monitoring to reduce barriers in PWH.

Monitor HIV viral load and liver fibrosis (e.g., Fibrosis-4 score) to guide timing of DAA initiation.
Account for competing risks such as death and spontaneous HCV clearance in treatment planning.

Recognize disparities in DAA initiation linked to race/ethnicity and substance use behaviors.
Address socioeconomic and behavioral barriers that may impede treatment uptake.

PWH aged ≥18 years with detectable HCV RNA receiving HIV care in North America

DAA initiation increased over time but disparities persist; higher fibrosis scores correlated with increased treatment initiation.

Engage PWH in regular HIV care to facilitate HCV testing and linkage to DAA treatment.
Implement targeted interventions to reduce racial/ethnic and behavioral disparities in DAA initiation.
Incorporate simplified treatment protocols to minimize monitoring burden and improve access.
Address modifiable risk factors such as substance use and uncontrolled HIV viremia to optimize treatment uptake.

Clinical Scorecard: Factors Influencing the Initiation of Direct-Acting Antivirals for Hepatitis C in HIV-Positive Individuals Under Antiretroviral Therapy in the US and Canada: Addressing the Treatment Disparity