Broader hepatitis C treatment does not lead to more reinfections in people living with HIV

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Wider access to direct-acting antivirals has been associated with a decline or stabilization in the rate of hepatitis C reinfection among people living with HIV and there is no evidence that reinfection undermines efforts to eliminate hepatitis C in this population, researchers reported at the 24th International AIDS Conference (AIDS 2022) last month.

Hepatitis C can be cured with short-acting direct-acting antiviral treatment, and many countries have set ambitious goals to eliminate hepatitis C as a public health problem by testing and treating people for the virus. People living with HIV are a priority group for hepatitis C elimination because the prevalence is high and they are relatively easy to reach through existing HIV care services.

The prevalence of hepatitis C has increased among people living with HIV over the past 20 years due to increased transmission among gay and bisexual men living with HIV through condomless sex and injection drug use. Concerns have been raised that sex without a condom associated with a higher prevalence of untreated hepatitis C could lead to a higher risk of re-infection with hepatitis C, undermining efforts to eliminate hepatitis C in people living with HIV.

Glossary

reinfection

In HIV, synonymous with superinfection. In hepatitis C, used when a person who has been cured of the virus becomes infected with hepatitis C again.

antiviral

A drug that acts against a virus or viruses.

without condom

Having sex without condoms, which used to be called “unprotected” or “risky” sex. However, it is now recognized that PrEP and U=U are effective tools for HIV prevention, without the need for condoms. However, PrEP and U=U do not protect against other STIs.

direct-acting antiviral (DAA)

Modern drugs for the treatment of hepatitis C, which act directly against the hepatitis C virus. They prevent the virus from reproducing by blocking certain stages of its life cycle.

person-years

In a study, “100 person-years of follow-up” could mean that information was collected on 100 people for one year, or 50 people for two years each, or ten people for ten years. In practice, each person’s follow-up time is likely to be different.

The International Collaboration on Hepatitis C Elimination in HIV Cohorts asked whether reinfection rates have changed as a result of wider access to direct-acting antivirals.

To answer these questions, the researchers looked at data from eight cohorts in six countries (Australia, Canada, France, the Netherlands, Spain and Switzerland) between 2010 and 2019.

They calculated the incidence of first cases of reinfection after treatment-induced or spontaneous clearance of hepatitis C in three periods for each cohort: the period before access to direct-acting antivirals, the period during which direct-acting antivirals were available on a limited basis, and the period during which direct-acting antivirals became available without restriction. These timelines varied from country to country depending on reimbursement criteria and national guidelines.

A total of 6195 people with virological evidence of hepatitis C clearance and subsequent follow-up data were eligible for inclusion in the analysis. Eighty-one percent were men, 46% were gay or bisexual men, and 34% were injection drug users. The median age at hepatitis C clearance was 49 years.

During the 13,527 person-years of follow-up, 790 reinfections occurred in the cohorts. Compared to the period before administration of direct-acting antivirals, the incidence was 21% lower during the limited access period and 18% lower during the extended access period. The incidence of reinfection decreased in all countries except Spain, where it increased over time.

The incidence of reinfection was significantly lower among people who inject drugs (-54%), suggesting that efforts to prevent reinfection should focus particularly on gay and bisexual men.

The study’s investigators say their findings suggest that reinfection is unlikely to pose a major threat to the elimination of hepatitis C in people living with HIV.

References

Stoove M et al. Incidence of HCV reinfection among people living with HIV before and during periods of limited and expanded access to HCV direct-acting antiviral therapies in five countries. 24th International AIDS Conference, Montreal, PESAC12 summary, 2022.

See the summary on the conference website (note that numbers have been updated in the conference poster).

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