Published:10 December 2021, INFOHEP
Access to direct-acting antivirals to cure hepatitis C has slashed incidence rates for groups most affected in Australia. Among gay and bisexual men living with HIV, incidence fell by 78% in 2019 when compared to 2015, the year before direct-acting antiviral treatment became widely available. A similar trend in hepatitis C infections was seen for HIV-negative men taking PrEP, with an 80% decline in 2019 compared to 2016.
BackgroundHepatitis C disproportionately affects gay, bisexual, and other men who have sex with men living with HIV. A smaller number of HIV-negative gay and bisexual men – particularly those taking HIV pre-exposure prophylaxis (PrEP) – are also affected. Common risk factors include condomless anal sex, sexualised drug use, sharing injecting and other drug equipment, fisting and sharing sex toys.
The introduction of direct-acting antivirals has simplified and improved hepatitis C treatment significantly – over 90% of people who take them are fully cured of the infection. This contrasts with prior treatments, which lasted for a year, produced many side effects, and only resulted in a cure rate of 50% to 60%. Additionally, the efficacy of direct-acting antivirals is not affected by HIV status.
Based on the success of direct-acting antivirals to reduce rates of hepatitis C, the World Health Organization set a goal of 80% incidence reduction by 2030, relative to a 2015 baseline. With targeted resources, this can be achieved faster in highly affected subgroups, such as gay and bisexual men living with HIV.
There are studies that have looked at national-level changes in hepatitis C incidence among gay and bisexual men with HIV after introducing direct-acting antivirals. Some examples include France, the Netherlands, Switzerland and England. However, there have been no published studies looking at hepatitis C incidence among HIV-negative PrEP users.
In Australia, both medications became broadly available from 2016 after the government subsidised direct-acting antivirals, with no restrictions on treatment based on liver disease stage, substance use, or reinfection status.
The treatment could also be prescribed by nonspecialist primary care providers, and was made available in general practices and sexual health clinics.
PrEP, which was initially available to 7,500 people (predominantly gay and bisexual men) through implementation trials in 2016, also became widely accessible in 2018 through government subsidisation and general practitioner prescriptions among gay and bisexual men with HIVA total of 6,744 men with HIV were included in the incidence analysis, comprising 33,150 person-years of follow-up with 290 new hepatitis C infections for the period. This produced an overall incidence of 1.03 per 100 person-years, with the highest incidence in 2010 (2.12 per 100 person-years) and the lowest in 2019 (0.22 per 100 person-years).
As direct-acting antivirals only became widely available in 2016, 2015 was used as the baseline comparison year. Incidence declined in all subsequent years, falling by 60% in 2017, 45% in 2018 and 78% in 2019, relative to 2015. There was no significant change in the overall incidence trend between 2009 and 2015 and between 2016 and 2019. But a distinct difference was present between 2015 and 2016, indicating the importance of direct-acting antivirals in the incidence decline between the two periods.
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