Impact of Hepatitis C Treatment Uptake on Cirrhosis and Mortality in Persons Who Inject Drugs : A Longitudinal, Community-Based Cohort Study

Ann Intern Med. 2022 Aug;175(8):1083-1091. doi: 10.7326/M21-3846. Epub 2022 Jul 12.


Background: Hepatitis C virus (HCV) infection can be cured, and the United States has joined the World Health Organization in calling for HCV elimination by 2030. However, historically low uptake of HCV treatment among people who inject drugs (PWID) threatens HCV elimination and exacerbates social and racial health disparities.

Objective: To assess whether all-oral HCV treatments were accessed by PWID and reduced liver disease burden and mortality.

Design: Community-based, longitudinal cohort study of persons with a history of injection drug use.

Setting: Baltimore, Maryland.

Participants: 1323 participants enrolled in the ALIVE (AIDS Linked to the IntraVenous Experience) study from 2006 to 2019 and chronically infected with HCV.

Measurements: Liver stiffness measures (LSMs) by transient elastography, HCV RNA, and mortality from the National Death Index.

Results: Among 1323 persons with evidence of chronic HCV infection at baseline, the median age was 49 years. Most were Black (82%), male (71%), and HIV-negative (66%). The proportion in whom HCV RNA was detected decreased from 100% (by definition) in 2006 to 48% in 2019. Across 10 350 valid LSMs, cirrhosis was detected in 15% of participants in 2006, 19% in 2015, and 8% in 2019. Undetectable HCV RNA was significantly associated with reduced odds of cirrhosis (adjusted odds ratio, 0.28 [95% CI, 0.17 to 0.45]) and reduced all-cause mortality risk (adjusted hazard ratio, 0.54 [CI, 0.38 to 0.77]).

Limitation: Noninvasive markers of liver fibrosis have not been validated in persons with sustained virologic response.

Conclusion: Many community-based PWID in Baltimore are receiving HCV treatment, which is associated with sharp decreases in liver disease and mortality. Additional efforts will be needed to reduce residual barriers to treatment and to eliminate HCV as a public health threat for PWID.

Primary funding source: National Institutes of Health.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Antiviral Agents / therapeutic use
  • Cohort Studies
  • Drug Users*
  • Hepacivirus / genetics
  • Hepatitis C* / complications
  • Hepatitis C* / drug therapy
  • Hepatitis C, Chronic* / complications
  • Hepatitis C, Chronic* / drug therapy
  • Humans
  • Liver Cirrhosis / complications
  • Longitudinal Studies
  • Male
  • Middle Aged
  • RNA / therapeutic use
  • Substance Abuse, Intravenous* / complications
  • Substance Abuse, Intravenous* / drug therapy


  • Antiviral Agents
  • RNA