Background: Direct-acting antivirals (DAAs) for hepatitis C virus (HCV) were approved in Canada in 2013. By 2018, treatment restrictions had been lifted in all provinces, making DAAs universally accessible. Here, we aim to assess progress toward HCV elimination in the DAA era (2014-2022) within the Canadian Co-infection Cohort.
Methods: The CCC is a multisite open cohort of people living with HIV-HCV coinfection with cohort visits scheduled biannually. We calculated annual cure rates overall by province and key population: gay bisexual and other men who have sex with men, people who inject drugs, and Indigenous peoples.
Results: Among the 952 participants eligible for DAAs, 65% (n = 623) were cured and 3% (n = 26) achieved late clearance without treatment by the end of the study period. Of the 35% (n = 303) who were not cured, 46% (n = 138) were lost to follow-up, 31% (n = 95) died, and 23% (n = 70) had insufficient data to determine their cure status. Annual cure rates increased from 2014 to 2019 and then decreased across the cohort and in all key populations. From 2015 to 2018, gay bisexual and other men who have sex with men had the highest cure rates, but by 2019 people who inject drugs and Indigenous peoples caught up. Annual cure rates dropped in all provinces with the onset of the COVID-19 pandemic (after 2019).
Conclusions: Universal accessibility of DAAs was an important step toward HCV elimination among people living with HIV-HCV coinfection, but this is not sufficient alone. Efforts are needed to re-engage those who remain uncured and reduce mortality in people living with HIV-HCV coinfection.
Keywords: HIV-HCV coinfection; Indigenous; direct-acting antivirals; elimination; gbMSM; hepatitis C; people who inject drugs; priority populations.
Lay Summary: The World Health Organization set targets to eliminate hepatitis C virus infection (HCV) globally by 2030. In late 2013 oral direct-acting antiviral (DAA) medications for HCV were approved in Canada. DAAs can treat HCV within 8–12 weeks with minimal side effects and result in over 95% cure rates. DAA reimbursement eligibility in Canada was initially restricted to people with advanced fibrosis because of cost ($45,000 to over $100,000 per patient). These restrictions were lifted in different provinces at different times, but by 2018 all restrictions were removed, making DAAs universally accessible in Canada. In this study we assessed the progress toward HCV elimination, defined as being successfully treated, by calculating annual cure rates (2014–2022) overall by province and by key populations: gay bisexual and other men who have sex with men, people who inject drugs, and Indigenous peoples. We used data from the Canadian Co-Infection Cohort (CCC), which is a cohort of people living with HIV-HCV coinfection recruited from clinic sites across six provinces. We found that we have made progress toward eliminating HCV (65% of participants were successfully treated by the end of 2022); however, we are still short of the World Health Organization target, which requires that 80% of those diagnosed with HCV are treated by 2030. Annual cure rates increased from 2014 to 2019 and then dropped. We found most of those who were not cured were disengaged from care, and 1 in 10 had died, with many deaths due to drug poisoning before treatment for HCV was initiated. Removing a major structural barrier to treatment by making DAAs universally accessible was important, but this was not sufficient alone. Therefore, new tailored interventions are needed for people living with HIV-HCV coinfection to re-engage people into care and reduce premature death.
© Canadian Association for the Study of the Liver, 2025.