Background: To inform hepatocellular carcinoma (HCC) surveillance after hepatitis C virus (HCV) cure with direct-acting antivirals (DAA), we estimated HCC risk post-DAA in people with HIV with advanced liver fibrosis or cirrhosis under universal DAA.
Methods: We used data from HepCAUSAL, a collaboration of cohorts of HIV-HCV co-infection from Europe and North America. Eligibility criteria were HIV-HCV co-infection, advanced liver fibrosis or cirrhosis, DAA naïve, HIV-RNA<50 copies/mL, on antiretroviral therapy, no HBV co-infection, no prior HCC diagnosis or liver transplant. Follow-up started when eligibility was met and ended at HCC diagnosis, death, loss to follow-up, six years, or database closure, whichever came first. We estimated the 6-year risk and annual probability of HCC if all eligible individuals had initiated DAA at baseline using a weighted pooled logistic model for the monthly HCC risk among DAA initiators.
Results: Of 3,824 eligible individuals (92% males, median age 60 years [IQR: 54,64]), 2,373 (62%) who initiated DAA, 43 had an HCC diagnosis during follow-up. The estimated 6-year HCC risk (95% CI) under universal DAA was 2.5% (1.6,3.9). Annual HCC probability was: 0.81% (0.34,1.54) between baseline and month 12 after DAA initiation, 0.64% (0.28,1.19) between year 1-2, 0.50% (0.27,0.84) between year 2-3, 0.34% (0.13,0.63) between year 3-4, 0.19% (0.07,0.33) between year 4-5, and 0.10% (0.01,0.24) between year 5-6.
Conclusion: An estimated 2.5% of people with HIV and advanced liver fibrosis or cirrhosis are diagnosed with HCC by 6 years post-DAA. Annual probability of HCC declines over time and falls below 0.4% after 3 years.
Keywords: advanced liver fibrosis; annual risk; cirrhosis.
© The Author(s) 2025. Published by Oxford University Press on behalf of Infectious Diseases Society of America.