France: the changing characteristics of people living with HIV on hepatitis C treatment
Fewer people living with HIV and hepatitis C (HCV) who have a history of injecting drug use and unstable housing are on newer, more effective HCV medication, new research from France finds.
The study is the first to assess the characteristics of people co-infected with HIV/HCV during two eras of HCV treatment: when medication consisting of pegylated interferon (PEG-IFN) and ribavirin was the standard of care, and when more effective, better tolerated and faster acting direct-acting antivirals (DAA) became available. As pharmaceutical companies continue to charge high prices for DAAs, many governments limit access to this medication.
Researchers aimed to compare the socio-behavioural characteristics of HIV/HCV co-infected patients initiating HCV treatment between the PEG-IFN and the DAA eras.
Researchers enrolled people co-infected with HIV/HCV between 2005 and 2016. During the study, health policy in France dictated that people with HCV were assessed for treatment on a case-by-case basis, although in May 2016 the government shifted its position to guarantee universal access to treatment.
A total of 580 patients were included in this analysis. Of these, 347 (60%) initiated PEG-IFN-based treatment, and 233 (40%) DAA-based treatment.
Those included in the first recruitment phase (2005 to 2008), during the PEG-IFN era, attended clinical visits either every six months if they had cirrhosis or every year if they did not. These participants also filled out annual socio-behavioural questionnaires. For people initiating HCV treatment, additional visits were scheduled, before, during and after the end of treatment. For those receiving DAA (from 2014 to 2015), clinical and biological data were collected at treatment initiation, at the end of treatment, and six months after the end of treatment, using medical questionnaires. Socio-behavioural questionnaires were filled out at treatment initiation and at the end of treatment.
The results suggest a change in the socio-behavioural characteristics among HIV-infected people being treated for HCV. Researchers found a significantly higher proportion of patients who received PEG-IFN treatment had unstable housing conditions and were more likely to have a history of injecting drug use. People on DAA were also older than those who received PEG-IFN treatment (mean age: 52-years-old, compared to 45-years-old). Two-thirds of all participants (65%) had significant liver fibrosis. The proportion of patients with significant fibrosis was higher in the DAA group (72%, compared to 62%).
Around two-fifths (39%) of all participants were people who used drugs. Overall, 45% on PEG-IFN had a history of drug use, compared to 30% of people on DAA. The proportion of patients with a history of injecting drug use was significantly higher in the PEG-IFN group (69%, compared to 39%).
Those who regularly used cannabis, something that is linked to relieving both opioid withdrawal symptoms and HIV/HCV-related symptoms, were also more likely to be on PEG-IFN than DAA (24%, compared to 16%).
Homelessness and temporary living arrangements were also found to be more frequent among people initiating HCV treatment in the PEG-IFN era, with the proportion of people living in unstable housing on PEG-IFN double that of the proportion on DAA (21%, compared to 11%).
These findings suggest that there is a change in the epidemiological profile of HIV-HCV co-infected patients receiving HCV treatment in France. It is indeed possible that the majority of co-infected patients who had socio-economic problems and/or a history of injecting drug use had already been treated for HCV in the PEG-IFN era.
The authors make the hypothesis of a change in the type of population now needing HCV treatment in France. However, it is important to remain vigilant concerning potential remaining social barriers to access to DAA. It is also important to address the social vulnerability of people who inject drugs, who face the greatest burden of the HCV epidemic. This is particularly important in contexts such as Europe where injecting drug use drives HCV transmission. Indeed, previous research on people who inject drugs living with HCV or HIV/HCV found HCV treatment to be effective, with participants as likely to adhere to treatment as others.