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The effects of hepatitis C treatment eligibility criteria on all-cause mortality among people with HIV.

Background
The cost of direct-acting antivirals (DAA) for hepatitis C virus (HCV) prompted many payers to restrict treatment to patients who met non-evidence-based criteria. These restrictions have implications for survival of people with HCV, especially for people with HIV/HCVco-infection who are at high risk for liver disease progression. The goal of this work was to estimate the effects of DAA access policies on 10-year all-cause mortality among people with HIV.


Methods
The study population included 3,056 adults with HIV in the Women's Interagency HIV Study and Multicenter AIDS Cohort Study from October 1, 1994 through September 30, 2015. We used the parametric g-formula to estimate 10-year all-cause mortality under DAA access policies that included treating: 1) all people with HCV; 2) only people with suppressed HIV; 3) only people with severe fibrosis; and 4) only people with HIV suppression and severe fibrosis.


Results
The 10-year risk difference (RD) of treating all co-infected persons with DAAs compared with no treatment was -3.7% (95% CI: -9.1%, 0.6%). Treating only those with suppressed HIV and severe fibrosis yielded a RD of -1.1% (95% CI: -2.8%, 0.6%), with 51% (95% CI: 38%, 59%) of co-infected persons receiving DAAs. Treating a random selection of 51% of co-infected persons at baseline decreased the risk by 1.9% (95% CI: -4.7%, 0.3%).


Conclusions
Restrictive DAA access policies may decrease survival compared to treating similar proportions of people with HIV/HCV coinfection with DAAs at random. These findings suggest that lives could be saved by thoughtfully revising access policies.