Boerekamps of Erasmus University Medical Centre in Rotterdam and colleagues
looked at outcomes among people with HIV/HCV co-infection after restrictions on the
use of DAAs were lifted in the Netherlands. As of November 2015, DAAs can be prescribed to all people with co-infection regardless of liver
The researchers looked at participants in the Dutch
ATHENA cohort, an ongoing study of HIV-positive people in care since 1998. Of
the 22,042 cohort participants screened for HCV at least once, the study team
identified 2422 with HCV co-infection. Of these, 1420 remained in care; most of
the rest either never had a confirmatory test, spontaneously cleared HCV, died
or were lost to follow-up.
Most of those still in care were men (89%) with
a mean age of 49 years. More than 90% were on antiretroviral therapy with an
undetectable HIV viral load. Two-thirds were MSM and 16% had a history of
injection drug use. The most common HCV genotypes were 1 (61%) and 4 (16%) and
a third had severe liver disease.
The number of people with co-infection receiving treatment
rose dramatically and rapidly after the restrictions were lifted. The researchers saw a high level of treatment
uptake among people without severe liver disease – a group that previously
would have been largely denied treatment.
As of May 2016 – six months after unrestricted
DAA availability – 78% of people still in care had started hepatitis C
treatment with either interferon-based therapy or DAAs, and 65% had achieved
sustained virologic response (SVR) or were still undergoing treatment.
As of January 2017, 82% had started treatment
and 70% were either cured or still on therapy. Among people treated with
DAAs, the SVR rate was very high, at 98%. About three-quarters (76%) of gay and
bi men had been cured or were still on treatment, compared to 45% of other
The researchers noted that women, former
injection drug users and people with uncontrolled HIV disease were
disproportionately more likely to still need hepatitis C treatment. Asked about
the under-representation of women, Boerekamps noted that women with hepatitis C
in the Netherlands are largely from Africa and may have more barriers to
Her colleague, Bart Rijnders, added that gay men had been targeted
for treatment in an effort to interrupt transmission networks. At a CROI press
conference Rijnders said that hepatitis C treatment uptake was very rapid among gay and bi men with co-infection, as this group is
very eager to be cured as soon as possible because the do not want to transmit
HCV to their partners.
presented late-breaking findings on changes in acute HCV infections among
HIV-positive MSM since the DAA roll-out, comparing HCV incidence in 2014 and 2016 – the first full year of unrestricted DAA
A Dutch mathematical model predicted that immediate
DAA treatment for HIV-positive MSM would reduce – though not eliminate – new
HCV infections in this population, and this study aimed to provide real-life
This analysis looked at data from 17 HIV treatment centres throughout the
Netherlands, accounting for about 80% of Dutch HIV-positive MSM in care. In
most cases acute HCV was defined as a positive HCV RNA test following a
In 2014, there were 93 identified acute HCV
infections, for an incidence rate of 11.2 per 1000 person-years (PY) of
follow-up. In 2016 there were 49 cases of acute infection, or 5.5 per 1000 PY.
In other words, annual
HCV incidence fell from 1.1% to 0.5% per year – a highly significant 51%
Annual incidence also declined further during 2016, from about
0.7% during the first half of the year to 0.4% during the second half.
Rijnders noted that there was an
"astonishing" 41% increase in new syphilis cases among HIV-positive
MSM during this period, so he was confident the reduced HCV incidence was not
attributable to changes in sexual risk behaviour – and in fact there was
evidence on an increase in 'chemsex' and 'slamsex' (drug use and drug injection
associated with sex).
"For the first time in more than 10 years,
the incidence of acute HCV in HIV-positive MSM in the Netherlands dropped
substantially," the researchers concluded. "Unrestricted access and
use of DAA for the treatment of chronic (and acute?) HCV is the most likely
is an example of what is possible
if you have the money and the drugs to treat everyone," Rijnders told
reporters at the press conference.