Characteristics associated with time-to-treatment initiation for chronic Hepatitis C with new direct acting antivirals

Background: Interferon-free direct-acting antivirals (DAAs) were introduced in 2013 and have transformed the therapeutic landscape for chronic Hepatitis C (HCV). Although treatment is recommended for almost all persons infected with HCV, clinical and psychosocial factors may affect treatment initiation. Methods: We conducted an observational cohort study of Kaiser Permanente Mid-Atlantic States members with prevalent or incident HCV infection identified from November 2013 through May 2016 to identify predictors of DAA initiation. We used Cox regression with time-dependent covariates to compare time to treatment by clinical, demographic and societal factors. Results: Of 2962 patients eligible for DAA therapy, 33% (n = 980) initiated treatment over the study period. The majority of patients (97%) were persistent with therapy and most (95%) tested for sustained virologic response (SVR) achieved cure. We found no effect of race, insurance type or fibrosis stage on treatment initiation. We observed that patients aged 41-60 years (aHR: 2.014, 95% CI: 1.12, 3.60) and 61-80 years (aHR: 2.08, 95% CI: 1.15-3.75) had higher treatment rates compared to younger patients. Incident cases were more likely to be treated than prevalent cases (aHR: 3.05, 95% CI: 2.40-3.89). Patients with a history of substance use disorder (SUD) were less likely (aHR: 0.805, 95% CI: 0.680, 0.953) to be treated. Conclusions: In the first 3 years of DAA availability, one-third of patients with HCV initiated therapy, and almost all were persistent and achieved cure. While curative, DAAs remain highly priced. Triaging for non-clinical reasons or perceptions about patients will stall our ability to eradicate HCV.