Favorable impact in Hepatitis C related mortality following free-access to direct-acting antivirals in Spain.

Background & aims Free treatments for hepatitis C virus (HCV) infection with direct-acting antivirals became widespread in Spain in April 2015. We aimed to test whether, after this intervention, there was a more favorable change in population mortality from HCV-related than from non-HCV-related causes. Approach & results Post-intervention changes in mortality were assessed using uncontrolled before-after and single-group interrupted time series designs. All residents in Spain during 2001-2018 were included. Various underlying death causes were analyzed: HCV infection, other HCV-related outcomes (hepatocellular carcinoma, liver cirrhosis, and HIV disease); and non-C hepatitis, other liver diseases, and non-hepatic causes as control outcomes. Changes in mortality after the intervention were first assessed by rate ratios (RR) between the post and pre-intervention age-standardized mortality rates. Subsequently, using Quasi-Poisson segmented regression models, we estimated the annual percent change (APC) in mortality rate in post- and pre-intervention periods. All mortality rates were lower during the post-intervention period, although RRs were much lower for HCV [0.53, 95% Confidence Interval -95%CI-: 0.51, 0.56] and HIV disease than other causes. After the intervention there was a great acceleration of the downward mortality trend from HCV, whose APC went from -3.2% [95%CI: -3.6%, -2.8%] to -18.4% [95%CI: -20.6%, -16.3%]. There were also significant accelerations in the downward trends in mortality from hepatocellular carcinoma and HIV disease, while they remained unchanged for cirrhosis and slowed or reversed for other causes. Conclusions These results suggest that the favorable changes in HCV-related mortality observed for Spain after April 2015 are attributable to scaling up free treatment with direct-acting antivirals and reinforce that HCV eradication is on the horizon.