Turning the tide on hepatitis C-related liver transplantation: the return on investment in hepatitis C treatment in Australia and New Zealand.

BACKGROUND Introduction of universal access to direct-acting antiviral therapy (DAAs) for hepatitis C (HCV) in Australia and New Zealand on March 31st 2016 has had a major impact on the number of people with chronic HCV infection, but the impact on liver transplantation rates is unknown. METHODS We conducted a retrospective registry study including all adult liver transplants from the Australian and New Zealand Liver and Intestinal Liver Transplant Registry dataset (ANZLITR). Interrupted time series analysis determined the impact of DAAs in 2016 on the number of HCV liver transplants per year. Cox regression analysis was used to determine the impact of DAAs on post liver transplant survival. RESULTS Between 1st January 1990 and 31st December 2019, 5318 adult liver transplants were performed, 29% (1531) were for hepatitis C infection. Prior to introduction of DAAs, there was a mean increase of 3.5 adult liver transplants performed for HCV per annum, but between 2016 to 2019 there was a mean decrease of 7.9 adult liver transplants per annum (p<0.0001). Similarly, the proportion of liver transplants performed for HCV increased from 9% (1990) to 33% in 2016, then fell to 23% in 2019 (p<0.001). The number and proportion of patients with hepatitis C waitlisted for liver transplantation also fell from 2016 (p<0.001) comparative to other indications. Introduction of DAAs was associated with a 31% reduction in death after liver transplantation, adjusted for age at transplant and hepatocellular carcinoma (HR 0.69, 95% CI 0.48-0.99, p=0.047). CONCLUSION The number of adult liver transplants performed for HCV-related liver cirrhosis and HCC has reduced since introduction of universal access to DAAs in 2016 in Australia and New Zealand.