Background:  Most HCV⁺ injection drug users (IDU) do not receive hepatitis C virus (HCV) treatment. The objective of this study was to determine the proportion of HIV⁺ and HIV^– IDU (former and active) who are eligible for and initiate HCV therapy with pegylated interferon (pegINF) + ribavirin (RBV) in the absence of geographic and financial barriers.

Methods:   Between March 2004 and March 2006, HCV⁺ IDU were enrolled sequentially from the Johns Hopkins Program for Alcoholism and Other Drug Dependencies and the Johns Hopkins University HIV clinic. Each IDU underwent a comprehensive evaluation:  medical, psychiatric, and drug/alcohol use history, depression screening, physical exam, and laboratory testing. Subjects were deemed ineligible for pegINF+RBV therapy if any of the following criteria were met:  HCV RNA not detected; pregnant or not willing to use birth control;  life expectancy <2 years (eg, advanced AIDS or cancer); active depression with suicidal ideation; allergic reaction to pegINF+RBV; severe hematologic abnormality (eg, hemoglobin <10.5 g/dL, ANC <1000/mm³, platelet count <50,000/mm³);  renal insufficiency (creatinine >2.5). All treatment-eligible subjects were given the opportunity to take pegINF+RBV, available on-site at no cost.

Result:  We enrolled 332 subjects (172 HIV/HCV co-infected; 158 HCV mono-infected). HIV-co-infected IDU were younger (41 to <44 years) and were more likely to be African American (90% to >74%), have a monthly income >$500 (52% to >23%) than those with HCV alone. No difference was observed in the prevalence of mental illness (~64%), alcohol abuse (~20%), or interest in receiving HCV treatment (~93%). HIV-co-infected IDU were more likely to have detectable HCV RNA (20 of 172 HIV/HCV co-infected, 11%; 29 of 143 of HCV mono-infected, 20%; p <0.001) and less likely to be eligible for HCV treatment (75 of 152 of HIV/HCV, 49%; 78 of 114 HCV, 68%; p = 0.002).  Reasons for ineligibility were:  severe depression (HIV/HCV 12%; HCV 30%); life expectancy <2 years (HIV/HCV 40%; HCV 30%); hematologic abnormality (HIV/HCV 49%; HCV 22%); renal insufficiency (HIV/HCV 10%; HCV 8%). Of the treatment-eligible IDU, ~40% initiated HCV therapy, defined as at least pegINF injection (31 of 75 HIV/HCV, 41%; 27 of 80 HCV, 36%).

Conclusions:  While ~50% of HIV/HCV-co-infected IDU were ineligible for HCV treatment, most (~80%) of HCV-mono-infected IDU were treatment-eligible. Despite the removal of financial and geographic barriers, only ~40% of treatment-eligible IDU initiated HCV treatment. Strategies are needed to increase HCV treatment uptake among IDU.