Frequent disengagement and subsequent mortality among people living with HIV and Hepatitis C in Canada: A prospective cohort study

Abstract Background The cascade of care, commonly used to assess HIV and Hepatitis C (HCV) health service delivery, has limitations in capturing the complexity of individuals’ engagement patterns. This study examines the dynamic nature of engagement and mortality trajectories among people living with HIV and HCV. Methods We used data from the Canadian HIV-HCV Co-Infection Cohort, which prospectively follows 2098 participants from 18 centers bi-annually. Markov multi-state models were used to evaluate sociodemographic and clinical factors associated with transitioning between the following states: (1) Lost-to-follow-up (LTFU), defined as no visit for 18 months; (2) Re-engaged (re-entry into cohort after being LTFU); (3) Withdrawn from the study (i.e. moved); (4) Death; otherwise remained (5) engaged-in-care. Results 1809 participants met the eligibility criteria and contributed 12,591 person-years from 2003-2022. LTFU was common, with 46% experiencing at least one episode, of whom only 57% re-engaged. One in five (n = 383) participants died during the study. Participants who transitioned to LTFU were twice as likely to die as those who were consistently engaged. Factors associated with transitioning to LTFU included detectable HCV RNA (aHR 1.37, 95% CI 1.13, 1.67), evidence of HCV treatment but no sustained virologic response (SVR) result (aHR 1.99, 95% CI 1.56, 2.53) and recent incarceration (aHR 1.94 95% CI 1.58, 2.40). Being Indigenous was a significant predictor of death across all engagement trajectories. Interpretation Disengagement from clinical care was common and resulted in higher death rates. People LTFU were more likely to require HCV treatment highlighting a priority population for elimination strategies.