Hepatitis C, HIV, and the evolving role of DAAs
Direct-acting antivirals (DAAs) have transformed hepatitis C virus (HCV) treatment, offering cure rates that were once unimaginable. For people living with both HIV and HCV, the landscape has been more complex. While DAAs effectively clear the hepatitis C infection, experts have long asked how this virologic success translates into cancer risk, particularly hepatocellular carcinoma (HCC), the most common form of liver cancer. A new study provides important clarity: the risk of HCC remains after HCV cure in HIV coinfection, but the likelihood of developing HCC appears to decline with each passing year after treatment.
What the study found
The findings suggest that even after achieving sustained virologic response (SVR) with DAAs, people with HIV who were previously infected with HCV carry a residual risk for developing HCC. Importantly, the study observed a gradual decrease in HCC risk over time following DAA-induced cure. This pattern underscores that liver cancer risk is multifactorial: it is shaped by prior liver damage, ongoing immune status, and other coexisting risk factors rather than by HCV infection alone.
Why risk persists
Several factors may continue to fuel HCC risk despite HCV clearance. Prior cirrhosis or advanced liver fibrosis, which often accompanies chronic HCV infection, remains a strong predictor of future liver cancer. In HIV coinfection, additional elements—such as immune system compromise, metabolic conditions, alcohol use, and coexisting liver diseases—may sustain an elevated risk. The persistence of HCC risk after SVR highlights the need for sustained liver cancer surveillance in this population.
Implications for patient care
The study’s results have practical implications for clinicians and patients. First, they reinforce the importance of ongoing liver cancer screening even after successful HCV treatment with DAAs, especially for those with a history of cirrhosis or other liver damage. Second, they suggest a hopeful trajectory: continued annual declines in risk mean that consistent follow-up and surveillance could yield improved long-term outcomes for HIV-HCV coinfected individuals.
Surveillance and prevention strategies
Medicinal strategies should be complemented by lifestyle and metabolic interventions. Maintaining a healthy weight, limiting alcohol, controlling diabetes, and monitoring liver function can all contribute to lowering HCC risk. Vaccination against hepatitis A and B, when appropriate, and regular imaging and biomarker assessments as recommended by hepatology specialists are essential components of a comprehensive care plan for coinfected patients.
The path forward
While DAAs have changed the treatment paradigm for HCV, their impact on long-term cancer risk in HIV coinfection is nuanced. Ongoing research is needed to refine risk models, optimize surveillance intervals, and identify subgroups who might benefit from intensified monitoring. In the meantime, the message to patients is clear: achieving SVR through DAA therapy is a major milestone, but it does not eliminate the need for vigilant liver cancer screening and lifestyle optimization.
Bottom line
Direct-acting antivirals dramatically improve HCV outcomes, and in HIV-HCV coinfected individuals, they also contribute to a gradual reduction in hepatocellular carcinoma risk over time. However, a persistent baseline risk remains, reinforcing the need for continued surveillance, risk-reduction strategies, and personalized care trajectories to protect liver health in the long term.
