Trends in HCV Infection Prevalence Among People with HIV in Spain Over Two Decades (2002-2023)

Abstract Background Hepatitis C virus (HCV) has significantly impacted people with HIV (PWH). Harm reduction programs, changing transmission patterns, and direct-acting antivirals (DAAs) have profoundly altered HIV/HCV coinfection trends. This study evaluates HCV prevalence in Spain over two decades. Methods We conducted nine cross-sectional studies (2002–2023) in 39–43 centers. Sampled individuals were randomly sampled from PWH actively followed at these centers, with proportional allocation. Main outcomes included anti-HCV antibody and active HCV infection (HCV-RNA+) prevalences. Results The reference population ranged from 31,800 to 47,006, with sample sizes of 1,260–1,867. HIV transmission patterns shifted from 2002 to 2023, with injection drug use (IDU) decreasing from 55% to 21% and men who have sex with men (MSM) increasing from 17% to 46%. HCV seroprevalence fell from 60.8% to 27.4%, and active infection from 46.3% to 0.9%. In the DAA era (2015–2023), active HCV dropped by 100% in heterosexuals, 94% in IDU, and 71% in MSM. Treatment uptake increased from 23% in 2002 to 99% by 2023 with all-oral DAAs. Cirrhosis among active HCV cases peaked at 23.1% in 2015 but fell to 0% by 2021. Among those achieving sustained virologic response (SVR), cirrhosis prevalence was 20.4% in 2023. Conclusions HIV/HCV coinfection has drastically declined in Spain, with active HCV infection prevalence below 1% since 2021. DAAs were pivotal in this achievement. However, cirrhosis remains a concern among those with SVR. Ongoing surveillance and prevention efforts are essential to sustain these gains and address residual risks.