*Purpose: End-stage renal disease (ESRD) patients co-infected with HCV and HIV have access to effective treatment options for HCV infection. However, they also have access to HCV-infected kidneys, which historically afford shorter times to transplantation. Given high waitlist mortality and rapid progression of liver fibrosis among co-infected kidney-only transplant candidates identifying the optimal treatment strategy is paramount.

*Methods: Two strategies, treatment pre- and post-transplant, were compared using Monte Carlo microsimulation of 1,000,000 candidates. The microsimulation was stratified by liver fibrosis stage at waitlist addition and wait-time over a lifetime time horizon.

*Results: Treatment post-transplant was consistently cost-saving as compared to treatment pre-transplant due to the high cost of dialysis. Among patients with low fibrosis disease (F0-F1), treatment post-transplant also yielded higher life months (LM) and quality-adjusted life months (QALM) except among F1 candidates with wait-times >18 months. For candidates with advanced liver disease (F2-F4), treatment pre-transplant afforded more LM and QALM unless wait-time was < 18 months. Moreover, treatment pre-transplant was cost-effective for F2 candidates with wait-times > 71 months and F3 candidates with wait-times > 18 months.

*Conclusions: Thus, optimal timing of HCV treatment differs based on liver disease severity and wait-time, favoring pre-transplant treatment when cirrhosis development prior to transplant seems likely.

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