*Purpose: The success of pilot trials of transplanting organs from hepatitis C virus (HCV) viremic donors into HCV-negative recipients (HCV D+/R-) has led to an expansion of this practice. DAA therapies remain costly, and insurance barriers to approval remain, especially with HCV D+/R- transplantation due to the off-label nature of treating acute HCV after intentional HCV transmission. It is unknown if socio-demographic disparities exist with respect to access to HCV D+ organs among HCV-negative patients.

*Methods: We used OPTN/UNOS data from 1/1/17-6/30/19. We included kidney, liver, heart, and/or lung recipients transplanted at a center that performed ≥10 HCV D+/R- transplants of that organ type. A state’s HCV Medicaid policies were categorized as Grades A-F according to the Center for Health Law and Policy Innovation of Harvard Law School and the National Viral Hepatitis Roundtable. Hispanics and blacks were categorized as “under-represented minorities.” We fit multivariable mixed effects logistic regression models (center as random effect) to evaluate factors associated with receiving an HCV D+/R- transplant. We used marginal standardization to predict the standardized proportion of HCV D+/R- recipients within insurance and state sub-groups standardized with respect to the distribution of all other covariates.

*Results: During the study period, 29 transplant centers performed ≥10 HCV D+/R- transplants of one organ type. In multivariable mixed effects models, women (OR: 0.70, 95% CI: 0.61-0.80, p<0.001) and under-represented minorities (OR: 0.80, 95% CI: 0.69-0.92, p=0.003) were significantly less likely to receive an HCV D+/R- transplant. Patients with an education level of grade school or less were significantly less likely to receive an HCV D+/R- transplant (OR: 0.55, 95% CI: 0.39-0.79 compared to college-educated; p=0.001). There was a significant interaction with Medicaid insurance and state HCV Medicaid grade (p=0.01), such that Medicaid insurance was only associated with a lower probability of receiving an HCV D+/R- in HCV Medicaid-restricted states (Figure).

*Conclusions: Women, under-represented minorities, patients with the least educational attainment, and Medicaid-insured patients living in HCV Medicaid-restricted states have less access to transplantation from HCV-viremic donors. Understanding the individual factors and public policies that contribute to the disparities in the transplant waitlist can aid in optimizing fair distribution of these limited resources.

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