The authors were interested in population-level evidence for the impact of direct-acting antivirals (DAA) on hepatitis C virus (HCV)-related disease burden. They examined trends in HCV-related decompensated cirrhosis and hepatocellular carcinoma (HCC) hospitalisation, and liver-related and all-cause mortality in the pre-DAA (2001-2014) compared with the DAA therapy (2015-2017) eras in New South Wales, Australia. They linked HCV notifications (1993-2016) to hospital admissions (2001-2017) and mortality (1995-2017). Of 99,910 people with an HCV notification, 3.8% had a decompensated cirrhosis diagnosis and 1.8% had an HCC diagnosis, while 3.3% and 10.5% died of liver-related and all-cause mortality, respectively. In the pre-DAA era, the number of decompensated cirrhosis and HCC diagnoses, and liver-related and all-cause mortality were found to consistently increase (incidence rate ratios 1.04 [95%CI 1.04-1.05], 1.08 [95%CI 1.07-1.08], 1.07 [95%CI 1.06-1.07] and 1.05 [95%CI 1.04-1.05], respectively) over each 6-monthly band. However, in the DAA era, decompensated cirrhosis diagnosis and liver-related mortality numbers declined (incidence rate ratios 0.97 [95%CI 0.95-0.99] and 0.96 [95%CI 0.94-0.98], respectively), and HCC diagnosis and all-cause mortality numbers plateaued over each 6-monthly band. During the DAA era, the authors found that alcohol-use disorder (AUD) was common in patients diagnosed with decompensated cirrhosis and HCC (65% and 46% had a history of AUD, respectively). AUD was also independently associated with liver-related mortality (incidence rate ratio 3.35, 95%CI 3.14-3.58). Therefore during the DAA era, there has been a sharp decline in liver disease morbidity and mortality in New South Wales, Australia.
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