Free access to direct-acting antivirals in Spain: more favorable impact on hepatitis C mortality among highly educated people.

BACKGROUND
In 2015, hepatitis C treatment with direct-acting antivirals (DAA) became free and widespread in Spain, significantly reducing hepatitis C-related mortality. However, health interventions can sometimes widen health inequalities. The objective is to assess the impact of DAA treatment on hepatitis C-related mortality by educational level.


METHODS
We analyzed deaths from hepatitis C, unspecified liver cirrhosis, hepatocellular carcinoma, alcohol-related liver diseases, other liver diseases, and HIV disease among individuals living in Spain during 2012-2019 and aged ≥25 years. We calculated age-standardized mortality rates per million person-years by period, sex, and education. Using Quasi-Poisson segmented regression models, we estimated the annual percent change in rates in pre-and post-intervention periods by education level and the relative inequality index (RII).


RESULTS
Hepatitis C mortality rates among low, middle, and highly educated people decreased from 25.2, 23.2, and 20.3/million person-years in pre-intervention period to 15.8, 13.7, and 10.4 in post-intervention period. Mortality rates from other analyzed causes also decreased. Following the intervention, downward trends in hepatitis C mortality accelerated at all education levels, although more in highly educated people and the RII increased from 2.1 to 2.7. For other analyzed causes of death, no favorable changes were observed in mortality trends, except for liver cirrhosis, hepatocellular carcinoma, HIV disease, and alcohol-related liver disease among higher-educated people.


CONCLUSION
Results suggest that DAA treatments had a very favorable impact on hepatitis C mortality at all education levels. However, even in a universal and free health care system, highly educated people seem to benefit more from DAA treatment than less educated people.