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BACKGROUND AND AIMS: Direct-acting antivirals (DAAs) are highly effective in treating hepatitis C. However, there is concern that cure rates may be lower, and reinfection rates higher, amongst people who inject drugs. We conducted a systematic review of treatment outcomes achieved with DAAs in PWID. METHODS: A search strategy was used to identify studies that reported sustained viral response (SVR), treatment discontinuation, adherence or reinfection in recent PWID and/or opioid substitution therapy (OST) recipients. Study quality was assessed using the Newcastle-Ottawa Scale. Meta-analysis of proportions was used to estimate pooled SVR and treatment discontinuation rates. The pooled relative risk of achieving SVR was also calculated using a generalised mixed-effects linear model. RESULTS: The search identified 8075 references; 26 were eligible for inclusion. The pooled SVR for recent PWID was 88% (95% CI, 83% - 92%) and 91% (95% CI 88% - 95%) for OST recipients. The relative risk of achieving SVR for recent PWID compared to non-recent PWID was 0.99 (95% CI, 0.94 - 1.06). The pooled treatment discontinuation was 2% (95% CI, 1% - 4%) for both recent PWID and OST recipients. Amongst recent PWID the pooled incidence of reinfection was 1.94 per 100 person years (95% CI, 0.87 - 4.32). In OST recipients, the incidence of reinfection was 0.55 per 100 person years (95% CI, 0.17 - 1.76). CONCLUSIONS: Treatment outcomes were similar in recent PWID compared to non-PWID treated with direct-acting antivirals. People that report recent injecting or OST recipients should not be excluded from hepatitis C treatment.