Hepatitis C virus (HCV) remains widely prevalent in the U.S. Treatment has improved, but rates of treatment initiation remain low. We sought to identify clinical and sociodemographic characteristics of patients that are associated with failure to initiate treatment of HCV infection. We conducted a retrospective cohort study in our primary care hepatitis C treatment clinic, affiliated with an urban academic hospital. Our population was multi-ethnic, HIV−, HCV+, treatment naïve patients. We measured rates of HCV treatment initiation and sociodemographic, viral, and patient-related variables associated with non-initiation of treatment. The total number of treatment-eligible patients was 168, of whom 41 began treatment and 127 did not. In multivariate analysis, individuals with HCV genotypes 1 and 4 were less likely than others to initiate treatment, as were patients with more medical comorbidities. Further research is needed to understand how factors around initiation interact and how interventions can overcome them.