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Disclosures
- Industry
– Investigator: Merck, GS, Abbvie – Consultant /Advisor: Merck, GS, Abbvie – Speaker: Merck, GS, Abbvie
- Government
– MOH – OHTN – CIHR – CDR – Health Canada – MAC-FI HIV, HCV
Clinical and Ethical Issues in Managing HCV Co-Infection Curtis - - PowerPoint PPT Presentation
Clinical and Ethical Issues in Managing HCV Co-Infection Curtis - - PowerPoint PPT Presentation
Clinical and Ethical Issues in Managing HCV Co-Infection Curtis Cooper, MD, FRCPC Associate Professor of Medicine University of Ottawa Division of Infectious Diseases Disclosures Industry Investigator: Merck, GS, Abbvie
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HIV-HCV Co-Infection
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Case
45 yo HIV-HCV male Risk Factor- IDU- still active Used ETOH in the past now the occasional
bender
HIV- Atripla x 6 years Episodes of treatment interruption but when on
ARVs, rarely misses
CD4- 450 HIV RNA- <40
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Case
Likely HCV-infected in early 20’s Genotype 1 HCV RNA 7.8 x 105IU/mL Received Peg-IFN / RBV in 2007 but interrupted
after 6 weeks for poor tolerance and a ‘bender’ (RNA declined by about 2 logs at week 4)
Bx in 2006 suggested stage 2 fibrosis but poor
quality and during a period of excess alcohol use
No Fibroscan performed but APRI 1.8
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Case
Patient is a daily MJ users and frequently takes
‘liver cleansing’ remedies
Has a longstanding PPI prescription which he
uses PRN for GERD
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Case
Patient wants therapy now…. Key questions:
What are the DAA treatment options? What are the DDI concerns? What is the best fibrosis assessment modality? What about re-infection risk? Are HCV treatment outcomes really as good in HIV-
HCV co-infection as they are in HCV mono-infection?
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Canadian HIV/Hepatitis C Management and Treatment Guidelines CIHR CANADIAN HIV TRIALS NETWORK (CTN)
- Similar mx in HIV-HCV as HCV mono-infection
- Anticipated SVR rates in HIV-HCV co-infection
are similar to HCV mono-infection with interferon- free, DAA regimens
- Carefully evaluate for DDIs before and during
treatment
- Select ARVs in anticipation of subsequent HCV
DAA treatment
- Discuss harm reduction strategies in those at risk
for HCV exposure
- Active injection drug use
- MSM
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Key Co‐Infection Regimens
- Sofosbuvir + daclatasvir
(ALLY‐2) (N=203)1
- Grazoprevir + elbasvir
(C‐EDGE) (n=218)2
Adapted from
- 1. Levin J, et al. Presented at EASL 2015; Poster #P1353.
- 2. Rockstroh JK, et al. Presented at EASL 2015; Poster #P0887.
Treatment-naive Treatment- experienced
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Naïve vs Experienced Overall Cirrhosis Status Overall HCV Rx Experienced HCV Rx Naïve No Cirrhosis Cirrhosis 321/335 142/150 179/185 63/67 258/268
SVR12 (%)
10
ION‐4
Overall
Error bars represent 95% confidence intervals.
Naggie S, et al. ION-4 Study. NEJM 2015
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Results: SVR12 by Cirrhosis or Prior Treatment
†Patients LTFU were incarcerated, one patient on Day 1 and one patient on Week 4
Error bars represent 95% confidence intervals. Brau, IAS, 2016; Data on File, Gilead Sciences.
12
ASTRAL-5 HIV/HCV Coinfection Study 95 94 100 93 97 94 97 20 40 60 80 100 SVR12 (%)
82 87 19 19 71 75 30 31
Non‐ cirrhotics Cirrhotics Treatment Naïve Treatment Experienced Total
101 106
High SVR12 achieved in HIV‐coinfected patients regardless of cirrhosis status and treatment experience
‡
45 48 56 58
Black Non‐black
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Drug-Drug Interactions between HCV DAAs and HIV Antiretrovirals
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Impact of DAA Regimens on Co-Infection Guidelines
Priority shifts from early HIV treatment to early HCV treatment Fewer contraindications for HCV treatment Target populations for HCV antiviral tx is expanded Issues related to DDI reduced Benefits for Patient-Health Care Team relationship Increased network of HCV treaters
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Barriers
Concentration of Barriers to Engagement and
Treatment Success
Socioeconomic Mental Health Substance Abuse Stigma Diverse populations within the HIV community
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Research Needs
Non-Genotype 1 Treatment Treatment of HIV-HCV co-infection in more
advanced disease
RGT HCV treatment post OLT
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HIV-HCV Management Conclusions
Gap in SVR has been bridged Safety and tolerability issues eliminated Tx issues not unique to HIV-HCV Same general approach to work-up, treatment
and long-term follow-up
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