The Case for Treatment Now

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The Case for Treatment Now

• Todd Wills, MD
• ETAC Infectious Disease Specialist

HEPATITIS C TREATMENT EXPANSION
INITIATIVE MULTISITE CONFERENCE CALL JULY 17, 2013
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Increases Rates of HCC in HIV/HCV Coinfection

• Results
• Among HIV/HCV coinfected participants, HCC
  incidence rose from 0.2 to 2.8 cases per 1000
  person-years between 2000 and 2009, with the
  largest jump in 2008-2009.
• Most patients with HCC (79) died during
  follow-up, all but 2 due to complications related
  to liver cancer.
• The median survival time after HCC diagnosis was
  91 days (interquartile range, 31 to 227 days).
• Compared with cases of HCC diagnosed before 2005,
  people diagnosed during later years did not have
  a higher survival rate.

N Merchante, E Merino, J López-Aldeguer, et al.
Increasing Incidence of Hepatocellular Carcinoma
in HIV-Infected Patients in Spain. Clinical
Infectious Diseases 56 (1)143-150. January 1,
2013.
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High Risk for Decompensation

• F3 fibrosis (biopsy), probability of
  decompensation 1 at 1 year, 2 at 3 years, 5
  at 5 years.
• Among patients with cirrhosis (biopsy),
  corresponding probabilities were 4, 13, and
  23.
• Among patients with 9.5-14.5 kPa (FibroScan),
  probability of decompensation 1 at 1 year, 3
  at 3 years, 4 at 5 years.
• Among patients with gt14.6 kPa (FibroScan), the
  probabilities were 7, 17, and 27, respectively.

J Macias, A Camacho, MA von Wichmann, et al.
Advanced fibrosis and the risk of liver
decompensation among HIV/HCV-coinfected
individuals consequences for the timing of
therapy against HCV. 48th Annual Meeting of the
European Association for the Study of the Liver
(EASL 2013). Amsterdam. April 24-28, 2013.
Abstract 474.
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HCV Treatment Lowers Risk of Cirrhosis
Complications

• baseline fibrosis, 10-year survival
• Patients with SVR HIV/HCV coinfected 66 vs HCV
  monoinfected 62 (p0.04)
• Untreated 7 vs 93, respectively (p0.009).
• Among untreated participants, coinfected were 9
  times more likely than HCV monoinfected to
  progress to cirrhosis over 10 years (1.41 vs
  0.18, respectively p lt 0.001).

T Poynard, MA Valantin, M Munteanu, et al
(FibroFrance-GHPS Group). Long Term Survival of
Liver Fibrosis after Virological Cure (SVR) in
HIV-HCV Coinfected Patients A Worrisome Latent
Disease??48th Annual Meeting of the European
Association for the Study of the Liver (EASL
2013). Amsterdam. April 24-28, 2013. Abstract
487..
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Acute HCV in MSM on the Rise

• Acute HCV in MSM on rise
• 17 incident cases (among 2250 subjects) in 5
  phase II/III studies of EVG/COBI/FTC/TDF1
• Observational study assessed HCV reinfections in
  high-risk HIV/HCV-coinfected MSM (N 64)2
• GT1a HCV 62.5 (n 40) - GT1b HCV 6.3 (n
  4)
• GT3a HCV 3.1 (n 2) - GT4d HCV 28.1 (n
  18)
• 33 cleared virus spontaneously or following
  treatment2
• 5-yr cumulative incidence of new infection by
  genotype2
• Same HCV genotype as original infection 6.1
  (95 CI 0 to 14.5)
• Different HCV genotype than original infection
  25.5 (95 CI 10.4 to 38.0)
• Results demonstrate continued risk of HCV
  reinfection after clearance2

1. Quirk E, et al. CROI 2013. Abstract 705. 2.
Thomas X, et al. CROI 2013. Abstract 708.
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Impaired HCV Specific Immune Response in HIV
Patients

• HIV infection had a detrimental effect on
  HCV-specific cytokine production in people with
  acute hepatitis C.
• The effect was particularly notable for
  HCV-specific interferon gamma production.
• Interferon gamma responses were both
  significantly lower in magnitude and smaller in
  breadth in HIV/HCV coinfected people.
• Reduced interferon production was associated with
  lower peripheral CD4 T-cell counts, but not with
  detectable HIV viral load.

JK Flynn, GJ Dore, G Matthews, R Ffrench, et al
(ATAHC Study Group). Impaired Hepatitis C Virus
(HCV)-Specific Interferon-Responses in
Individuals with HIV Who Acquire HCV Infection
Correlation With CD4 T-Cell Counts. Journal of
Infectious Diseases 206(10)1568-1576. November
15, 2012.