Elimination of Hepatitis C in Individuals With HIV Infection
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Professor of Medicine
The Johns Hopkins Medical Institutions
Baltimore, Maryland
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Dr Thomas has no relevant financial affiliations to
disclose. (Updated 11/12/18)
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After attending this presentation, learners will be able to:
▪
List two 2030 elimination goals for HCV infection
▪
Compare treatment of HCV infection in a person with HIV
infection and someone without
ARS Question 1: Which is most true about the expected
future (2040) mortality from chronic HCV and HBV?
1.
Should decrease in parallel with HIV
2.
Will exceed HIV
3.
Will exceed TB
4.
Will exceed malaria
5.
Will exceed HIV+TB+malaria
ARS Question 1: Which is most true about the expected
future (2040) mortality from chronic HCV and HBV?
1.
Should decrease in parallel with HIV
2.
Will exceed HIV
3.
Will exceed TB
4.
Will exceed malaria
5.
Will exceed HIV+TB+malaria
Global health importance of hepatitis
Foreman Lancet 2018; IHME, 2015 http://ghdx.healthdata.org
WHO Hepatitis Elimination Goals
WHO Global Hepatitis Report 2017
90% reduction in incidence
HCV
2015
2020 (30%)
2030
WHO Hepatitis Elimination Goals
WHO Global Hepatitis Report 2017
65% reduction in mortality
HCV
2015
2020 (10%)
2030
Targets to eliminate hepatitis C
WHO Global Hepatitis Report 2017
Global cascade of HCV care and 2030 WHO elimination
goals: 90/80 target
WHO Global Hep Report 2017
Elimination prefix cascade
ARS Question 2: A 53 year old man with 1a HCV and HIV
on r/DRV, FTC, and TDF with F1-2 disease presents for
HCV treatment. Which is true?
1.
Needs 24 weeks of treatment due to HIV
2.
Doesn’t need treatment due to low F score
3.
Change ART first
4.
Add ribavirin to regimen
5.
Must screen for HCC before starting
ARS Question 2: A 53 year old man with 1a HCV and HIV
on r/DRV, FTC, and TDF with F1-2 disease presents for
HCV treatment. Which is true?
1.
Needs 24 weeks of treatment due to HIV
2.
Doesn’t need treatment due to low F score
3.
Change ART first
4.
Add ribavirin to regimen
5.
Must screen for HCC before starting
Efficacy of SOF/LDV in HIV Co-infected patients
Naggie S. NEJM 2015.
335 patients SOF/LDV x 12 wk
•
82% male, 34% AA, 98%
geno 1
•
55% experienced
•
20% cirrhosis
•
All 10 relapses were in AA
•
8/10 on EFV
Efficacy of SOF/VEL in HIV/HCV Coinfection
Wyles CID 2017
106 patients SOF/VEL x 12 wks
–
86% male
–
45% AA
–
18% cirrhosis
–
62% GT1a, 11% GT3
•
SVR
–
cirrhosis: 19/19 (100%)
–
SVR treatment-experienced: 29/31
(94%)
Patients With
SVR12, %
101
106
63
66
11
12
11
12
11
11
5
5
2 Relapse
1 LTFU
1 LTFU
1 Withdrew
Consent
Efficacy of GLE/PIB in HIV/HCV Coinfection
Rockstroh CID 2018
150 patients G/P x 8 or 12 wks
–
18% Black
–
19% TE
–
16% GT3
–
88% F0-F1
•
SVR:
–
93% SVR in cirrhosis (14/15)
–
1 breakthrough GT3 cirrhosis
Patients With
SVR12, %
150
153
150
151
GLE/PIB for 8 weeks works well in cirrhosis
Brown AASLD 2018
280 patients G/P x 8 wks
–
10% Black
–
Treatment naive
–
Compensated cirrhosis
–
NO HIV
60 Genotype 3 + cirrhosis not
yet known
150
153
150
151
Efficacy of elbasvir/grazoprevir in HIV Co-infection
218 patients ELB/GRA x 12 wks
–
175 male
–
38 African American
–
35 cirrhosis
–
164 on TDF containing
Rockstroh Lancet HIV 2015
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Treatment of HCV in HIV/HCV Coinfection
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Cure of HCV in HIV-infected reduces ESLD and HCC
Limketkai JAMA 2012; Berenguer Hepatol 2009; Merchante J Antimicrobiol Ther 2018
Kiser, HCVguidelines.org
Boerekamps CID 2018
Elimination of HCV in HIV infected in Netherlands
•
Athena cohort >98% of HIV pos in
recognized in Netherlands
•
69% MSM, 15% PWID
•
DAAs made available in 2015
•
15 months of data through Feb 2017
Boerekamps CID 2018
Elimination of HCV in HIV infected in Netherlands
Boerekamps CID 2018
Elimination of HCV in HIV infected in Netherlands
Elimination of HCV in HIV infected persons in France
Cotte CROI 2018
ARS Question 3: How many HCV infected people need to
be cured to eradicate HCV from HIV-infected population?
1.
20,000
2.
200,000
3.
2,000,000
4.
20,000,000
ARS Question 3: How many HCV infected people need to
be cured to eradicate HCV from HIV-infected population?
1.
20,000
2.
200,000
3.
2,000,000
4.
20,000,000
2.27 million persons are HIV/HCV coinfected
Platt Lancet ID 2016
Elimination prognosis?
Elimination prognosis?
Public health response to eliminate HCV
•
Requires shifting to public health response
•
HIV example
–
ART given to >20 million persons (>240 million person
months)/year
•
Cost of HIV ~20 billion USD/year
•
Can build on HIV infrastructure for HIV/HCV elimination
–
2 million/2-3 months each <6 million person months TOTAL
•
Must avoid 2040 forecast for status quo
Thanks!
JHU HIV
–
Mark Sulkowski
–
Seun Falade-Nwulia
–
Kathleen Ward
–
Richard Moore
–
Shruti Mehta
WHO
–
Yvan Hutin
–
Godfrey
–
John Ward
HCV/HIV
–
David Wyles
–
Susanna Naggie
Q
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A
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w
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WHO elimination indicators and targets
WHO Global Hepatitis Report 2017
WHO goals for elimination of hepatitis C
•
“A world where viral hepatitis transmission is stopped and
everyone has access to safe, affordable and effective treatment
and care”
WHO
•
Elimination
:
Reduction to zero of the incidence of infection
caused by a specific agent in
a defined geographical area
as a
result of deliberate efforts; continued measures to prevent re-
establishment of transmission are required. Example: measles,
poliomyelitis.
WHO Global Hepatitis Report 2017; Hill J Virus Elimin 2016
Why elimination and not eradication?
HCV
could
be eradicated
Every HCV-infected person can be detected
Eradicate infection by treatment
Humans are only source
Transmission can be prevented
Public health importance
HCV
could
be eradicated
Every HCV-infected person can be detected
Eradicate infection by treatment
Humans are only source
Transmission can be prevented
Public health importance
International commitment
Discussing the goals, treatment options, and global impact of Hepatitis C in individuals with HIV infection, this presentation by Dr. David L. Thomas from Johns Hopkins Medical Institutions sheds light on important aspects such as mortality projections, WHO elimination goals, and targets for hepatitis C intervention. The content also includes interactive questions related to the future outlook of chronic HCV and HBV mortality. Dr. Thomas has no relevant financial affiliations to disclose.
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Presentation Transcript
Elimination of Hepatitis C in Individuals With HIV Infection David L. Thomas, MD, MPH Professor of Medicine The Johns Hopkins Medical Institutions Baltimore, Maryland
Financial Relationships With Commercial Entities Dr Thomas has no relevant financial affiliations to disclose. (Updated 11/12/18)
Learning Objectives After attending this presentation, learners will be able to: List two 2030 elimination goals for HCV infection Compare treatment of HCV infection in a person with HIV infection and someone without
ARS Question 1: Which is most true about the expected future (2040) mortality from chronic HCV and HBV? 1. Should decrease in parallel with HIV 2. Will exceed HIV 3. Will exceed TB 4. Will exceed malaria 5. Will exceed HIV+TB+malaria
ARS Question 1: Which is most true about the expected future (2040) mortality from chronic HCV and HBV? 1. Should decrease in parallel with HIV 2. Will exceed HIV 3. Will exceed TB 4. Will exceed malaria 5. Will exceed HIV+TB+malaria
Global health importance of hepatitis Foreman Lancet 2018; IHME, 2015 http://ghdx.healthdata.org
WHO Hepatitis Elimination Goals 90% reduction in incidence 2015 2020 (30%) 2030 ~1.75 million ~1.23 million 175,000 HCV WHO Global Hepatitis Report 2017
WHO Hepatitis Elimination Goals 65% reduction in mortality 2015 2020 (10%) 2030 ~400,000 ~360,000 140,000 HCV WHO Global Hepatitis Report 2017
Targets to eliminate hepatitis C Intervention 2015 2020 2030 HCV diagnosed 20% 30% 90% HCV treatment 1% 3 million 80% Donations screened 97% 97.5% 100% Harm reduction (syr/person/yr) 27 200 300 Safe injection 95% 100% 100% WHO Global Hepatitis Report 2017
Global cascade of HCV care and 2030 WHO elimination goals: 90/80 target 2015 Reality 2030 Target 80 Number worldwide (millions) 70 60 50 40 30 20 10 0 Infected Diagnosed Treated Cured WHO Global Hep Report 2017
Elimination prefix cascade Eradication Elimination Micro- elimination HIV positive Nano- elimination National Pico- Clinic elimination Patient
ARS Question 2: A 53 year old man with 1a HCV and HIV on r/DRV, FTC, and TDF with F1-2 disease presents for HCV treatment. Which is true? 1. Needs 24 weeks of treatment due to HIV 2. Doesn t need treatment due to low F score 3. Change ART first 4. Add ribavirin to regimen 5. Must screen for HCC before starting
ARS Question 2: A 53 year old man with 1a HCV and HIV on r/DRV, FTC, and TDF with F1-2 disease presents for HCV treatment. Which is true? 1. Needs 24 weeks of treatment due to HIV 2. Doesn t need treatment due to low F score 3. Change ART first 4. Add ribavirin to regimen 5. Must screen for HCC before starting
Efficacy of SOF/LDV in HIV Co-infected patients 100 97 96 96 95 335 patients SOF/LDV x 12 wk 82% male, 34% AA, 98% geno 1 55% experienced 20% cirrhosis All 10 relapses were in AA 8/10 on EFV 80 94 SVR12 (%) 60 40 20 0 Naggie S. NEJM 2015.
Efficacy of SOF/VEL in HIV/HCV Coinfection 106 patients SOF/VEL x 12 wks 86% male 45% AA 18% cirrhosis 62% GT1a, 11% GT3 SVR cirrhosis: 19/19 (100%) SVR treatment-experienced: 29/31 (94%) 95 95 92 100 92 100 100 Patients With 80 SVR12, % 60 2 Relapse 1 LTFU 1 Withdrew Consent 1 LTFU 40 20 101 106 63 66 11 12 11 11 11 12 5 5 0 Total 1a 2b 2 3 4 Wyles CID 2017
Efficacy of GLE/PIB in HIV/HCV Coinfection 150 patients G/P x 8 or 12 wks 18% Black 19% TE 16% GT3 88% F0-F1 SVR: 93% SVR in cirrhosis (14/15) 1 breakthrough GT3 cirrhosis 98 99 100 80 Patients With SVR12, % 60 40 20 150 153 150 151 0 SVR12 ITT mITT Noninferiority Threshold Rockstroh CID 2018
GLE/PIB for 8 weeks works well in cirrhosis 280 patients G/P x 8 wks 10% Black Treatment naive Compensated cirrhosis NO HIV 60 Genotype 3 + cirrhosis not yet known 150 153 150 151 Brown AASLD 2018
Efficacy of elbasvir/grazoprevir in HIV Co-infection 218 patients ELB/GRA x 12 wks 175 male 38 African American 35 cirrhosis 164 on TDF containing Rockstroh Lancet HIV 2015
Treatment of HCV in HIV/HCV Coinfection 100 99 98 97 96 95 95 95 100 Patients With SVR12, % 90 80 70 60 50 40 30 20 10 0 SOF/VEL ELB/GRZ LDV/SOF GLE/PIB 1 2 3 4 HIV/HCV HCV Composite slide adapted from Naggie S, Duke University. 1. Wyles D, et al. Clin Infect Dis. 2017;65(1):6-12; 2. Rockstroh JK, et al. Lancet HIV. 2015;2(8):e319-327; 3. Naggie S, et al. N Engl J Med. 2015;373(8):705-713; 4. Rockstroh JK, et al. European Association for the Study of the Liver (EASL) The International Liver Congress 2017. April 19 23, 2017; Amsterdam, the Netherlands. Abstract LB-522.
Cure of HCV in HIV-infected reduces ESLD and HCC Limketkai JAMA 2012; Berenguer Hepatol 2009; Merchante J Antimicrobiol Ther 2018
HCV Care Continuum among 594 HIV/HCV infected patients in an urban HIV clinic Chronic HCV Referred Evaluated Prescribed Initiated Cured Reinfected 594 547 517 457 426 374 5
Elimination of HCV in HIV infected in Netherlands Athena cohort >98% of HIV pos in recognized in Netherlands 69% MSM, 15% PWID DAAs made available in 2015 15 months of data through Feb 2017 Boerekamps CID 2018
Elimination of HCV in HIV infected in Netherlands Boerekamps CID 2018
Elimination of HCV in HIV infected in Netherlands Boerekamps CID 2018
Elimination of HCV in HIV infected persons in France Cotte CROI 2018
ARS Question 3: How many HCV infected people need to be cured to eradicate HCV from HIV-infected population? 1. 20,000 2. 200,000 3. 2,000,000 4. 20,000,000
ARS Question 3: How many HCV infected people need to be cured to eradicate HCV from HIV-infected population? 1. 20,000 2. 200,000 3. 2,000,000 4. 20,000,000
2.27 million persons are HIV/HCV coinfected Platt Lancet ID 2016
Eradication Elimination prognosis? Elimination Micro- elimination HIV positive Nano- elimination National Pico- Your patients elimination
Eradication Elimination prognosis? Elimination Micro- elimination HIV positive Nano- elimination National Pico- Your patients elimination
Public health response to eliminate HCV Requires shifting to public health response HIV example ART given to >20 million persons (>240 million person months)/year Cost of HIV ~20 billion USD/year Can build on HIV infrastructure for HIV/HCV elimination 2 million/2-3 months each <6 million person months TOTAL Must avoid 2040 forecast for status quo
Thanks! JHU HIV WHO Mark Sulkowski Seun Falade-Nwulia Kathleen Ward Richard Moore Shruti Mehta Yvan Hutin Godfrey John Ward HCV/HIV David Wyles Susanna Naggie
WHO elimination indicators and targets WHO Global Hepatitis Report 2017
WHO goals for elimination of hepatitis C A world where viral hepatitis transmission is stopped and everyone has access to safe, affordable and effective treatment and care WHO Elimination: Reduction to zero of the incidence of infection caused by a specific agent in a defined geographical area as a result of deliberate efforts; continued measures to prevent re- establishment of transmission are required. Example: measles, poliomyelitis. WHO Global Hepatitis Report 2017; Hill J Virus Elimin 2016
HCV could be eradicated Every HCV-infected person can be detected Eradicate infection by treatment Humans are only source Transmission can be prevented Public health importance
HCV could be eradicated Every HCV-infected person can be detected Eradicate infection by treatment Humans are only source Transmission can be prevented Public health importance International commitment
