the intersection of hiv and hepatitis c · sarah kattakuzhy, md. co-director, dc partnership for...
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DC Partnership for HIV/AIDS Progress Clinical Division
The Intersection of HIV and Hepatitis C
Sarah Kattakuzhy, MDCo-Director, DC Partnership for HIV/AIDS Progress Hepatitis Clinical Research Program
Assistant Professor, University of Maryland Institute of Human Virology
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Major Historical Milestones in HIV and HCV
HIV Causal organism isolated
First description of P. carinii
cluster
First serum assay
approved
First treatment approved
Combination antiviral therapy
1975 1980 1985 1990 1995 2000
First description
of non A non B hepatitis
Hepatitis C
Causal organism
isolated and cloned
First treatment approved
First serum assay
approved
Combination antiviral therapy
Curran, MMWR 2011; Center for Disease Control Viral Hepatitis Fact Sheet
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Viral Characteristics
• Retrovirus• Double stranded• RNA DNARNA
• Flavivirus• Single stranded, positive sense• RNA RNA
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Viral Characteristics
HIV Hepatitis C
Target Host Cell CD4+ T Cell Hepatocyte
Replication Latent Active
Population 1 million 5 million
Mutation Rates Very high Very high
Virions/Day 1010 1012
Genetic Archive Yes No
Adapted from Soriano et al, JAC 2008
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Current Directly Acting Antivirals
REGIMEN
SOF/RBV
LDV/SOF
SOF/VEL
DAC/SOF
PRO-D/TECHNIVIE@
GRZ/ELB
Genotypes
ALL
1 & 4
ALL
ALL
1 & 4
1 & 4
Duration
12-24 WKS
12-24 WKS#
12 WKS#
12-24 WKS#
12-24 WKS
12-16 WKS$
SVR (%)
70-100
>95
>99
>95
>90
>95
# RBV to be added for decompensated cirrhosis@Dasabuvir has no activity against genotype 4$ RBV to be added for those with baseline NS5A mutations AASLD-IDSA HCV Guidance (hcvguidance.org)
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Hepatitis C Care Continuum100
50
43
27
16
9
0
10
20
30
40
50
60
70
80
90
100
Chronic HCV Infection Diagnosed and Aware Access to OutpatientCare
HCV RNA Confirmation Prescribed HCVTreatment
Achieved Cure
Adapted from Yehia et al PLOS One 2015
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Where does the HCV field go from here?
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Dramatic Progress in HIV Treatment
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Scientific Advancements
Combination ART
Refined Technical Approach
Algorithm-based
Minimal lab monitoring
Task Shifting
Incorporating care into
existing settings
Use of generics
Rapid Diagnostic
Testing
Key Factors in HIV Treatment Implementation
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Key Factors in HIV Treatment Implementation
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Key Factors in HIV Treatment Implementation
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Hepatitis C Care Continuum100
50
43
27
16
9
0
10
20
30
40
50
60
70
80
90
100
Chronic HCV Infection Diagnosed and Aware Access to OutpatientCare
HCV RNA Confirmation Prescribed HCVTreatment
Achieved Cure
Adapted from Yehia et al PLOS One 2015
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HCV Treatment Implementation
Scientific Advancements
Combination DAA Therapy
Refined Technical Approach
Algorithm-based
Minimal lab monitoring
Task Shifting
Incorporating care into
existing settings
Use of generics
Rapid Diagnostic
Testing
NIH ASCEND Investigation
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Study Design
Two urban health systems
16 providers
5 NP 5 PCP
Uniform 3-hour training
6 Specialist (ID/Hepatology)
Kattakuzhy, Annals of Internal Medicine 2017
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Methods
• No study team involvement after initial visit
• Standardized visit schedule based on AASLD-IDSA guidance• Monthly provider visits• Week 4 safety labs • HCV viral load testing at week 4 and SVR12
Kattakuzhy, Annals of Internal Medicine 2017
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Primary Outcome89.4%
(135/151) 86.3% (138/160) 83.0%
(240/289)85.5%
(513/600)
0
10
20
30
40
50
60
70
80
90
100
NP PCP Specialist Overall
Perc
enta
ge w
ith S
VR
p=0.19
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HCV Treatment Implementation
Scientific Advancements
Combination DAA Therapy
Refined Technical Approach
Algorithm-based
Minimal lab monitoring
Task Shifting
Incorporating care into
existing settings
Use of generics
Rapid Diagnostic
Testing
?
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HCV Medication Cost
University of Washington Hepatitis C Curriculum; van de Ven, Hepatology 2015
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• Gilead License Agreements
• Emerging observational data that licensed generics have equal efficacy
HCV Generics
Hill et al, J Virus Erad 2017
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Limited Advocacy
Delayed serious outcomes reduce urgency
Unequal access to medications
Disenfranchised populations excluded
Younossi et al, J Viral Hepat 2016
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Limited Government Investment
• Research Funding on HCV is tied to subgroups of political interest, not to disease or implementation needs
• Senate Finance Committee inquiry into Sovaldi pricing December 2015 did not lead to significant price changes
• No PEPFAR or RWCA equivalents
• Medicaid coverage varies state to state and includes non-evidence based restrictions on liver fibrosis stage, substance use, and provider type.
Barua et al, Annals 2015https://www.finance.senate.gov/ranking-members-news/wyden-grassley-sovaldi-investigation
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Where does the HCV field go from here?
• Refine our technical approach through large scale, randomized implementation studies
• Increase advocacy, engaging marginalized populations
• Gain government buy-in
• Obtain access to generic medications
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Thank You
NIH•Henry Masur MD•Michael A. Polis MD, MPH•H. Clifford Lane MD•Anthony S. Fauci MD
IHV•Robert Redfield MD•Shyam Kottilil MD, PhD•Eleanor Wilson MD, MS•Lydia Tang MD•Amy Nelson RN•Jennifer Hoffman RN, NP•Angie Price NP
DC-PFAP HCRP• Elana Rosenthal MD• Rachel Silk RN• Chloe Gross RN• Elizabeth Akoth RN• Kristi Hill• Laura Nussdorf• Poonam Mathur DO
Community Partners•Unity Healthcare•Family Medical Counseling Services•HIPS•RAP•DC DOH •WWH
Office of AIDS Research
Patients of the District of Columbia
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Hepatitis C: Global Epidemiology
World Health Organization, 2017
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Hepatitis C: National Epidemiology
Clin Infect Dis. 2017;64(11):1573-1581
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Clinical Characteristics
HIV Hepatitis C
Transmission Blood, Sex, Mother to Child Blood, Sex, Mother to Child
Progression Slow, ~10 years to fatal disease Slow, ~20 years to fatal disease in some
Mortality High in nearly all infected patients if untreated
High in advanced fibrosis patients if untreated
Drug Targets Multiple Multiple
Therapy Duration Lifelong 8-24 weeks
Current Therapeutic Goal Suppression Eradication