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7/4/181

Hepatitis C in 2018

Geoff Stetson, MDAssistant Professor of Medicine, UCSFHospitalist, San Francisco VA Medical Center

I have no disclosures

Hepatitis C in 2018

Life moves pretty fast…

Hepatitis C in 2018 Hepatitis C in 20184

1970 - 2011

2011 - NOW


7/4/182

We are winning!!!

5 Hepatitis C in 2018 6

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Source: data obtained from the CDW 10/8/17 and prepared by Population Health Services 10P4V

Credit: Dr. Alexander Monto, MD

Hepatitis C in 2018

7

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Surveillance for Viral Hepatitis - US, 2014. National Vital Statistics System: Mortality. www.cdc.gov. Accessed 6/29/17. Credit: Dr. Alexander Monto, MD

Hepatitis C in 2018 8

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Hepatitis C in 2018


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Rate of Overdose Deaths Involving Heroin per 100,000


Hepatitis C in 2018

Acute HCV vs. Deaths from Drug Overdose

10

≤ 0.40.5–0.91.0–1.41.5–2.5> 2.5Unknown

Rate per

100,000Population

2.8–1111.1–13.513.6–1616.1–18.518.6–2121–35.5

Rate per

100,000Population

Acute HCV 2014

Deaths from Drug Overdose 2014

Credit: Dr. Chad J Zawitz, MD

Hepatitis C in 2018

Two steps forward, one step back…

11 Hepatitis C in 2018

Roadmap

§Introduction

§Importance of Hepatitis C§Approach to Screening and Diagnosis

§Effect of Cure on Morbidity and Mortality

§Treatment options, approaches, and resources§Conclusion



7/4/184

W hy Is Hepatitis C Important?


Hepatitis C is important because…

§Cirrhosis – liver scarring

• Reduced function – bleeding, HE• Portal hypertension – ascites, varices, HRS

• Hepatocellular carcinoma

• Death – multiple causes including liver failure§Chronic Hepatitis C Virus (HCV) + EtOH = 75% of Cirrhosis


Who is at risk for Cirrhosis?

§~20-35% of patients with HCV à Cirrhosis

§Risk Factors:

• Older age

• Double hit (e.g. alcohol, NAFLD)

• Asian or Caucasian

§Genotype does not matter (except 3a)


Who is at risk for HCC?

§Of patients with Cirrhosis, ~3-5%/year à HCC

§Risk factors:• Decompensated cirrhosis

• Older age

• Family history of HCC



7/4/185

Risk of Cirrhosis and HCC to individuals is largely unknown


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Forecast Burden of HCV-Related Morbidity and Mortality

D e a th s D C C H C C

DCC = decompensated cirrhosis; HCC = hepatocellular carcinoma. Rein DB, et al. Dig Liver Dis. 2011;43(1):66-72.Credit: Dr. Alexander Monto, MD

Hepatitis C in 2018

Rising Incidence of HCV-related Cirrhosis and HCC at SFVA

19

Data derived from Liver Cube, national VA liver disease management tool. Credit: Dr. Alexander Monto, MD

Hepatitis C in 2018 20

0

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D e a th s D C C H C C

DCC = decompensated cirrhosis; HCC = hepatocellular carcinoma. Rein DB, et al. Dig Liver Dis. 2011;43(1):66-72.Credit: Dr. Alexander Monto, MD

Hepatitis C in 2018


7/4/186

NOW is the time to act!


Take home points – part 1

§HCV Treatment has changed a lot

§Now well tolerated and effective§HCV rates are on the rise

§Morbidity and Mortality from HCV are on the rise


Roadmap

§Introduction





Step 1: find people with HCV

24

SVR = sustained virological response.Yehia BR, et al. PLoS One. 2014;9(7):e101554.Credit Dr: Chad J. Zawitz, MD

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C hr on ic H C V-In fe ct io n

D ia gn os e da nd A w ar e

A cc es s toO ut pa ti en t

C ar e

H C V RN AC on fi rm ed

P re sc rib e dH C V

T re at me n t

A ch ie ve d S VR

Gaps Along the HCV Care Cascade

Unaware of DiagnosisScreen

+Confirm

+Communicate

Hepatitis C in 2018


7/4/187

Step 1: find people with HCV

§50% don’t know they’re infected

§Screening is key!§But whom should we screen?


Which of these patients should NOT be screened?1. 45 y/o woman with HIV, CD4 count of 500, VL

undetectable

2. 45 y/o woman with history of sexual intercourse

with a person who engages in IVDU

3. 45 y/o healthy woman from Nicaragua

4. 55 y/o healthy woman from the United States

5. 45 y/o woman with history of MVA requiring transfusion in 1990


27

Groups to Screen

Individual Risk Factors for Exposure

Demographic Risk Factors for Infection

Evidence of Liver Disease

Hepatitis C in 2018

Individual Risk Factors for Exposure

§Any IVDU

§Sexual intercourse with a person with hx of IVDU§Sexual intercourse with a person with HCV

§Blood transfusion before 1992

§Clotting factor transfusion before 1987§Birth to HCV-infected mother

§Needle stick



7/4/188

Demographic Risk Factors

§1945-1965 Birth Cohort

§HIV infection (faster progression, worse prognosis)

§MSM

§Hemodialysis

§Incarcerated or history of incarceration

§Born in high or moderate prevalence countries


Gower E, Estes C, BlachS, Razavi-Shearer K, RazaviH. Global epidemiology and genotype distribution of the hepatitis C virus infection. Journal of hepatology 2014;61:S45-57.

Hepatitis C in 2018

HCV Burden is Higher in Marginalized Populations

31

0 % 1 0% 2 0% 3 0% 4 0% 5 0% 6 0% 7 0% 8 0% 9 0% 1 00 %

IV D Us

H om e les s

In ca rc era te d

H os pit ali ze d

N ati ve In dia ns

B ab y B o om er s

V ete ra ns

N ur sin g Ho me R es id en ts

G en er al US

H C V S e ro p re v a le n c e

Denniston M, et al. Ann Int Med. 2014;160(5):293-300; US Department of Veterans Affairs. State of Care for Veterans with Hepatitis C, 2014. www.hepatitis.va.gov. Accessed 6/29/17; Edlin BR, et al. Hepatology. 2015;62(5):1353-1363; Grebely J, et al. Inl J Drug Policy. 2015;26(10):1028-1038; Maier MM, et al. 2016;106(2):353-358; Galbraith JW, et al. Hepatology. 2015;61(3):776-782. Credit: Dr. Chad J. Zawitz, MD.

These populations experience:• High burden of comorbidities• Inconsistency of HCV testing• Limited access to health care, let

alone HCV care

Hepatitis C in 2018

Evidence of Liver Disease

§Persistent elevation of liver transaminases – 8.6%

32

Spradling PR, Rupp L, Moorman AC, et al. Hepatitis B and C virus infection among 1.2 million persons with access to care: factors associated with testing and infection prevalence. Clinical infectious diseases : an official publication of theInfectious Diseases Society of America 2012;55:1047-55.

Hepatitis C in 2018


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AASLD/IDSA Recommendations for Screening

33

§ O n e -tim e H C V tes ting :

• A n yo n e b o rn b e tw e e n 1 9 4 5– 1 9 6 5 * w ithou t p rio r assessm en t o f r isk

• O th e rs w ith 1 + risk fa c to rs

• A n yo n e w h o a sks to b e te s te d

§ A n n u a l H C V tes ting :

• P e rso n s w h o in je c t d ru g s

• H IV-p o s itive M S M w h o h a ve u n p ro te c te d

sex

§ P e rio d ic H C V tes ting :

• O th e rs w ith o n g o in g r isk fa c to rs fo r H C V

Risk Behaviors, Exposures, and Other

Considerations• IVDU (current or ever)

• HIV-infected MSM

• Intranasal illicit drug use• HIV infection• Unexplained chronic liver disease (persistently

elevated ALT)• Tattoo or body piercing (unregulated)

• Have ever been incarcerated

• Long-term hemodialysis (ever)• Received blood/organs prior to 1992

• Received clotting factors prior to 1987• Healthcare workers after exposures to HCV-

infected blood • Children born to HCV-infected women

• Solid organ donors (deceased and living)• Sexually active persons about to start PrEP

*Regardless of country of birthAASLD = American Association for the Study of Liver Diseases; IDSA = Infectious Diseases Society of America.; PrEP=pre-exposure prophylaxisAASLD/IDSA. HCV Testing and Linkage to Care. http://www.hcvguidelines.org/evaluate/testing-and-linkage. Accessed 9/22/17.Credit: Dr. Chad J. Zawitz, MD.

Hepatitis C in 2018

Step 2: How to Screen?

What is the correct first step to screen a healthy patient born between 1945 and 1965 for hepatitis C?

1. Hepatitis C RNA PCR2. Hepatitis C culture

3. Hepatitis C antigen

4. Hepatitis C antibody


7/4/18Presentation Title and/or Sub Brand Name Here35

Recommended Testing Sequence for Identifying Current Hepatitis C Virus (HCV) Infection

HCVantibody

Reactive

Not Detected Detected

No current HCV infection

Additional testing as appropriate† Link to care

Current HCV infection

Nonreactive

HCV RNA

No HCV antibody detected

STOP*

* For persons who might have been exposed to HCV within the past 6 months, testing for HCV RNA or follow-up testing for HCV antibody is recommended. For persons who are immunocompromised, testing for HCV RNA can be considered.† To differentiate past, resolved HCV infection from biologic false positivity for HCV antibody, testing with another HCV antibody assay can be considered. Repeat HCV RNA testing if the person tested is suspected to have had HCV exposure within the past 6 months or has clinical evidence of HCV disease, or if there is concern regarding the handling or storage of the test specimen.

Source: CDC. Testing for HCV infection: An update of guidance for clinicians and laboratorians. MMWR 2013;62(18).

Who is this patient?

§Hepatitis C Antibody (IgG) – Positive

§Hepatitis C RNA PCR – PositiveA. Healthy Patient

B. Patient w/ Chronic Hep C

C. Patient w/ Hep C exposure, now clearedD. Patient w/ Acute Hep C

E. Immunosuppressed patient w/ Chronic Hep C



7/4/1810


§Hepatitis C Antibody (IgG) – Positive

§Hepatitis C RNA PCR – NegativeA. Healthy Patient






§Hepatitis C Antibody (IgG) – Negative

§Hepatitis C RNA PCR – PositiveA. Healthy Patient





Adult groups to (potentially) screen differently§HIV

§Hemodialysis§Needle Sticks

§Acute Hepatitis C (technically not screening)


Once you confirm the dx of chronic hep C (Ab+, RNA+), what other tests or assessments do you want to perform before starting HCV treatment?



7/4/1811

Step 3: Assuming Chronic HCV, what next?

41

Hist

ory -Substance Use

-Mental Health-Comorbid Conditions-Cirrhosis Complications-Prior HCV Tx

Phys

ical Stigmata:

-Spider angiomata-Palmar erythema-Splenomagaly-Jaundice/Icterus-Caput medusa

Labs

-Basic Labs: LFTs, INR, CBC, BMP-UA-Upreg-HCV genotype-HCV viral load-HIV-HAV-HBV

Hepatitis C in 2018

Assessing for Fibrosis

§Why assess for fibrosis?

• Guide treatment regimen and duration• Guide HCC screening post-treatment

• Determine urgency of treatment


Methods for Assessing Liver Fibrosis

43

Liver Fibrosis Imaging

• Ultrasound• MRE, MRI,

CT scan

Transient Elastography• FibroScan

Serum Markers

• APRI, FIB-4• FibroTest• HepaScore

Liver Biopsy

• Invasive • Rarely done

since 2014

MRE = magnetic resonance elastography; MRI = magnetic resonance imaging; CT = computed tomography; APRI = aspartate aminotransferase-to-platelet ratio index; FIB = fibrosis.LeroyV, et al. J Hepatol. 2014;S0168-8278(14)00137-8; Holmberg SD, et al. Clin Infect Dis. 2013;57(2):240-246; Chou R, Wasson N. Ann Intern Med. 2013;158(11):807-820; Poynard T, et al. J Hepatol. 2014;60(4):706-714; UdellJA, et al. JAMA. 2012;307(8):832-842; de Lédinghen V, Vergniol J. Gastroenterol Clin Biol. 2008;32(6 Suppl 1):58-67; Tapper EB, et al. Clin Gastroenterol Hepatol. 2014;S1542-3565(14)00818-0; Smith JO, et al. Aliment Pharmacol Ther. 2009;30(6):557-576; Lurie Y, et al. World J Gastroenterol. 2015;21(41):11567-11583; Castera L, et al. J Hepatol. 2008;48(5):835-847; Chin JL, et al. Front Pharmacol. 2016;7:159; AASLD/IDSA. Recommendations for Testing, Managing, and Treating HCV. www.hcvguidelines.org. Accessed 6/29/17. Credit: Dr. Alexander Monto, MD.

See online calculators for APRI, FIB-4, etc. (eg, www.gihep.com)

Hepatitis C in 2018

How to interpret the results

44

METAVIR Scale

Score F0 F1 F2 F3 F4

F ib r o s is

(s c a r r in g )

N o

d a m a g e

M ild

P o r ta l

f ib r o s is

w ith o u t

s e p ta

M o d e r a te

P o r ta l

f ib r o s is

w ith r a r e

s e p ta

A d v a n c e d

N u m e r o u s

s e p ta ,

n o t

c ir r h o s is

S e v e r e

C ir r h o s is

GhanyMG, et al. Hepatology. 2009;49(4):1335-1374; AASLD/IDSA. Recommendations for Testing, Managing, and Treating HCV.

www.hcvguidelines.org. Accessed 6/29/17.

Credit: Dr. Alexander Monto, MD. Images courtesyof: Dr. Zachary Goodman, MD.

Hepatitis C in 2018


7/4/1812

45

Child Turcotte Pugh (CTP) ClassificationFactor 1 point 2 points 3 points

Total bilirubin (µmol/L) < 34 34-50 > 50

Serum albumin (g/L) > 35 28-35 <28

INR < 1.70 1.70-2.30 > 2.30

Ascites None Mild Moderate to Severe

Hepatic Encephalopathy NoneGrade I-II

(or controlled w/ meds)

Grade III-IV(or refractory)

InterpretationCTP Class Score

Severity of Liver

Disease1-Year Survival 2-Year Survival

Perioperative

MortalityA 5-6 Mild: Compensated 100% 85% 10%

B 7-9Moderate: Significant

Functional Impairment81% 57% 30%

C 10-15Severe:

Decompensated45% 35% 82%

Hepatitis C in 2018

Take Home Points – Part 2

§50% of people with HCV are unaware

§Screen 3 groups: • High individual risk

• High prevalence groups

• Evidence of liver disease§Work-up of a patient with HCV should include:

• Fibrosis staging

• Child Pugh scoring46 Hepatitis C in 2018

Roadmap

§Introduction





SVRIm p ro v e d H e p a t ic

O u tc o m e s

Improved Liver Histology

Reduced Liver Decompensation

Reduced Risk for HCC

Reduced Risk for Liver Tx

Reduced Liver-Related Mortality

V ir a l E ra d ic a t io n

Decreased Transmission

Im p ro v e d E x t ra -

H e p a t ic O u tc o m e s

Reduced Overall Mortality

Improved QOL

Reduced Risk for Malignancy

Improved DM/CVD/CKD

Outcomes

Improved Mental Health

Hepatitis C in 2018


7/4/1813

Clinical Benefits of SVR:All-Cause Mortality in a Retrospective VA Study

49

GT1 (n = 12,166) GT2 (n = 2,904) GT3 (n = 1,794)

VA nationwide 2001–200713% cirrhosisBackus L, et al. Clin Gastroenterol Hepatol. 2011;9(6):509-516.Credit: Dr. Alexander Monto, MD

Cu

mu

lati

ve

Mo

rta

lity

(%

)

S V R ra te : 3 5 % S V R ra te : 7 2 % S V R ra te : 6 2 %

Hepatitis C in 2018

HCV Cure and Other Health Benefits

50

T2DM Cumulative Incidence

Cum

ulativ

e In

ciden

ce (%

)

Follow-up (years)2 ,8 4 2 J a p a n e s e n o n d ia b e t ic p a t ie n ts

w ith H C V fo l lo w e d a n a v e ra g e o f 6 .4

y e a rs a f te r a n t iv ir a l th e ra p y

Additional evidence exists suggesting SVR benefits for:• Lymphoma incidence• CVA incidence

References1. Arase Y, et al. Hepatology. 2009;49:739-744.2. Arase Y, et al. J Med Virol. 2014;86:169-175.

3. Arcaini L, et al. Ann Oncol. 2014;25:1404-1410.4. Hsu YC, et al. Hepatology. 2014;59:1293-1302.

Hepatitis C in 2018

Case Introduction: Meet Gina

§Gina is a 67-year-old woman that was diagnosed with HCV GT1B in 2001

§No previous HCV Treatment

§Hx of substance use disorder:

• Opioid use (injected heroin) 1970-1978

‒ On ORT since 1978 with 2 relapses prior to 1992

‒ Sustained remission from opioids since then

• Cannabis use (intermittently) since 1980

‒ Currently smokes 2-3 X/week


Case Introduction: Meet Gina

§Gina is a 67-year-old woman that was diagnosed with HCV GT1B in 2001

§Other medical conditions:

• Hypertension since 1985, at times poorly controlled• Hypertensive nephropathy since 2009



7/4/1814

Patient Evaluation

53

N o ta b le V ita l S ig n sB P 1 5 2 /9 5 m m H g

B M I 2 3 .5

A b d o m e nN o H S M

N o A s c ite s

O th e r N o rm a l

A te n o lo l 1 0 0 m g d a i ly

C h lo r th a l id o n e 5 0 m g d a i ly

A m lo d ip in e 1 0 m g d a i ly

B u p re n o rp h in e +

N a lo x o n e (S u b o x o n e ®)

8 m g /2 m g

1 ta b S L d a i ly

H C V R N A Q u a n t 1 0 ,2 0 0 ,0 0 0 IU /m L

H C V G T 1 b

To ta l B i l i r u b in 1 .1 m g /d L

A lb u m in 3 .7 m g /d L

IN R 1 .2

P la te le ts 1 8 3 ,0 0 0 /m m 3

F ib ro S u re F 2

C re a t in in e 3 .2 m g /d L

e G F R 2 8 m L /m in (C K D -4 )

G lu c o s e 9 3 m g /d L

U r in e D ru g S c re e n C a n n a b in o id s

Physical Exam Laboratory Values

Medications

Hepatitis C in 2018

What are your concerns for initiating treatment? What treatment options are

available for this patient?


2013

Sovaldi(sofosbuvir)

+ RBVGT 2/3, CP A-C

-------

Sovaldi + Olysio(simperevir)

+/- RBVGT 1/4, CP A

2014

Harvoni (sofosbuvir / ledipasvir)

+/- RBVGT 1, CP A-CGT 4-6, CP A

-------ViekiraPak/XR

(ombitasvir /paritaprevir / ritonavir + dasabuvir)

+/- RBVGT 1b>1a, CP A

2015

Daklinza(daclatasvir) + Sovaldi

GT 1/3, CP A-C-------

Technivie

(ombitasvir / paritaprevir/ ritonavir)

+ RBVGT 4, CP A

2016

Zepatier(elbasvir / grazoprevir)

+/- RBVGT 1/4, CP A

-------

Epclusa(sofosbuvir / velpatasvir)

+/- RBVGT 1-6, CP A-C

2017

Mavyret(glecaprevir / pibrentasvir)GT 1-6, CP A

-------Vosevi

(sofosbuvir / velpatasvir/ voxilaprevir)

GT 1-6, CP A

55

FDA Approval Timeline

R B V = ribav ir in , G T = geno type , C P = C h ild -P u g h S co re

Hepatitis C in 2018

Mechanisms of Action

56

NS3 Protease

Inhibitor

NS5A Replication

Complex Inhibitors

NS5B Nucleoside

Inhibitors

NS5B

Nonnucleoside Inhibitors

Brand Name

sofosbuvir Sovaldi®

simeprevir Olysio®

ledipasvir sofosbuvir Harvoni®

paritaprevir/ritonavir ombitasvir dasabuvir Viekira ®

paritaprevir/ritonavir ombitasvir Technivie®

daclatasvir Daklinza®

grazoprevir elbasvir Zepatier®

velpatasvir sofosbuvir Epclusa®

voxilaprevir velpatasvir sofosbuvir Vosevi™

glecaprevir pibrentasvir Mavyret™

Hepatitis C in 2018


7/4/1815


SEE NEXT SLIDELiang TJ, Ghany MG. Current and Future Therapies for Hepatitis C Virus Infection. New England Journal of Medicine 2013;368:1907-17. 58 Hepatitis C in 2018

Lindenbach BD, Rice CM. Unravelling hepatitis C virus replication from genome to function. Nature 2005;436:933.

59

D A A T h erap y H C V G TP a tie n t

A g e (y rs )W ks o f

T h erap yTa b le ts

p er D a y *

sofosbuvir (Sovaldi®) + RBV 2, 3 ≥ 12 12–24 1

sofosbuvir/velpatasvir (Epclusa®) ± RBV 1–6 ≥ 18 12 1

ledipasvir/sofosbuvir (Harvoni®) ± RBV 1, 4–6 ≥ 12 8–24 1

elbasvir/grazoprevir (Zepatier®) ± RBV 1, 4 ≥ 18 12–16 1

paritaprevir/ritonavir/ombitasvir (Technivie™) ± RBV 4 ≥ 18 12 2

paritaprevir/ritonavir/ombitasvir/dasabuvir (Viekira XR™) ± RBV 1 ≥ 18 12–24 3

daclatasvir (Daklinza™) + sofosbuvir (Sovaldi®) ± RBV 1, 3 ≥ 18 12 2

simeprevir (Olysio®) + sofosbuvir (Sovaldi®) 1, 4 ≥ 18 12–24 2

sofosbuvir/velpatasvir/voxilaprevir (Vosevi™) 1–6† ≥ 18 12 1

glecaprevir/pibrentasvir (MavyretTM) 1–6†† ≥ 18 8-16 3

Approved Interferon-Free DAA Regimens

*Not including ribavirin (when indicated). Credit: Dr. Alexander Monto, MD† Approved for patients with prior NS5A or sofosbuvir failure; †† Approved for patients with GT1-6 without cirrhosis or with mild cirrhosis, including patients with moderate to severe kidney disease and patients with GT1 and prior NS5A inhibitor or NS3/4A PI failure.FDA. Drugs@FDA: FDA-Approved Drug Products. www.fda.gov/drugsatfda. Accessed 8/4/17; Falade-Nwulia O, et al. Ann Intern Med. 2017;166(9):637-648.

Hepatitis C in 2018

How should we treat Gina?67 y/o W with GT1B, F2

60

Treatment Naïve Harvoni® Viekira™** Epclusa® Mavyret™***

1 aNo Cirrhosis

12 wksaClass I, Level A

12 wks + RBVClass I, Level A

12 wksClass I, Level A


Cirrhosis 12 wksClass I, Level A



1 bNo Cirrhosis 12 wksa

Class I, Level A12 wks



Class I, Level A

Cirrhosis12 wks




Class I, Level A

*Not recommended for use in moderate-to-severe hepatic impairment (Child-Pugh B or C); ** Contraindicated in patients with moderate or severe hepatic impairment (Child-Pugh B or C); *** Not recommended in patients with moderate hepatic impairment (Child-Pugh Class B) and contraindicated in patients with severe hepatic impairment (Child-Pugh C). aLDV/SOF for 8 wksis recommended for patients who are non-Black, without HIV infection, and HCV RNA < 6 million IU/mL (Class I, Level B).AASLD/IDSA. Recommendations for Testing, Managing, and Treating Hepatitis C. www.hcvguidelines.org.

R E C O M M E N D E D a n d A L T E R N A T IV E r e g im e n s fo r t r e a tm e n t -n a ïv e p a t ie n ts

All of these regimens have >92% efficacy

Hepatitis C in 2018


7/4/1816

hcvguidelines.org


Guidance for Renal Impairment

CKD 1-3

GFR > 30

• No dose adjustment needed for:

• sofosbuvir• Harvoni®

• Epclusa®• Vosevi™

• Zepatier®

• Mavyret™

CKD 4-ESRD

GFR < 30

• Zepatier®

• GT 1a, 1b, or 4

• X 12 weeks

• Mavyret™

• GT 1-6

• X 8-16 weeks


Assuming successful treatment…

§Metavir F3 or F4

• Q6Mo RUQ U/S HCC screening• Endoscopic evaluation for varices

§Metavir F0, F1, F2

• Treat them as if they never had HCV


Overall Take Home Points

§We have effective/tolerable HCV treatments!

§Morbidity, mortality, and acute infections are rising§Screen three groups:

• Individual risk, population risk, liver dysfunction

§Curing HCV has tremendous health benefits§hcvguidelines.org for assistance with treatment



7/4/1817

Thank you!


Special Thanks

§Dr. Alexander Monto, MD

• Professor of Clinical Medicine, UCSF• Director of the Liver Clinic, SFVAMC

• World-renowned Hep C expert


PARKING LOT


Clinical Benefits of SVR:Liver and All-Cause Mortality

68

All-Cause Mortality Liver-Related Mortality

T im e ( y e a rs ) T im e ( y e a rs )

All

-Ca

us

e M

ort

alit

y (

%)

Liv

er-

Re

late

d M

ort

alit

y o

r

Liv

er

Tx

(%)

• 5 3 0 E u ro p e a n s w ith a d va n ce d fib ro s is fo llo w e d fo r m e d ia n 8 .4 ye a rs a fte r H C V tre a tm e n t

• 1 9 2 (3 6 % ) a ch ie ve d S V R

van der Meer AJ, et al. JAMA. 2012;308(24):2584-2593. Credit: Dr. Alexander Monto, MD

Hepatitis C in 2018


7/4/1818

Clinical Benefits of SVR:Liver and All-Cause Mortality

69

HCC Liver Failure

T im e ( y e a rs ) T im e ( y e a rs )

Liv

er

Fa

ilure

(%

)

HC

C (

%)

• 5 3 0 E u ro p e a n s w ith a d va n ce d fib ro s is fo llo w e d fo r m e d ia n 8 .4 ye a rs a fte r H C V tre a tm e n t

• 1 9 2 (3 6 % ) a ch ie ve d S V R

van der Meer AJ, et al. JAMA. 2012;308(24):2584-2593. Credit: Dr. Alexander Monto, MD

Hepatitis C in 2018

Persons Who Inject Drugs (PWIDs)Active

Injectors• Occasional drug

use does not impact adherence, treatment completion or efficacy

• Frequent drug use (daily or every other day) does

ORT

• HCV treatment outcomes improved among those treated for opioid addiction compared to untreated individuals

Former Injectors

• Successful HCV outcomes are more likely to be achieved if PWIDs are stabilized for addiction and then undergo HCV therapy


Robaeys G, et al. Clin Infect Dis. 2013;57(Suppl 2):S129-S137; Dimova RB, et al. Clin Infect Dis.2013;56(6):806-816; Zeremski M, et al. World J Gastroenterol. 2013;19(44):7846-7851; Grebely J, et al. Clin Infect Dis. 2016;63(11):1405-1411; Dore GJ, et al. Ann Intern Med. 2016;165(9):625-634.

HCV trials focused on PWIDs have shown comparable SVR, adherence, and reinfection rates compared to rates seen in non-PWID populations

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