Access to HCV treatment for people with HIV/HCV
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Washington D.C., USA, 22-27 July 2012 www.aids2012.org Access to HCV treatment for people with HIV/HCV Professor Gregory Dore Viral Hepatitis Clinical Research Program, Kirby Institute, The University of New South Wales & St Vincent’s Hospital, Sydney
description
Access to HCV treatment for people with HIV/HCV. Professor Gregory Dore Viral Hepatitis Clinical Research Program, Kirby Institute, The University of New South Wales & St Vincent’s Hospital, Sydney. Disclosures. Burden of HIV and HCV. MSM. PWID. HIV. HCV. HCV. HIV. - PowerPoint PPT Presentation
Transcript of Access to HCV treatment for people with HIV/HCV
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Access to HCV treatment for people with HIV/HCV
Professor Gregory Dore
Viral Hepatitis Clinical Research Program, Kirby Institute, The University of New South Wales
& St Vincent’s Hospital, Sydney
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Disclosures
Roche MSD Janssen BMS Gilead
Research Grants Yes Yes Yes Yes Yes
Advisory Board Yes Yes Yes Yes Yes
Travel Sponsorship Yes Yes Yes No Yes
Stocks No No No No No
Consultancy No Yes Yes No Yes
Washington D.C., USA, 22-27 July 2012www.aids2012.org
Burden of HIV and HCV
HIV
HCV
MSM PWID
HCV
HIV
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Without effective HIV management, including adherence to antiretroviral therapy, consideration of HCV treatment is problematic
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HIV mortality by CD4 cell count
0
2
4
6
8
10
12
14
AIDS Liver Other
<5050-99100-199200-349350-499>500
DAD Arch Intern Med 2006
/100 py
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Directly observed ART in opiate pharmacotherapy setting
Berg KM. CID 2011;153:936-943
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Directly observed ART in opiate pharmacotherapy setting
Berg KM. CID 2011;153:936-943
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The complexity and lack of tolerability of IFN-based therapy mean that a major impact on HCV disease burden among PWID populations will not be achieved
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HCV treatment uptake in HIV/HCV
ESLD = 19Advanced HIV = 16Psych co-morb = 6
Drug/alcohol = 6HCV RNA –ve = 9
F0/1 = 30Patient refusal = 10
Mehta SH et al, AIDS 2006;20:2361-2369
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The advent of IFN-free direct acting antiviral therapy will provide the feasibility to rapidly scale-up HCV treatment programs for PWID
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DAA development timeline
20122010 20142011 20152013
DAA combination
PEG-IFN + RBV
PEG-IFN + RBV + DAA Treatment complexity
Dore GJ. Med J Aust 2012;196:629-632
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IFN-free DAA therapy: genotype 1, treatment naïve
Series10
10
20
30
40
50
60
70
80
90
100
ABT PI/NNI/RBV (1a/1b, 12 wks, n=33)GS NI/RBV (1a/1b, 12 wks, n=25)Linear (GS NI/RBV (1a/1b, 12 wks, n=25))
EASL 2012
SVR 4-12 %
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HCV treatment strategiesPhase I (IFN-based therapy, 2012-2014): • Treat primarily as liver disease• Target treatment to F2-4 • Increase disease staging (i.e. Fibroscan assessment)• Community-based disease staging (i.e. Portable Fibroscan)• Expand treatment access: Prisons, Methadone clinics, Rural & Regional,
Nurse Practitioners/Consultants, GPs , ID specialists
Phase II (IFN-free therapy, 2014 and beyond): • Treat primarily as infectious disease • Treat all stages of disease• Major involvement of infectious disease and primary care clinics, with
advanced disease in liver clinics • Strategies to optimize adherence• ? Treatment as prevention
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Hepatic elastography
Vergniol J et al. Gastroenterology 2011:140:1970-1979.
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Progression to ESLD, HCC, liver-mortality
F0 F1 F2 F3 F4 Total0
10
20
30
40
50
/1,000 py
Johns Hopkins HIV/HCV Clinic (n=631)
Baseline liver biopsy 1993-2009; Median follow-up = 5.4 years
Sulkowski M et al, CROI 2010
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Community-based HCV treatment
Arora S E et al. Hepatology 2010; 52:1124-1133
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Without removal of barriers to treatment access, including DAA treatment price reform, the impact of improving therapy on HCV disease burden will be modest
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Removing barriers to treatment accessPatient directed: • Improved education and counseling • Evaluation of peer-based support• Management of co-morbidities, particularly psych and drug and alcohol
Provider directed: • Improved education and training • Expansion of practitioner base: addiction medicine, ID, primary care• Incentives for involvement in HCV treatment and care
Infrastructure based: • Improved HCV screening and assessment • Development of multidisciplinary teams• Community based programs, including telehealth/telemedicine
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Price of first generation ART
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Impact of improving HCV treatment
Thomas DL. Lancet 2010;376:1441-1442
