SS 2017: Treatment Updated on Hepatitis B or C co-infection

Treatment Updated on
Hepatitis B or C co-infection
Anchalee Avihingsanon, MD, PhD
HIV-NAT, Thai Red Cross AIDS Research Centre
Bangkok, Thailand
06 Oct 2017

HBV, HCV : Silent Killer
75% unknown HCV2
248M*
110M*
35 M
HBV ( HBsAg+)
HCV
HIV
7 M
1Bosch FX, et al. Clin Liver Dis. 2005;9:191-211
2 Mitchell AE, et al. Hepatology. 2010;51:729-733.
3 Sungkanuparph S J Med Assoc Thai 2004, 4Law WP AIDS 2004
* WHO guideline on HBV and HCV testing Feb2017
Thailand: 8-10% of HIV/HBV, HIV/HCV3,4
3-4 M
Liver cancer in Asia : 80% HBV
30% to 50% of HCC
associated with HBV in the
absence of cirrhosis1
HBV is 100 times
more infectious
than HIV

3Regional Action Plan for Viral hepatitis in South-East Asia 2016-2021
Mortality due to viral hepatitis in South-East Asia 2015
HBV 39.4 M
HCV 10.3 M
Viral hepatitis death 410,000,
78% from HBV, HCV related HCC, cirrhosis
HBV > 8% : North Korea, Myanmar,
Timor-Leste
HBV 2-7%: Bangladesh, India, Thailand
HBV<2%: Bhutan, Napal, Sri Lanka

4
Goh GB, Best Practice & Research Clinical Gastroenterology 2015; 29(6): 919-928, Zhu RX, Gut Liver 2016;10(3):332-339
Hepatocellular carcinoma in Asia
HCC in SriLanka
N=105 in 2011 from
North Colombo liver unit
79% cirrhosis
Majority from NASH
Siriwardana RC :
The Sri Lanka J of Surgery
2013: 31(2):14-18

low prevalence of HBV and HCV in Sri Lanka
• 460 samples of liver disease patients during Jan2006-Dec 2007, only 32 samples(6.9% )
was positive for HCV RNA1
• HCV GT1b (46.9%), HCV GT2b (21.9%), 2a (15.6%, mixed infection (1+2) (3.1%)
• 1933 samples of liver disease patients during July2006-Aug 2010, only 219 samples
(11.33%) was positive for anti HCV Ab and 54 of 219 (24.66%) had HCV RNA positive 2
• HCV GT1 (48.97%), HCV GT2 (25%), HCV GT3 (18.7%), HCV GT4 (4.17%), mixed infection (1+2) (2.08%)
• 4980 samples of healthy blood donor during Aug –Dec 2009, only 53 samples (1.06%) was
positive for anti HCV Ab and 8of 54 (15.09%) had HCV RNA positive 3
• HCV GT3 (100%)
• A community based study in 1995, prevalence of HBsAg positive was 2.5%4
• Substance abuser in 2005, anti HBc positive was 7.6% and none had positive HBsAg5
• National STD/AIDS control 2016 : HBV 0% for MSM, PWID, FSW and 0.5% of clients of SW
HCV 0% for MSM, clients of SW, 2.3% of PWID, 0.4% FSW
1 Senevirathna D Southeast Asian J Trop Med Public Health2008;39 (6): 1054-1056; 2 Senevirathna D Asian J of Medical
Sciences May-June 2015: 6(3); 3 Senevirathna D Asian J Transfus Sci 2011;5 (1): 23-25; 4 Eeswaraarachchige P Postgraduate
Institute of Medicine, Colombo 1993; 5 Tissera HA Thesis PGIM University of Colombo 2005, Noordeen FNN SriLankan J of
Infectious Disease 2015:(5(2): 42-50

Interferon alfa-2b
Lamivudine
Adefovir
Peginterferon alfa-2a
Telbivudine
TDF
1990 1998 2002 2005 2006 2008
HBV Treatment Landscape in 2017
Entecavir
Both HIV and HBV activity
Always check HIV prior using
Emtricitabine : both HIV/HBV activity but not yet FDA
approved for HBV treatment
First line for HBV monoinfection
: Entecavir, TDF, Peg IFN, TAF
2016
TAF
tenofovir Exalidex ( TXL) :
( 60x for HBV, 200x for HIV)
tenofovir disopoxil fumarate (TDF) , tenofovir alafenamide (TAF)

Tenofovir Alafenamide (TAF) : TAF/FTC, TAF/FTC/RPV,
TAF/FTC/Elvitegravir/cobi, TAF ( Vemlidy)
– Enhances delivery of active drug (TFV-DP) to hepatocytes
– Lower dose reduces circulating TFV levels >90% (297 vs 3410ng*h/mL)
– Lower risk of extrahepatic toxicity : lesser bone and renal toxicity
 Abnormal lipids > TDF but no change of Chol: HDL
 Drug interaction : TAF is reduced significantly by rifampicin
 Up to year 2017 : No data on pregnancy, PrEP

TAF HBV Phase III in HBV mono, 48 week results
Study 108: HBeAg-
N=425
Study110:HBeAg+
N=873
Asian 70% 80%
GT
B
C
D
21%
40%
32%
17%
52%
23%
HBV DNA, log10IU/ml 5.7
20% >7log10
7.6
50%>8log10
HBV DNA<29IU/ml 93% TAF vs 94% TDF 64% TAF vs67%TDF
ALT normalization 50% TAF vs 32% TDF 45%TAF vs 36% TDF
HBeAg loss 14% TAFvs 12%TDF
HBsAg loss <1% <1%
BMD spine -0.88% TAF vs -2.51% TDF -0.42% TAF vs -2.29% TDF
BMD hip -0.29% TAF vs -2.16 TDF -0.10% TAF vs -1.72% TDF
eGFR changed -1.4 TAF vs -4.7 TDF -0.3 TAF vs -4.7 TDF
elevated LDL cholesterol 4-5% in TAF vs <1 % TDF
Lancet Gastroenterol Hepatol 2016 Nov;1:1856
TAF has comparable efficacy to TDF but more favorable effects on renal and bone markers
TAF 25mg daily
with food
CrCl > 15ml/min
Drug interaction:
certain
anticonvulsants,
Rifampin, St John’s
wort.

TAF/FTC/EGV/cobi switching in HIV-HBV
N=72, Asian 10%, TDF 96%
HBeAg+42%
Median duration of HBV 12 yr
HBe Ag loss 3% at wk24 and 7% at week48
HBsAg loss 1% at wk24 and 3% at week48
 Stable eGFR but improved renal biomarkers (UPCR, UACR, RBP/cr,
β2M/Cr) and bone markers
 worsening of TC ( 183 to 193 mg/dl) and TC: HDL ratio 3.5 to 3.7
J Gallant: J Acquir Immune Defic Syndr 2016; 73:294

New Guidelines 2017
HBV/HIV Co-infection
Any CD4 count, Any HBV DNA
Lamivudine experienced Lamivudine Naive
Add or substitute
one NRTI with TDF
(TAF)*
as part of cART
cART including
TDF (TAF) + FTC
or 3TC
EACS 2016, DHHS 2017, WHO 2016* If HIV RNA <50 c/ml
CrCl > 60 cc/min : TDF or TAF
CrCl 30-59 : TAF
Guidelines for the prevention and treatment of OI in HIV-infected adults and adolescent :
updated Aug3,2017
TAF should be avaoided
in CrCl <30

HEALTHY LIVER FIBROTIC LIVER CIRRHOTIC LIVER
Chronic Hepatitis C Is
a Progressive Disease
HIV / HCV co-infection is
double trouble
• Compared to HCV mono, HIV/HCV is associated with
• Susceptibility to mucosal transmission, higher rates of persistence
–  viraemia (8-20x faster)1,2
•  perinatal HCV transmission (20% vs 6%) and sexual HCV transmission(3% vs <1%)1,3
–  chance of HCV spontaneous clearance esp CD4<200 cells/uL (5%) vs CD4>500ells/uL ( 8.3%)
vs HIV-(13.8%) 1,2,4
• Risk of chronic HCV 90% in HIV + vs 70-80 % HIV-
– Accelerated rate of fibrosis
–  hepatic fibrosis (2–5-fold greater), cirrhosis (2-3 fold), liver failure (16 fold) decompensation, hepatocellular
carcinoma (6 fold) and liver-related mortality1,5
1. WHO 2016 Management of hepatitis C and HIV coinfection. 2. Sherman KE, et al. Gastroenterology 2005;128:313–27;
3. Vallet-Pichard A, Pol S. J Hepatol 2006;44(S1):S28–34. 4.Thomas DL. JAMA 2000; 284:450-456
To reduce the burden of
HIV/HCV co-infection we must
screen, test, and treat!

Genotype 3 is associated with liver fibrosis/HCC
• Associated with more rapid
progression of fibrosis and higher risk
of HCC
• Suboptimal responses to first-
generation DAAs
• The most common HCV GT in
Thailand ( GT 3 : 45-50%, GT1:
30-35%, GT6 : 15-20%)
1. Messina JP, et al. Hepatology. 2015;61:77-87.
2. Nkontchou G, et al. J Viral Hepat. 2011;18:e516-e522.
HCC-Free Survival by Genotype[2]
1.0
0.8
0.6
0.4
0.2
0
0 12108642
251
33
25
44
56
3
1
3
85
8
3
6
166
24
10
25
207
27
20
37
Genotype 1
Genotype 2
Genotype 3
Genotype 4
Yrs
P = .001
HCC-FreeSurvival
Genotype 3
Genotype 1
Genotype 2
Genotype 4

HIV/HCV coinfection : extrahepatic (40-70%)
Adapted from Operskalski EA and Kovacs A. Curr HIV/AIDS Rep. 2011;8:12–22.
Immune
activation
Immune
dysfunction
HIV/HCV
Liver
disease
HIV disease
progression
Metabolic
disorders
GI tract
Neurologic
disease
Cardio-
vascular
Kidney
disease
Bone
disorders
• CD4 apoptosis
• Abnormal T-cell responses and cytokine production
• Cytotoxic T-cell accumulation in liver
• Impaired CD4 recovery post-HAART
• Severe immunodeficiency
• Diabetes mellitus
• Insulin resistance
• Microbial
translocation
• Steatosis
• Fibrosis
• Cirrhosis
• End-stage liver
disease
• Liver-related death
• Global cognitive impairment
• Cognitive-motor impairment
• Dementia
• Peripheral neuropathy
• Cerebrovascular
disease
• Acute myocardial
infarction
• Opportunistic
infections
• Wasting syndrome
• Proteinuria
• Acute renal failure
• Chronic kidney
disease
• Osteonecrosis
• Osteoporosis
• Bone fracture
Mixed cryoglobulinemia/
cryoglobulinemic vasculitis
B-cell NHL

Benefits of HCV Therapy Extend Beyond the Liver: Diabetes
• HCV cure significantly reduces
incidence of type 2 DM[1]
– HCV pts have 2-3 x greater odds of
DM[2]
• SVR may prevent and improve IR[3]
– Overall : SVR : IR 7%, non SVR : IR 17%
– Genotype1,4 : SVR : IR 8%, non SVR : IR
16%
– Genotype2, 3 : SVR : IR 7%, non SVR : IR
20%
• IR and DM increase risk and rate
of fibrosis[2]
• PegIFN + RBV associated with
improved renal/cardiovascular
outcomes in pts with DM + HCV[4]
1. Arase Y, et al. Hepatology. 2009;49:739-744.
2. Brandman D, et al. Diabetes Care. 2012;35:1090-1094.
3. Aghemo A, et al. Hepatology. 2012;56:1691-1687.
4. Hsu YC, et al. Hepatology. 2014;59:1293-1302.
ESRD in DM Pts Treated or
Untreated With PegIFN + RBV[4]
CumulativeincidenceofESRD(%)
Treated pts
(DM + HCV; n = 1411)
Untreated pts
(DM + HCV; n = 1411)
Untreated pts
(DM only; n = 5644)
P < .001
10
8
6
4
2
0
0 1 2 3 4 5 6 7 8
Yrs
HIV/HCV : increased risk of insulin resistance
and diabetes mellitus

A perfect storm for sexual HCV transmission among
MSM-HIV positive
Drugs
HIV
Sex
•Bloody practices
•Semen exposure
•Other STDs,
syphilis
•Sildenafil
•Internet : group
sex
•Crystal
methamphetamine
–Higher levels of virus in plasma and semen
–Immune deficiency, especially at GI mucosa

Hepatitis C Is an INFECTIOUS Virus:
Treatment as Prevention
1. Terrault NA, et al. Hepatology. 2013;57:881-899. 2. Thomas SL, et al.
Int J Epidemiol. 1998;27:108-117. 3. Larsen C, et al. PLoS One.
2011;6:1-9. 4. Shepard CW, et al. Lancet Infect Dis. 2005;5:558-567.
Infection in
monogamous
heterosexual
couples is
rare[1]
Risk of
transmission
from mother
to child is low[2]
Sex between men
who are HIV-
positive increases
the risk of
contracting
HCV[3]
People who
inject drugs
account for the majority of
new cases of HCV in
developed countries[4]
HCV infection= STI among MSM
 viraemia (8-20x
faster)1,4

Benefits of Achieving SVR
↓ Cirrhosis
↓ Decompensation
↓ HCC
↓ Transplantation
↓ All-cause mortality
Improved QoL
Malignancy
Diabetes
CVD
Renal
Neurocognitive
Cure
Improved clinical
outcomes
1. Smith-Palmer J, et al. BMC Infect Dis. 2015;15:19.
2. Negro F, et al. Gastroenterology. 2015;149:1345-1360.
3. George SL, et al. Hepatology. 2009;49:729-738.
4. van der Meer AJ, et al. JAMA. 2012;308:2584-2593
Hepatic Extrahepatic
Decreased
transmission
Virologic cure does
not protect against
reinfection
Risk of Late Relapse or Re-Infection with
Hepatitis C After Sustained Virological
Response: Meta-Analysis of 66 Studies in
11,071 Patients
1. Low Risk
43 studies
N = 9,419
Avg. FU = 4.1±2.1y
Reinfection =1.1%
(95%CI 0.9–1.4%)
2. High Risk
(IDUs/prisoners)
16 studies
N = 819
Avg. FU = 2.9±1.6y
Reinfection =13.2%
(95%CI 9.9–17.2%)
3. HIV/HCV Co-
Infected
7 studies
N = 833
Avg. FU = 3.1±1.2 years
Reinfection=21.7%
(95%CI 18.3–25.5%)
How to monitor
Reinfection?

HCV should be treated prior advanced liver fibrosis
• 1000 patients with bridging fibrosis or cirrhosis who achieved SVR following
IFN-based HCV therapy followed for median of 5.7 yrs
• Cirrhotics at greatest risk of HCC following SVR
• 51 cases developed HCC
Van der Meer AJ, et al. AASLD 2013. Abstract 143. Reproduced with permission.
CumulativeHCC
Occurrence(%)
Cirrhosis
Bridging Fibrosis
P = .064
8-Yr HCC Rate,
% (95% CI)8.5
(5.8-11.2)
1.8
(0-4.3)
Yrs
12
10
8
6
4
2
0
0 1 2 3 4 5 6 7 8
Age >60 yrs : 12%(5.3-19.1)
45-60 yrs:9.7(5.8-13.6)
<45 yrs: 2.6%(0-5.5)
Platelet <150,000
AST/ALT ratio> 90

Treatment and Care of active HCV infection
CDC. MMWR Morb Mortal Wkly Rep. 2013;62:362-365.
HCV antibody test Provide care
or link to care
Reactive
Nonreactive
Stop
HCV RNA test Detected
Not detected
No current HCV
infection
Current HCV infection
Additional testing as
appropriate
HCV genotype
Fibrosis/Cirrhosis
Co-infection :
HIV, HBV
Diabetes, fatty
liver, renal disease
Treatment
duration
Use of ribavirin
Follow-up care :
HCC screening
Monitor for
progressive fibrosis
:APRI (AST platelet
ratio index), FIB-4,
FibroSure, FibroScan
< 0.5 : No fibrosis
>1.5 significant
fibrosis
>2.0 cirrhosis

HIV-HCV
HIV
HAART
HCV
DAA
>90% SVR achievable
Manageable drug-drug interaction
Less toxicity
• HCV related mortality/morbidity
• Quality of life
• Risk of ART related hepatotoxicity
• HCV transmission
Direct Acting Antivirals (DAAs) against HCV

Manns MP, et al. Lancet. 2001;358:958-965. Fried MW, et al. N Engl J Med. 2002;347:975-982. Poordad F, et al. N Engl J Med. 2011;364:1195-1206.Jacobson IM, et al. N Engl J
Med. 2011;364:2405-2416.Lawitz E, et al. N Engl J Med. 2013;368:1878-1887.Afdhal N, et al. N Engl J Med. 2014;370:1889-1898. Ferenci P, et al. N Engl J Med.
2014;370:1983-1992.Feld JJ, et al. N Engl J Med. 2014;370:1594-1603.Kwo P, et al. EASL 2015. Abstract LB14. Zeuzem S, et al. Ann Intern Med. 2015;163:1-13. Feld JJ, et al.
N Engl J Med. 2015;373:2599-2607. Foster GR, et al. N Engl J Med. 2015;373:2608-2617.
IFN
6 Mos
PegIFN/
RBV
12 Mos
IFN
12 Mos
IFN/RBV
12 Mos
PegIFN
12 Mos
2001
1998
2011
Standard
Interferon
Ribavirin
Peginterferon
1991
PegIFN/
RBV +
DAA
IFN/RBV
6 Mos
6
16
34
42 39
55
70+
0
20
40
60
80
100
DAA +
RBV ±
PegIFN
90+
2013
All–Oral
DAA±
RBV
Current
95+
All-Oral
TherapyDirect-Acting
Antivirals
Current All-Oral Therapies Highly Effective, Simple, Well
Tolerated for both HCV mono and HCV/HIV co-infection
Nearly Everyone With HCV Can Now Be Treated Successfully

Current All-Oral Regimens for HCV Infection ( as of 09/2017)
Regimen Trade name Approved
Genotypes
Grazoprevir/elbasvir Zepatier 1, 4
Ombitasvir/paritaprevir/ritona
vir
Technivie 4
Ombitasvir/paritaprevir/ritona
vir + dasabuvir
Viekira Pak 1
Sofosbuvir + daclatasvir * Sovaldi+ Daklinza 1, 3
Sofosbuvir/ledipasvir Harvoni 1, 4, 5, 6
Simeprevir + sofosbuvir Olysio+Sovaldi 1
Sofosbuvir/velpatasvir * Epclusa
1, 2, 3, 4, 5,
6
Sofosbuvir/velpatasvir/voxilapre
vir*
Vosevi
1, 2, 3, 4, 5,
6
Glecaprevir/pibrentasvir* Mavyret
1, 2, 3, 4, 5,
6
References in slidenotes.
*Pangynotypic
 Effective > 95%
 Single-pill formulations
or
2-pill combinations
Previous SOF or NS5A treatment
*SOF / Peg IFN/RBV 12 weeks
Previous NS5A or NS3/4 PI treatment
October 2017: grazoprevir-ruzasvir-uprifosbuvir for pangenotype is stopped

Daclatasvir
Approved DAAs against HCV ( as 9/2017)
HCV Non-Structural (NS) Proteins
Protease inhibitors
“…previrs”
NS5A inhibitors
“…asvirs”
Polymerase inhibitors
“…buvirs”
Boceprevir Telaprevir
Simeprevir
Grazoprevir
Paritaprevir
Ledipasvir:LDV
Velpatasvir:
VELElbasvir
Ombitasvir
Nucs Non-Nucs
Sofosbuvir * Dasabuvir
Adaptaded from Pawlotsky J-M, Gastroenterology; 146: 1176-92, 2014
SOF/ VEL VEL : CYP3A, CYP 2B6, CYP2C8
Transporter : P-gp, BCRP, OATP1B1/3
SOF/ LDV LDV, SOF :Transporter : P-gp, BCRP
Daclatasvir
DCV: CYP 3A
Transporter : P-gp
grazoprevir:CYP3A,OATP1B1/3
Elbasvir : CYP3A
Voxilaprevir
Glecaprevir Pibrentasvir

Daclatasvir
Protease inhibitors
“…previrs”
NS5A inhibitors
“…asvirs”
“…buvirs”
Simeprevir
Grazoprevir
Paritaprevir Ledipasvir:LDV
Velpatasvir:
VEL
Elbasvir
Ombitasvir
Nucs Non-Nucs
Simeprevir
CYP 3A
Contraindication: RTV boosted PI, EFV,
amiodarone,
Ca2+ blockers, statin, midazolam etc
Contraindication: RTV boosted PI, RIF, amiodarone,
Ca2+ blockers, statin, midazolam etc
Voxilaprevir
Glecaprevir
Pibrentasvir
Paritaprevir, RTV, ombitasvir+/-dasabuvir
:PrO(D) : CYP3A, CYP2C8

Daclatasvir
Protease inhibitors
“…previrs”
NS5A inhibitors
“…asvirs”
“…buvirs”
Simeprevir
Grazoprevir
Paritaprevir
Ledipasvir:LDV
Velpatasvir:
VEL
Elbasvir
Ombitasvir
Nucs Non-Nucs
Glecaprevir/Pibrentasvir
:G/P: Transporter : P-gp, BCRP, OATP1B1/3
Weekly inhibitors of CYP3A, CYP1A2, UGT1A1
SOF/VEL/Voxilaprevir
: vosevi
VEL : CYP3A, CYP 2B6, CYP2C8
VOX: CYP3AContraindication : atazanavir, RIF, carbamazepine,
Efavirenz, St John’s wort
Pibrentasvir
Voxilaprevir
Glecaprevir

Recommended for GT1 Tx-Naive or IFN-Exp’d Pts Without Cirrhosis
HCV Genotype Recommended Regimens (All 12 Wks)
1a
 LDV/SOF
 SOF/VEL
 DCV + SOF
 SMV + SOF
 EBR/GZR*
 OBV/PTV/RTV + DSV + RBV
1b
 LDV/SOF
 SOF/VEL
 DCV + SOF
 SMV + SOF
 EBR/GZR
 OBV/PTV/RTV + DSV
*Only if no baseline NS5A elbasvir RAVs detected.
AASLD/IDSA. HCV guidance. September 2016.
DSV, dasabuvir; EBR, elbasvir; GRZ, grazoprevir, LDV,
ledipasvir; OBV, ombitasvir; PTV, paritaprevir; RAV, resistance
associated variant; SOF, sofosbuvir; VEL, velpatasvir.
WHO 2016 alternative : SOF / Peg IFN/RBV 12 weeks
 No 8-wk regimens
of SOF/LDV
recommended in
HIV/HCV
coinfection
 Other
recommendations
on treatment
duration and
inclusion of RBV
same for HCV
monoinfection,
HIV/HCV
coinfection

Recommended for GT1 Tx-Naive or IFN-Exp’d Pts With
Compensated Cirrhosis
HCV
Genotype
Recommended Regimens (All 12 Wks)
Treatment Naive IFN/RBV Experienced
1a
 EBR/GZR*
 LDV/SOF
 SOF/VEL
 EBR/GZR*
 LDV/SOF + RBV
 SOF/VEL
1b
 EBR/GZR
 LDV/SOF
 SOF/VEL
 EBR/GZR
 LDV/SOF + RBV
 SOF/VEL
*Only if no baseline NS5A elbasvir RAVs detected.
WHO 2016 : SOF+DCV 24 weeks included

Recommended Regimens for Treatment-Naive Pts With GT2, 4,
5, 6 HCV
• All regimens 12 wks
HCV
Genotype
No Cirrhosis Compensated Cirrhosis
2  SOF/VEL  SAME
4
 OBV/PTV/RTV + RBV
 SOF/VEL
 EBR/GZR
 LDV/SOF
 SAME
5 or 6
 SOF/VEL
 LDV/SOF
 SAME

Management of Pts With Genotype 3
Tx Experience Cirrhosis? Y93H RAV? Recommended Regimens
Naive No --
 12 wks DCV + SOF
 12 wks SOF/VEL
Naive Yes No
 24 wks DCV + SOF ± RBV
 12 wks SOF/VEL
Naive Yes Yes
 24 wks DCV + SOF + RBV
 12 wks SOF/VEL + RBV
PegIFN/RBV No No
 12 wks DCV + SOF
 12 wks SOF/VEL
PegIFN/RBV No Yes
PegIFN/RBV Yes --

HIV/HCV : drug-drug interaction

Simepre
vir
daclatas
vir
sofosbu
vir
ledipasv
ir
OBV/
PTV/r
+DSV
OBV/
PTV/r
Grazopre
vir/elbasv
ir
Velpat
asvir
Raltegravir
Dolutegravir
Elvitegravir/cobicistat
30 mg
QD*
Not with
TDF
*
NRTIs
Abacavir
Emtricitabine
Lamivudine
Tenofovir DF
Not with
cobi or
RTV
TAF
Zidovudine
These drugs should not be coadministered
Potential interaction – may require dosage adjustment or
close monitoring
No clinically significant interaction expected
* Has not been studied
Liverpool HEP Interactions
www.hep-druginteractions.org/

Simeprev
ir
daclatas
vir
sofosbu
vir
ledipasvi
r
OBV/
PTV/r
+DSV
OBV/
PTV/r
Grazopre
vir/elbasv
ir
Velpatas
vir
These drugs should not be coadministered
Potential interaction – may require dosage adjustment or
close monitoring
No clinically significant interaction expected
* Has not been studied
Efavirenz 90 mg QD
Etravirine
*90 mg QD * * * * * *
Nevirapine
*90 mg QD
↓
* * * * * *
Rilpivirine
Atazanavir/ritonavir 30 mgQD
Not with
TDF
No RTV
Darunavir/cobicistat
Not with
TDF
↑
Darunavir/ritonavir
Not with
TDF
Only if no
PI
mutations (
no RTV)
Lopinavir/ritonavir
Not with
TDF
↑

ART and DAAs
• ART switches when needed
• Daclatasvir requires dose adjustment with ATV/r ( DCV 30 mg) and efavirenz or etravirine ( DCV 90 mg)
• Elbasvir/grazoprevir should not be used with efavirenz , nevirapine, etravirine, cobicitat ,or any HIV protease
inhibitor
• SOF/VEL 400/100 mg should not be used with efavirenz , nevirapine or etravirine
• eGFR > 60 cc/min/1.73m2
• SOF/LDV( 400/90) : be careful in TDF with boosted PI or TDF with cobicistat
• eGFR > 60 cc/min/1.73m2
• Paritaprevir/ritonavir/ombitasvir plus dasabuvir should not be used with DRV, EFV, LPV/r, ETR,NVP, cobi or
rilpivirine
• Daily DCV plus SOF +/- RBV is recommended regimen when ART changed can not be made
• SOF/LDV 8 weeks is not recommended ( even in low HCV RNA <600,000IU/ml, fibrosis <F3)
AASLD April12, 2017

of 36
Key-message
HIV-HCV : HCV viraemia,  risk of HCV transmission,  chance of HCV spontaneous
clearance , Accelerated rate of fibrosis , extrahepatic manifestation
 HCV is curable with short course of DAAs, all HCV should be treated
 Response rate is similarly to HCV monoinfection
 Drug-drug interaction : important and serious
 Reinfection esp MSM HIV+, active IDU without harm reduction
 HBV reactivation in HBsAg positive cases
 Cancer screening if advanced liver fibrosis/cirrhosis

SS 2017: Treatment Updated on Hepatitis B or C co-infection

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