Edward Lalo Cachay, M.D., M.A.S., of UC San Diego Owen Clinic, presents "A Decade of Treating HCV in Patients with Ongoing Barriers to Care" at AIDS Clinical Rounds

1. The UC San Diego AntiViral Research Center sponsors weekly
presentations by infectious disease clinicians, physicians and
researchers. The goal of these presentations is to provide the most
current research, clinical practices and trends in HIV, HBV, HCV, TB
and other infectious diseases of global significance.
The slides from the AIDS Clinical Rounds presentation that you are
about to view are intended for the educational purposes of our
audience. They may not be used for other purposes without the
presenter’s express permission.
AIDS CLINICAL ROUNDS

2. A"Decade"of"Trea,ng"HCV"in"Pa,ents"
with"Ongoing"Barriers"to"Care
Edward&Cachay&MD,&MAS&
Associate&Professor&of&Clinical&Medicine&
October&16,&2015&&

3. HCV"is"a"disease"of"the"disenfranchised"
2&
14&
17& 19&
29&
35&
50&
90&
0&
10&
20&
30&
40&
50&
60&
70&
80&
90&
100&
1&
%"HCV"an(body"posi(ve"
US&
populaHon&
&AA&born&
in&1950s&
Hospitalized&
paHents&
Severely&
mentally&ill&
Prisoners&
Homeless&
people&
People&IDU&
≤&10&yrs&
People&IDU&
>&10&yrs&

4. February"2008
• Rates&of&hepaHHs&C&were&increasing&in&the&general&populaHon&and&~&
10&Hmes&higher&among&HIV&infected&paHents.&
• HIV&coUinfected&paHents&with&hospital&inpaHent&care&consHtuted&7.5&
Hmes&as&many&hospitalizaHons&and&incurred&2.9&Hmes&the&charges&in&
1995,&relaHve&to&all&HIV&hospitalizaHons&and&charges.&&
• In&contrast&to&the&general&populaHon,&rates&in&HIV&infecHon&
represented&incident&cases.&
&
Hepatology:"2005,"42:"1406J13"

5. HCV&incidence&in&HIV&MSM&in&relaHonship&to&calendar&year&
Rate/&100UPY&
MetaUregression&
Polynomial&fit&&&&&&&&&&
(with&95%&CI)&
Year&of&esHmate&

6. Tim"who"was"32yo"was"admiMed"to"our"ICU"in"April"2007
• Tim"suffered"a"massive"myocardial"infarc,on"resul,ng"in"severe"conges,ve"
heart"failure.
• "Suspected"induced"by"intravenous"methamphetamine"use.
• Tim"was"diagnosed"with"HIV"and"also"HCV.
• Tim"had"history"of"bipolar""disorder,"he"acknowledged"a""prior"suicidal"aMempt"
at"age"21"while"‘under"the"influence’.
• CD4:"450,""HIV"VL"load">750,000"copies/ml"(at"diagnosis)
&
&

7. March"2008":"Referred"for"HCV"treatment"considera,on:
• HCV"genotype"3""and"HCV"viral"load"HCV"RNA"9’000,000
• He"had"started"HAART"2"months"prior
• Grade"I"liver"enzyme"eleva,on,"albumin"4.6,"INR:"1.0"and"had"‘a#normal#
looking#liver#on#a#CT#scan’"while"in"the"ICU.
• Tim"said"“my"liver"is"fine"and"does"not"bother"me"all”."
• Nick"has"Ryan"White"insurance
• Tim"was"at"the",me"on"a"rehabilita,on"program"in"San"Marcos."
&

8. Thinking&of&HCV&treatment&opHons&in&2007,&
was&Tim&a&good&candidate&for&HCV&therapy?&&
1. Yes&
2. No&&

9. The"conven,onal"approach:
• HCV&GT&3&considered&to&have&more&favorable&responses&to&PegUIFN&
and&ribavarin&(&~50%).&
• CoUmorbidiHes&could&be&exacerbated&during&HCV&therapy.&
• Psychiatry&issues&would&likely&become&too&challenging.&
“&No&major&evidence&of&liver&fibrosis,&conHnue&rehabilitaHon,&treat&your&
HIV,&follow&closely&with&your&PMD,&remain&absHnent&and&RTC&in&1&
year…”&

10. Survival&by&HCV&AnHbody&Status&at&Clinic&Entry,&adjusted&for&Entry&CD4.&
Owen&Clinic,&n&=,&5,978&

11. What"propor,on"of"HIV"pa,ents"with"known"HCV"and"in"HIV"care"
were""treated"for"HCV"in"the"United"States"at"the"end"of"2010?
1.&Less&than&3%&
2.&5%&
3.&8%&
4.&15%&
5.&30%&

12. In"average"in"less"than"2.5%"of"pa,ents"coJinfected"with"HIV/HCV"
were"cured"of"HCV""at"the"end"of"2012
100%&paHent&with&
known&HIV/HCV&
&
never&treated&
25%&adverse&events&
10%&lost&to&followUup&
35%&sustained&viral&response&
30%&virological&failure&

13. Factors"that"contribute"to"low"HCV"treatment"uptake"
among"HIV"coJinfected"pa,ent"s
Pa(ent"" &Provider"
Medical"
system"
Limited&tesHng&
centers&
Low&№&providers&
confident&delivering&HCV&
treatment&
Too&complex&
percepHon:&
A. PaHents&
B. Management&
Depend&on&subU
specialty&clinic&
Too&much&paper&work:&
A. PaHent&access&&
B. Underinsured&
Low&reimbursement&
incenHve&
Adapted from Grebely et al. 2013. JID; 207 (Suppl 1)

14. The"problem"is"not"limited"to"the"USA
From 1947 HIV-infected patients included, with a median follow-up time of 107 months
(IQR: 57–156), only 23% received treatment for HCV (456 patients)
Grint D et al. HIV Med. 2013;14:614-23
0.00"
1.00"
2.00"
3.00"
4.00"
5.00"
6.00"
7.00"
8.00"
9.00"
Incidence&per&100&PYFU&
1998" 2000" 2002" 2004" 2006" 2008" 2010"
Incidence&rate&of&uptake&of&HCV&treatment&in&
EuroSIDA&by&region&
South&
North&
West&
East&C&
East&&
Copyright © Edward Cachay MD, MAS.

15. April"2008:"Shortage"in"staff"and"reimbursement"became"major"disincen,ves"
for"on"site"subJspecialty"care"for"our"HCV/HIV"pa,ents."
HIV&provider&
Pharmacist&
Psychiatrist&
Substance&
counselor&
UCSDGOwen"
Hepa((s"Clinic"
is"born..."
Copyright © Edward Cachay MD, MAS.

16. Our&Goal:&To&improve&the&efficiency&of&the&HCV&staging&process&
of&paHents&coUinfected&with&HIV/HCV&and&to&increase&the&
absolute&number&of&paHents&&who&start&and&complete&
treatment&&for&HCV&at&any&given&Hme&point.&

17. Owen"coJinfec,on"hepa,,s"clinic

18. HIV/HCV"coJinfected"pa,ents"had"more"coJmorbid"condi,ons"
The&median&№&of&comorbid&condiHons&was&greater&for&persons&with&HCV&coUinfecHon&(p<0.0001)&
0%"
10%"
20%"
30%"
40%"
50%"
0" 1" 2" 3+"
№"of"comorbid"condi(ons"
Percentage"with"condi(ons"
HIV&monoinfected&
HIV/HCV&
Goulet'et'al.'AIDS'2005;'19'(suppl'3):'S99:S105'
Copyright © Edward Cachay MD, MAS.
n=&25,116&&

19. Among"HIV/HCV"coJinfected"pa,ents"there"is"a"high"prevalent"of"low"health"literacy,"ongoing"
substance"dependences,"neuropsychiatry""disorder"and"unstable"housing
Illegal&substance&use&
Neuropsychiatry&disease&
Alcohol&dependence&
Poverty&
Cachay et al. AIDS Res Ther 2011, 8:e29

20. HIVcontrol
BARRIERS
LIVERstatus
Co-morbidities
The Owen Hepatitis Co-Infection
staging table of HCV among HIV-
infected patients
Lesson"#1:"More"than"assessing"liver"fibrosis…
Copyright © Edward Cachay MD, MAS.

21. The"‘CCR’"rule"and"prospec,ve"engagement"in"care:
• Commitment:&HIV&viral&load&undetectable&
• Consistency:&Follow&through&with&medical&&&&&
&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&recommendaHons&and&or&appointment&
• Reliability:&Avoid&‘no&shows’&,call&to&‘reschedule’.&
Copyright © Edward Cachay MD, MAS.

22. Key"prac,cal"points
• No&reUschedule&penalty&for&late&arrivals&
• Always&it&is&a&good&Hme&to&start&over&again&
• ‘Cutback’&as&much&as&you&can&but&‘come&back’&no&maqer&what&
• SD&needle&exchange&program&/&methadone&clinics&

23. Clinic"visit"schedule"for"HIV"pa,ents"on"HCV"treatment"based"on"their"specific"barriers"and/or"medical"coJmorbidi,es"(in"
weeks)
! 0! 1! 2! 3! 4! 5! 6! 7! 8! 9! 10! 11! 12! 14! 16! 18! 20! 22! 24! 26! 28! 30! 32! 34! 36! 40! 44! 48!
Group&1& ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !
Pharmacists!! X! !!!!!!!!!X! !!!!!!!!!!X! ! ! ! X! ! ! ! X! ! X! ! X! ! X! ! X! ! X! ! X! X! ! X!
Providers! X! ! ! ! X! ! ! ! X! ! ! ! X! ! X! ! X! ! X! ! X! ! X! ! X! X! X! X!
Group&2& ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !
Pharmacists! X! X! X! X! X! ! X! ! X! ! X! ! X! X! ! X! ! X! ! X! ! X! ! X! ! X! ! X!
Providers! X! ! ! ! X! ! ! ! X! ! ! ! X! ! X! ! X! ! X! ! X! ! X! ! X! ! X! X!
Group&3& ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !
Pharmacists! X! X! ! X! ! X! ! X! ! X! ! X! ! ! X! X! X! X! X! ! X! ! X! ! X! ! X! X!
Providers! X! X! X! X! X! ! X! ! X! ! X! ! X! X! X! X! X! X! X! X! X! X! X! X! X! X! X! X!
!
Group 1: patients without major significant medical comorbidity, social barriers and no ongoing illicit substance use
Group 2: patients with ongoing substance use (including intravenous) and/or homelessness
Group 3: patients with severe neuropsychiatry disease (including prior suicidal attempts) and/or medical comorbidity
Cachay et al, AIDS Res Ther. 2013 Mar 28;10(1):9
Lesson&#2:&One&size&does&not&fit&all&
Copyright © Edward Cachay MD, MAS.

24. What"happened"with"Tim?
05/2008&
No"show"
"Completed"
Echocardiogram"
HCV&Treatment&
iniHaHon&
1&
2&
4&
5&
SVR&
3.&HIV&
VL&UD&
End&HCV&
therapy&
Psych"
“ProspecHve&engagement&in&care”&
Copyright © Edward Cachay MD, MAS.
06/2008& 06/2008& 07/2008&07/2008&
Call"to"reG
schedule"
07/2008& 08/2008& 08/2009&
09/2008&
02/2010&

25. ‘Valida,on"of"the"HCV/HIV"
primary"care"model"’
SubGspecialty"model
(January"2005GMarch"2008)
N&=152
N&=&22
N&=&199
Ini(al"
evalua(on
study inclusion
Received"HCV"
treatment
N&=146
N&=39
Primary"care"Model
(April"2008"–"June"2010)
N&=&195
Excluded"pa(ents"(n"="47)
UEntered&on&HCV&treatment:&9
UUndetectable&HCV&viral&load:&13&
UPursued&clinical&trial:&11
UIncomplete&staging:&10
UTreatment&beyond&3/08:&4
Excluded"pa(ents"(n"="49)
UEntered&on&HCV&treatment:&7
UUndetectable&HCV&viral&load:&6
UPursued&clinical&trial:&2
UIncomplete&staging:&12
UTreatment&beyond&8/11:&22
Untreated"pa(ents"(n=130)
UAdvanced&cirrhosis:&13&
UU&Uncontrolled&AIDS:&9&
UPaHent&choice:&19
UPrior&nonUresponse:&6
ULost&to&followUup:&45&
U&Drug/alcohol:&8
UUnstable&psych:&12
U&Homelessness&/language&
literacy:&18
Untreated"pa(ents"(n=107)
UAdvanced&cirrhosis:&17&
UUncontrolled&AIDS:&22&
U&&PaHent&Choice:&29
U&&&Prior&nonUresponse:10
U&&&Lost&to&follow&up:&22
U&&&Unstable&psych:&5
U&&&&Drug/alcohol&use&&&
U Homelessness&/language&literacy:& 1
U The&referral&rate&did&not&differ&during&the&two&
periods&(0.10&vs.&0.12/paHentUyr,&p = 0.18).&
&
U Similar&treatment&disconHnuaHon&rates&due&to&
adverse&events&(29%&vs.&16%),&loss&to&followUup&
(8&vs.&8%),&Owen&vs&subUspecialty,&respecHvely.&
&
U Increase&trend&to&higher&HCV&SVR&(44&vs.&35%)&
for&Owen&vs.&&SubUspecialty&model,&
respecHvely.&
Cachay&et&al.&AIDS&Res&Ther.&2013&

26. Clinic"Model HighGrisk"
(n="17)
NonGhighGrisk""
(n=31)
P"value
№&PaHents&with&Sustained&viral&response&(%) 5(29) 16(52)
0.14
№&PaHents&who&disconHnued&HCV&therapy&due&
to&nonUviral&response&(%)
2(12) 7(23)
0.36
№&PaHents&who&disconHnued&HCV&therapy&due&
to&treatmentUrelated&side&effects&(%)
6(35) 8(26)
0.49
№&PaHents&lost&to&followUup&(%) 3(18) 1(3)
0.08
Cachay et al, AIDS Res Ther. 2013 Mar 28;10(1):9
Early"preliminary"observa(ons:""Successful"HCV"treatment"
of"HIV"pa(ents"with"ongoing"barrier"to"care"is"possible"
There&were&no&differences&between&groups&in&age,&ethnicity,&liver&fibrosis,&proporHon&of&
HCV&genotype,&baseline&laboratory&exams&,&HCV&RNA&,&CD&and&HIV&VL.&&

27. Cure"of"HCV"means"a"lot"to"our"pa,ents
Cachay"et"al."2011,"AIDS"Res"Ther.;8:29"
0" 5" 10" 15" 20" 25"1" 4"3"2" 5" 6"
40"60"80"100"120"
40"60"80"100"120"

28. 2011:"HRSA""‘UCSD"CoJinfec,on"Clinic"a"model"to"replicate’
PegUIFN&+&&RBV&
PegUIFN&+&RBV&+&DAA&
DAA&combinaHon&
2016&2011& 2013&2012& 2014& 2015&2010&
Treatment"complexity"
HIV"primary"care/ID"clinics"
to"treat"HCV""
2005&

29. Lesson"#3:"Do"not"do"harm
• Use&of&triple&therapy&with&pegylatedUInterferon&+&Ribavirin&+&
Telaprevir&promised&~&75%&chance&of&HCV&cure&
• Following&treatment&of&our&first&25&paHents&with&triple&therapy,&we&
observed&something&different:&&
&&‘&One&of&two&paHents&treated&with&HCV&triple&therapy&could&be&cure&of&
HCV&…but&at&&the&cost&of&one&in&two&developing&serious&adverse&
reacHons&(Grade&III&or&IV)&that&required&hospitalizaHon’.&
Cachay&et&al.&AIDS.&2013;27(18):2893U7.&

30. HCV"treatment"uptake"at"UCSD"Owen"Clinic"
Cachay et et al. Plos One 2014
2008& 2009& 2010& 2011& 2012&
0&
1&
3&
2&
4&
5&
6&
7&
8&
HCV&treatment&uptake&per&100PYFU&
Copyright © Edward Cachay MD, MAS.
2013&
Mean&
95%&&CI&
2014&

31. May"2013:
&
• We&advocated&for&IFNUfree&DAA&combinaHons&for&our&paHents,&before&
any&professional&guideline&was&available.&

32. Sofosbuvir:"HCV"vs"HCV/HIV,"in"genotype"1,2"and"3
SOF/P/R&& SOF/R& GT2&naive&
89& 89&
68&
95& 94&
90&
93& 91&
0&
10&
20&
30&
40&
50&
60&
70&
80&
90&
100&SVR"rate" HCV& HIV/HCV&
AnHviral&Drugs&Advisory&Commiqee&MeeHng,&FDA&review,&10/24/13&&
C208,&C216,&C206,&C212,&HPC3007,&Dieterich,&14th&European&AIDS&Conference,&2013;&&
Lawitz&et&al.&NEJM&2013&
81&
89&
79&
88&
GT2&
experienced&
GT3&naive&
GT3&
experienced&
Lesion&#4:&‘HIV&is&no&longer&a&poor&prognosHc&factor&for&response&to&HCV&treatment’&

33. We"were"looking"forward"to"the"exci,ng",mes"coming"ahead!
IFN& pegIFNURBV& Triple& All&oral&DAA&
Sustained&viral&response&(cure)&&
1990s& 2000s& 2011& 2014&
10%&
35%&
65%&
>&90%&
No.&
Adapted from Expert Opin Pharmacother. 2013;14:1161-70
Copyright © Edward Cachay MD, MAS.

34. Treatment"only"helps"those"who"receive"it
100&%& 100&%&& 100&%&
20&%& 20&%&
10&%& 19&%&
90&%&
85&%&
All&HCV&
PaHents&
Diagnosis&
and&therapy&
Cure&
PegUIFN/RBV& 95%&SVR&
95%&SVR,&increase&diagnosis&and&
linkage&to&treatment&

35. 1"pill"of"Sofosbuvir"~"1,000$

36. Consequences"of"high"price"of"HCV"medica,ons
0&
1&
2&
3&
4&
5&
6&
7&
8&
1& 2& 3& 4&
2013&
Q4&
Q2& Q3& Q4& 2015&
Q1&
2014&
$&Billions&
per&month& Sales&>&$&2.5&
billion/month&
Profits&&>&$&1.4&
billion/month&
Source:&Gilead&sales,&adapted&from&
IDWeeK&2015.&Sunday&11&

37. • U.S.&is&the&only&country&that&places&no&limit&to&drug&prices&
• Government&grants&drug&patents&under&HatchUWaxman&Act&
• Purpose:&to&incenHvize&development&of&the&drugs&the&public&needs&
• When&these&drugs&are&placed&out&of&reach&of&the&public,&government&
needs&to&weight&preventable&morbidity&and&mortality&vs.&company&
monopoly&pricing&rights.&
• Federal&law&28&U.S.C.&§&1498&(a)&allows&government&to&use&patent&
invenHon&without&permission&of&the&owner.&

38. The"HCV"market"running"and"their"impact"on"
lowering"the"prices"
Gilead"
AbbVie"
BMS"
Janssen"
Merck"
&&&&&&&&&
Roche&
Boehringer&

39. Consequences"of"high"price"in"2014
• Conflict&&between&provider,&paHent&and&payer&over&raHoning&
&UU&&“you&must&wait&unHl&you&have&severe&liver&damage&to&g&t&treated”&
&UU&“&You&need&to&be&clean&and&sober&to&be&treated”&&
&UU&“&I&am&not&worth&the&treatment”&

40. 2014:"Payer"restric,ons"(Public"and"private)..aka..
Alcohol&and&substance&use&&
Fibrosis:&Most&state&Medicaid&required&F3/4&
&&&&&&&&&&&&&&&6&States&required&liver&biopsies&&
Prescriber&specialtyU&monopoly&&&
Onerous&preUauthorizaHon&procedures:&
&&&&&&&&&&&&&&&&&~&12&hours&per&paHent&&
U Contradict&medical&
specialty&guidance&
&
U Purely&for&financial&reasons&&
&
U Discriminatory&
&
U Illegal&&

41. HCV is the only disease where there has to be significant organ damage to
treat.
Ann Intern Med. 2013;158(9):658-666.
Persons with HIV had liver fibrosis measurements equal to those of persons without HIV, who were, on average, 9.2 years older

42. REVEALJHCV:"‘HCV"is"a"systemic"infec,on’"
Lee"et"al."J"Infect"Dis"2012;"206:"469J77.""
2.8
1.5
1.3
1.4
5.4
21.6
12.5
1.9
//
All causes death
Liver-related
Liver cancer
Cirrhosis
Extrahepatic
Cancers*
Cardiovascular
Kidney
Adjusted hazard ratios
HCV Ab-pos vs
HCV Ab-neg
U 23,820"adults"followed"for"a"mean"of"16.2"years"
U 1095"HCV"Ab+"(4%)"
U 69%"of"HCV"Ab+"were"HCVGRNA"pos"
U 2394"deaths"during"the"study"period"
*esophagus, prostate & thyroid

43. "
"
Hepa,,s"C"surpasses"HIV"as"a"cause"of"death"in"the"US"
Rate"per""100"000"Persons"
2000"1999" 2001" 2002" 2003" 2004" 2005" 2006" 2007"
Hepa((s"B"
Hepa((s"C"
HIV"
adapted from Ann Intern Med. 2012, 156:271-8
0&
1&
2&
3&
4&
5&
6&
7&
HIV" Chronic"liver"
disease"
Alcohol"related"condi(ons" Hepa((s"B"
&1.8&(1.6&U2.0)& 32.1&(31.0U33.3)& 4.6&(4.4&U4.8)& 29.9&(26.5U33.6)&
Why&do&we&have&to&exclude&people&who&use&drugs&or&alcohol?&

44. The"most"frequent"reason"for"not"ini,a,ng"HCV"therapy"is"the"presence"
of"ongoing"barriers"to"care"in"the"IFNJera
Known"HCV"infec,on"with"established"HIV"care
100%"(n=751)"
Referred"for"HCV"treatment"
40%"(n=301)"
AMended"≥"1"clinic"visit"for"HCV"evalua,on"
37%"(n=281)"
Final"decision"is"made"regarding"
HCV"therapy"ini,a,on
33%"(n=248)"
Start"HCV"treatment
"12%"(n=88)"
""""HCV"cure"
"""""5%(n=41)"
Cachay"et"al."PLoS"One."2014";9:e102883
&&&
&&&&&
U&Barriers&to&care:&78&of&195&(40%)&
U&PaHent&did&not&want&IFNUbased&regimens:&45&of&195&(23%)&
U&Advanced&liver&disease:&34&of&195(18%)&&
U&Prior&null&response&:&16&of&195(8%)&
U&Spontaneous&clearance:&16&of&195(8%)&
U&ContraindicaHon&to&IFN/or&RBV:&6&of&195(3%)&
Reasons&for&not&starHng&HCV&treatment:&

45. Where"do"we"stand"in"this"fight?"
MedicaHon&
manufacturer& InsurancesU&
Health&payees&

46. Nothing"speaks"beMer"than"data"and"that"is"the"best"way"to"
advocate"for"our"pa,ents

47. HCV"treatment"regimens"used"in"HIV"coJinfected"pa,ents"in"2014"at"
UCSD
Genotype" N"="30" Regimens"
1a& &23& &&&RBV&+&SOFU24&weeks&&&&&&&&&&&&&&&&&&&&&&&&&&&&(&2)&
&&&SIM&+&SOFU12&weeks&&&&&&&&&&&&&&&&&&&&&&&&&&&&(12)&
&&&SIM&+&SOFU24&weeks&&&&&&&&&&&&&&&&&&&&&&&&&&&&(&4)&
&&&SIM&+&SOF&+&RBVU24&&weeks&&&&&&&&&&&&&&&&(&1)&
&&&LDV&+&SOFU12&weeks&&&&&&&&&&&&&&&&&&&&&&&&&&&&(&2)&
&&&LDV&+&SOFU24&&weeks&&&&&&&&&&&&&&&&&&&&&&&&&&&(&2)&
2& &3& &&&SOF+RBVU12&weeks&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&(&3)&
3& &2& &&&SOF+RBVU24&weeks&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&(&2)&
4& &2& &&&SIMF+SOF&+&RBVU12&weeks&&&&&&&&&&&&&&&&&(&1)&
&&&SIM&+&SOFU24&weeks&&&&&&&&&&&&&&&&&&&&&&&&&&&&&(&1)&
Cachay et et al. OFID under review

48. Characteris,cs"of"pa,ents"with"cirrhosis"("n=22)
Genotype&
"""X""&
&&&&&&&&&&1a&
&&&&&&&&&&2&
&&&&&&&&&&4&
&&&&19&(86%)&
&&&&&1&(5%)&
&&&&&&2&(9%)&
Median&&MELD&score&&(range)& &&&11&(6U20)&
Prior"liver"decompensa(on""
&&Ascites&&
&&HepaHc&encephalopathy&&
&&Esophageal&varices&bleeding&&
10"
&9&
&7&
&&3&
Cachay et et al. OFID under review

49. "
90%"of"our"treated"pa,ents"will"not"fulffil"clinical"trial"enrollment"
"
5&
2& 2& 2&
4&
2&
Comorbilidad& Barreras&de&
salud&
TARGA&
compleja&+&
comorbilidad&
comorbilidad&+&
barreras&de&
salud&
TARGA&
compleja&+&
barreras&+&
comorbilidad&
Child&CUcirrosis&
Cirrho(cs"pa(ents"with"GT"1a"(n=17)"
Comorbidity&& Barriers&to&
care&
Complex&ART&&
+&
&comorbidity&
Comorbidity&
+&&
Barriers&to&care&
Complex&ART&&
+&
Barriers&
+&
&comorbidity&
Child&C&
Cirrhosis&&
Cachay et et al. OFID under review

50. 0
75 83.3
4
SMV + SOF± RBV x 12 Wks
Real"world
. 1Dieterich D, et al. AASLD 2014. Abstract 46.
n =
UCSD
SVR4(%)
100
80
60
40
20
COSMOS F3/F4
N=&145& N=&30&N=&13&
93
89.6
N=&29&
TRIO&
Mt"Sinai
81.08
N=&37&
"Penns."/"
New"Jersey
N=33&
83.03
North
west
HIV&cohorts&
90
80
Cachay et et al. OFID under review

51. What"is"the"impact"of"barriers"to"care"on"HCV"treatment"
response?"
• Ongoing&barriers&to&care&&definiHon:&drug/alcohol&use,&homelessness&,&
poverty&and&neuropsychiatry&disease.&
• RetrospecHve&comparison&of&all&paHents&treated&an&Owen&HCV&clinic&
• Our&treatment&protocol&for&treaHng&HCV&among&paHents&with&barriers&to&
care&has&been&unchanged&since&clinic&incepHon&(2008),&we&compared&
treatment&outcomes&across&HCV&treatment&era&:&
&&&&U&Dual&therapy&(pegylated&interferon&plus&ribavirin,&2008U2011);&&
&&&&U&Triple&therapy&(pegUIFN&plus&ribavirin&and&telaprevir,&2011U2013);&&
&&&&U&IFNUfree&DAA&therapy&(2014&)&

52. Cachay et et al. IDweek 2015- abstract 1672

53. Cachay et et al. IDweek 2015- abstract 1672

54. Results:"
• HCV&eradicaHon&among&paHents&with&ongoing&barriers&to&care&
improved&from&40%&(95%&CI:&21U61)&to&75%&(95%&CI:&48U93)&in&the&
dual&and&DAA&eras,&respecHvely.&
• Using&DAA&and&an&inclusive&HCV&treatment&protocol&75%&of&HIV/HCV&
treated&paHents&with&ongoing&barriers&to&care&achieved&HCV&
eradicaHon.&

55. S,ll"much"remains"to"be"done

56. Conclusions:
• A&HIV&primary&care&model&is&a&effecHve&way&to&increase&HCV&treatment&
uptake&among&HIVUinfected&paHents.&
• Our&data&supports&that&HIVUinfected&paHents&with&ongoing&barriers&to&
care&(e.g.&drug/alcohol&use)&achieve&similar&proporHons&of&HCV&cure&than&
paHents&without&barriers&to&care&&if&they&seek&voluntarily&HCV&treatment.&
• We&need&collaboraHons&of&all&fronts&in&our&society&to&effecHvely&treat&
HCV&in&our&paHents:&Pharma,&Public&payers,&Local&&&federal&government.&&

57. Acknowledgements
U Christopher&Mathews&
U Chuck&Hicks&
U Robert&Schooley&
U Alex&Kuo&&
U My&Owen&colleagues&
U Jerry&Collins&
U Susan&McQuillen&
&&
• Owen&HCV&team&
U&Craig&Ballard&
U&David&Wyles&
U Bradford&Colwell&
U Francesca&Torriani&
U Miguel&Goicoechea&(2008U2011)&
U Lucas&Hill&

58. People&with&ongoing&barriers&to&care&are&a&reflecHon&of&us&as&society.&
They&provide&us&the&opportunity&to&look&at&the&place&where&we&live&from&
a&different&perspecHve.&Working&together&with&tolerance&and&inclusion&
are&key&to&promote&the&common&good&of&everyone&in&our&society.&
&
&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&Edward&Cachay&