Mark Sulkowski, M.D. of Johns Hopkins University School of Medicine, presents "HIV-HCV coinfection: still special in 2015?" at AIDS Clinical Rounds

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AIDS CLINICAL ROUNDS

2. 1
Mark Sulkowski, MD
Professor of Medicine
Johns Hopkins University School of Medicine
Baltimore, Maryland
HIV-HCV coinfection: still special in
2015?

3. Disclosures
PI for research grants related to HCV
– Funds paid to Johns Hopkins University
– AbbVie, BMS, Gilead, Janssen, Merck
DSMB related to HBV
– Funds paid to Johns Hopkins University
– Gilead
Scientific advisor related to HCV
– Terms of these arrangement are being managed by the
JHU in accordance with its conflict of interest policies
– AbbVie, Achillion, BMS, Gilead, Janssen, Merck

4. Special aspects of HIV/HCV coinfection:
Epidemiology/Natural History
• Epidemiology
– Ongoing transmission leading to acute HCV
infection especially among MSMs
– High prevalence of chronic HCV infection
• Natural history
– Rapid progression to cirrhosis despite effective
ART
– Limited access to liver transplantation
3

5. Chronic HCV Infection is Prevalent in
~ 25% of HIV-infected Persons
65
15
8
0
10
20
30
40
50
60
70
IDU Sex MSM
% HIV-
HCV
HIV Exposure
HIV-HCV
HIV
Prevalence differs by HIV risk group
Sherman K et al. Clin Infect Dis 2002; Sulkowski M et al. Ann Intern Med 2003.

6. Sexual transmission of HCV among monogamous,
HIV negative, heterosexual partners is rare
• Maximum incidence was 1 case of transmission per 190,000 sexual contacts
Terrault NA et al. Hepatology 2013;57:881-889

7. HCV is a sexually transmitted disease
among HIV-infected MSMs
• 74 HIV-positive MSM
diagnosed with recent HCV
between 2005 and 2010
– No IDU
– Antiretroviral therapy, 74%
– HCV associated with
receptive anal intercourse
(AOR = 23) and sex while on
methamphetamine (AOR
28.56)
• NS5B sequences were
obtained in 50 men
– Phylogenetic analysis
revealed 5 clusters of
genotype 1a
Fierer DS et al. MMWR July 22, 2011; van der Helm JJ et al. AIDS 2011, 25:1083–1091
Incidence of HCV in HIV-infected MSM from
12 cohorts within CASCADE

8. Mother-to-child transmission in 77 prospective cohort
studies of at least 10 mother-infant pairs
If 35% of 170 million persons infected with HCV are women of childbearing age,
given an annual fertility rate of 2%, 10,000 – 60,000 babies will be infected each year
Roberts and Yeung. Hepatology 2002

9. HCV in Young Nonurban Injection Drug
Users
• Rising rates of HCV infection among young adults who started
prescription opioid use before transitioning to heroin injection
• Massachusetts – changing epidemiology of HCV (MMWR)

10. 62 year man with HIV and HCV
genotype 1a coinfection
• Currently on DRV/r + TDF/FTC with
undetectable HIV RNA and CD4 551
– CD4 nadir was 30
– HTN, type 2 DM, obesity
• ALT 43 U/L, AST 56 U/L; plt count
145,000, total bilirubin 0.5, Alb 4.3
• He asks about his hepatitis C
What’s your recommendation?

11. Liver&disease&staging&–&distribu0on&and&
quan0ty&of&hepa0c&fibrosis&
No#Fibrosis# Stage#1#
Fibrous#expansion#of##
some#portal#areas#
Stage#2#
Fibrous#expansion#of#most#portal#
areas#with#occasional#portal#to#portal#
bridging#
Stage#3# Stage#4#
Cirrho>c#
Liver#
Fibrous#expansion#of#portal#areas#
with#marked#bridging#(portalCtoCportal#and#
portalCtoCcentral)#
Cirrhosis#
Faria SC, et al. Radiographics. 2009;29:1615-1635. Adapted from Everson GT.

12. Liver&disease&stage&is&independently&associated&with&
0me&to&death&(any&cause),&ESLD&or&HCC&

13. Liver&disease&stage&is&independently&associated&with&
0me&to&liverDrelated&death,&ESLD&or&HCC&

14. An0retroviral&therapy&was&associated&with&
reduced&risk&of&liver&outcomes&&
Limketkai&et&al.&JAMA.&July&25,&2012,308(4):370D378&

15. HCV&disease&progression&remains&faster&in&HIV&
infected&pa0ents&DD&despite&effec0ve&ART#
• If&HIV&RNA&<#1000#copies/mL:#+65%&excess&risk&
• If&HIV&RNA&>#1000copies/mL:#+82%&excess&risk&
• If&CD4&<#200/mm2:#+203%&excess&risk&
• If&CD4&>#200/mm2:&56–63%&excess&risk&
ART, antiretroviral therapy; HCV, hepatitis C virus; HIV, human immunodeficiency virus.
Lo Re V 3rd. Ann Intern Med 2014.

16. Factors&associated&with&hepa0c&decompensa0on&among&HIV/HCV&
coinfected&persons&treated&with&ART&
Lo&Re&V&et#al#Annals#of#Internal#Medicine#2014&

17. ElastographySerum
Biomarkers
Op0ons&for&liver&disease&staging&
Liver
Biopsy

18. Liver&biopsy&is&not&the&gold&standard&
for&liver&disease&staging&

20. FIBD4&calculator&
hap://www.hepa00sc.uw.edu/page/clinicalDcalculators/fibD4&

22. Special&aspects&of&HIV/HCV&coinfec0on:&&
HCV&Treatment&
• HCV&cure&is&associated&with&improved&survival&
• Interferon&is&a&problem&in&this&popula0on&
– HIV&providers&and&pa0ents&were&not&enthusias0c&&
– Prevalent&mental&health&disorders&
– Poor&IFN&response&associated&with&HIV&coinfec0on&&
• However,&response&to&interferonDfree,&HCV&
DAAs&may&not&be&impacted&by&HIV&coinfec0on&
• HCV&cure&is&associated&with&improved&survival&
21&

23. Goal&of&HCV&treatment&is&viral&cure&
HCV&life&cycle&favors&resistance&development&not&persistence&
HIV# HBV# HCV#
(+)# (C)# (+)#
RT#
Human#
RNApol#
RT#
RT#
NS5B#
NS5B#
HIV# HBV# HCV#
Stable#genome# Provirus& cccDNA& (none)&
Virion#NA#polymerase# Host&RNApol& HBV&RT& HCV&NS5B&
ErrorCprone#replica>ons#per#cell## One& Mul0ple& Mul0ple&
Plas>city#of#genome# High& Constrained& Very&high&
Recombina>on# Common& Common& Rare&

24. HCV&cure&is&associated&with&survival&in&HIV/HCV&
coinfected&pa0ents&
Limketkai&et&al.&JAMA.&July&25,&2012,308(4):370D378&

25. Interferon&alfa&(RIP&1992&–&2014)&

26. &
&
HCV (n =114,005) HIV/HCV (n = 6,502)
Drug use 39% 56%
Alcohol use 44% 48%
Depression (major) 18% 23%
Bipolar 10% 10%
Anemia 12% 24%
Hepatitis B 3% 9%
Received HCV
treatment
12% 7%
Butt A. Alimentary Pharmacology & Therapeutics
Volume 24, Issue 4, Pages 585-591. 2006
HIV/HCV&coinfected&pa0ents&have&more&comorbid&
medical&and&psychiatric&condi0ons&that&may&complicate&
HCV&care&

27. Lower&SVR&Rates&in&Pa0ents&With&HIV/HCV&Compared&&
to&HCV&Alone&with&PegIFN&+&RBV&800&mg/day&&
HCV genotype 1 and high levels of HCV RNA level (> 800,000 copies/mL)
Hadziyannis SJ et al. Annals Intern Med 2004; Torriani FJ et al. New Eng J Med 2004
18
36
0
25
50
HIV/HCV HCV alone
Sustained Virologic
Response, %

28. HIV&Coinfec0on&Leads&to&Higher&Levels&&
of&HCV&RNA&
ME Eyster, MW Fried, AM Di Bisceglie and JJ Goedert. Blood. 1994 84: 1020-1023

29. Mehta SH et al, AIDS, 2006
HIV/HCV#coinfected#pa:ents#a;ending#the#Johns#
Hopkins#HIV#clinic#1999A2003##
HCV&treatment&cascade&in&HIVDinfected&pa0ents&in&
Bal0more&

30. HCV&treatment&with&IFN/RBV&is&not&effec0ve&due&to&
contraindica0ons:&Na0onal&VA&cohort&
Kramer&et&al.&J&Hepatol.&2011&Jul&12.&[Epub&ahead&of&print]&
&&

31. HCV&life&cycle:&&Mul0ple&an0viral&targets&iden0fied&&
1. Entry##
2. Endosomal#release#and#IRES#
dependent#transla>on#
3. Protease#cleavages#
4. Membranous#web#forma>on#
5. NS5B#RNA#dependent#
polymerase#(RdRp)#
6. Lipoprotein#assembly#linked#to#
NS5A#
7. Cellular#targets#
S.&Ray&et&al&Fields&Viology&

32. The&pursuit&of&the&op0mal&an0viral&cocktail(s)&
Antiviral
NS3 NS5A
NonCNuc#
NS5B
Nuc#
NS5B
RBV
Sofosbuvir/Ledipasvir#FDC#
Sofosbuvir#+#Daclatasvir#
Paritaprevir/ritonavir/Ombitasvir#
+#Dasabuvir#
Asunaprevir/Daclatasvir/
Beclabuvir##FDC#
1a only
Grazoprevir/Elbasvir#FDC#
MK/Grazoprevir/Elbasvir#FDC#
Sofosbuvir/Ledipasvir/GS##
&
&

33. AASLD/IDSA&Guidance:&HCV/HIVDCoinfected&Pa0ents&
• Treatment&should&be&priori0zed&in&pa0ents&at&high&risk&for&liverD
related&complica0ons&
– Includes&pa0ents&with&HCV/HIV&coinfec0on,&regardless&of&fibrosis&stage&
• Trea0ng&pa0ents&at&high&risk&for&transmijng&HCV&to&others&may&
decrease&transmission&and&HCV&disease&prevalence&
– Includes&MSM&with&highDrisk&sexual&prac0ces&and&ac0ve&injec0on&drug&
users&
AASLD and IDSA. HCV Management Guidance. 2015.

34. TreatmentDNaive&GT1&HCV&Pa0ents&
Subtype&(A&or&B?)&and&Cirrhosis&(yes&or&no?)&
Subtype Noncirrhotic Compensated Cirrhotic
Regimen Duratio
n,
Wks
Regimen Duratio
n,
Wks
GT1a or
1b
LDV/SOF 12* LDV/SOF 12
GT1a OMV/PTV/RTV + DSV +
RBV
12 OMV/PTV/RTV + DSV +
RBV
24
GT1b OMV/PTV/RTV + DSV 12 OMV/PTV/RTV + DSV +
RBV
12
GT1a SMV + SOF ± RBV 12 SMV + SOF ± RBV 24
GT1b SMV + SOF 12 SMV + SOF 24
*Shorter course can be considered in pts with pretreatment HCV RNA < 6 million IU/mL at provider’s discretion but should
be done with caution.
AASLD/IDSA HCV Guidelines.

35. AllDoral,&interferonDfree,&highly&
effec0ve&HCV&regimens&

36. LDV/SOF: ION-1 and ION-2: FDC ± RBV
for 12 or 24 Wks in GT1 Patients
1. Mangia A, et al. EASL 2014. Abstract O164. 2. Afdhal N, et al. NEJM. 2014;[Epub ahead of print].
3. Afdhal N, et al. EASL 2014. Abstract O109.
&
SOF/LDV&+&RBV&(n&=&111)&
&
&
SOF/LDV&(n&=&109)&
&
Wk#24#
ION-2[2,3]:
Treatment-
experienced
HCV GT1; 20%
cirrhotics
(N = 440)
&
SOF/LDV&+&RBV&(n&=&111)&
&
&
SOF/LDV&(n&=&109)&
&
Wk#12#
&
SOF/LDV&+&RBV&(n&=&217)&
&
&
SOF/LDV&(n&=&214)&
&
Wk#24#
ION-1[1,2]:
Treatment-naive
HCV GT1; cirrhosis in
15% to 17% per arm
(N = 865)
&
SOF/LDV&+&RBV&(n&=&217)&
&
&
SOF/LDV&(n&=&217)&
&
Wk#12#
SVR12#
99#
97#
98#
99#
94#
96#
99#
99#

37. NIAID&ERADICATE:&SOF/LDV&in&TN&GT&1&
HIV/HCV&coDinfected&pa0ents&&&
#
Event,#n#(%)#
SOF/LDV#
ART#naïve#(n=13)#
SOF/LDV#
ART#experienced#
(n=37)#
D/C&due&to&AEs& 0& 0&
Grade&4&AEs& 0& 0&
Death& 0& 0&
Grade&≥2&lab&abnormality&in&>5%&of&popula0on#
Hypophosphataemi
a&
1&(8)& 7&(19)&
Decreased&ANC& 2&(15)& 4&(11)&
Elevated&ALT& 1&(8)& 3&(8)&
Elevated&AST& 1&(8)& 3&(8)&
Osinusi&A&et&al.&J&Hepatol&2014;60(Suppl):S7&and&Osinusi&A,&et&al.&65th&AASLD;&Boston,&MA;&November&7D11,&2014.&Abst.&84&
ANC,&absolute&neutrophil&count;&AST,&aspartate&aminotransferase&
Treatment#Response:#
#
Safety#data:#
#
12/12 22/22

38. 97 96 96
0&
20&
40&
60&
80&
100&
IOND3:&GT&1,&TreatmentDNaive,&NonDCirrho0c,&LDV/SOF±RBV&x&8&
or&12&weeks&
LDV/SOF&+&RBV&LDV/SOF& LDV/SOF&
8&weeks& 12&weeks&
LDV/SOF#
8#weeks#
LDV/SOF+RBV#
8#weeks#
LDV/SOF#
12#weeks#
Relapse&Rates&<&6M& 2%&(2/123)& 2%&(3/138)& 2%&(2/131)&
Relapse&Rates&>&6M& 10%&(9/92)& 8%&(6/77)& 1%&(1/85)&
SVR12(%)
119/123 133/138 126/131
Efficacy&and&Relapse&in&Subjects&with&Baseline&HCV&RNA&<#6#Million&IU/mL&
HARVONI&®&[PI].&Gilead&Sciences,&Inc.&Foster&City,&CA&October&2014&
Kowdley&K,&et&al.&N#Engl#J#Med#2014;370:1879D1888.&
Jacobson&I,&et&al.&AASLD,&2014,&Poster&#1945.&
Data&on&File,&Gilead&Sciences&

39. Paritaprevir/ritonavir/Ombitasvir + Dasabuvir ± RBV
GT 1a/1b Treatment Naive or Experienced
Andreone&P,&et&al.&DDW&2014.&Abstract&929e.&Ferenci&et&al,&CROI,&2014.&Press&release.&&
n=209
n=210
99%
99%
PEARL-III
GT 1b
Naive
ABT-450/r/Ombitasvir + Dasabuvir + RBV
ABT-450/r/Ombitasvir + Dasabuvirn=91
n=88
100%
97%
PEARL-II
GT 1b
Experienced
n=205
n=100
90%
97%
PEARL-IV
GT 1a
Naive
ABT-450/r/Ombitasvir + Dasabuvir + RBV
ABT-450/r/Ombitasvir + Dasabuvir
ABT-450/r/Ombitasvir + Dasabuvir + RBV
ABT-450/r/Ombitasvir + Dasabuvir
Week 0 12
SVR12

40. Sulkowski MS et al. JAMA in press
HIVDHCV&Coinfec0on&study:&TURQUOISEDI:&3&DAAs&+&RBV&

41. Treatment&of&persons&infected&with&
HCV&genotype&2&or&3&

42. 88# 88#
67#
91# 95#100# 100#
67#
100#
79#
0&
20&
40&
60&
80&
100&
49/54&
TN
24 weeks
TN
12 weeks
6/6
SVR12&in&GT&2&and&GT&3&
Cirrhosis&vs&No&Cirrhosis&(PHOTOND1&and&2)&

43. Special&aspects&of&HIV/HCV&coinfec0on:&&
HCV&Treatment&
• Most&HIV/HCV&coinfected&pa0ents&receive&
an0retroviral&therapy&
– Overlapping&toxicity&is&possible&
– Drug&interac0ons&are&likely&and&difficult&to&predict&&
• CYP3A4&inhibi0on&(ritonavir);&induc0on&(Efavirenz)&
• Must&study&the&DAA&regimen&+&ART&regimen&in&healthy&
volunteers&
– However,&longDterm&adherence&to&ART/clinic&visits&
predicts&adherence&to&HCV&therapy&
42&

44. ARV&Interac0on&Score&Card&
Simeprevir# Sofosbuvir# Ledipasvir# Daclatasvir# AbbVie#3D#
ATV/r& No&data& &ATV&↔&SOF&↔& No&data& DCV&↑*& ATV&↔;&ABT450&↑&
DRV/r& SIM&↑;&DRV&↔& SOF&↑;&DRV&↔& No&data& DCV&(↑)& DRV&↓;&3D&&↓&
LPV/r& No&data& No&data& No&data& DCV↔& LPV&↔;&ABT450&↑&
TPV/r& No&data& No&data& No&data& No&data& No&data&
EFV& SIM&↓;&EFV&↔& SOF&↔;&EFV&↔& LDV&↓;&EFV&↓& DCV&↓*& No&PK&data**&
RPV& SIM&↔;&RPV&↔& SOF&↔;&RPV&↔& LDV&↔;&RPV&↔& No&data& ABT450&↑;&RPV&↑&
ETV& No&data& No&data& No&data& No&data& No&data&
RAL& SIM&↔;&RAL&↔& SOF&↔;&RAL&↔& LDV&↔;&RAL&↔& No&data& 3D&↔;&↑&RAL&
ELV/cobi& No&data& No&data& No&data& No&data& No&data&
DLG& No&data& No&data& No&data& No&data& No&data&
MVC& No&data& No&data& No&data&& No&data& No&data&
TDF& SIM&↔;&TDF&↔& SOF&↔;&TDF&↔& LDV&↔;&↑TDF& DCV&↔;&TDF&↔& 3D&↔;&TDF&↔&
*&Decrease&DCV&dose&to&30mg&QD,&Increase&DCV&dose&to&90mg&QD,&**&3D&+&EFV&led&to&premature&study&discon0nua0on&due&to&toxici0es&

45. Ledipasvir&is&associated&with&increase&
in&tenofovir&exposure&

46. What’s&OK&to&combine?&
• No&ART&=&LDV/SOF&[No#3D/r]&
• Integrase&inhibitor&+&NRTIs&=&Any&HCV&DAA&&
• NNRTI&+&Other&agents&=&LDV/SOF&
• HIVD1&protease&inhibitors&
– Any&PI/r&+&other&ARVs&(nonDTDF)&=&LDV/SOF&
– PI/r&+&TDF/FTC&–&depends&on&the&pa0ents&ability&to&
tolerate&higher&exposure&to&TDF&&
– ATV&+&Any&NRTI&or&RAL&or&DTG&=&3D/r&[drop#RTV]&
&

47. 56DyearDold&man&with&HIV/HCV&genotype&1A&
• Cirrhosis:& &MELD&15&with&Cr&1.6,&INR&1.3,&bili&1.3;&IL28B&TT&
&
• HIV: &&&Atazanavir/r&+&raltegravir&+&TDF/FTC&with&CD4&249&and&HIV&RNA&&
<&20&c/mL&
&
• HCV&treatment&
2011:&&PegIFN/RBV&+&telaprevir&!&breakthrough&&
– At&treatment&week&4,&HCV&RNA&=&46&IU/mL;&week&12,&HCV&RNA&=&1,299&IU/mL&
2014:&&Sofosbuvir&+&ribavirin&!&breakthrough&&
– Baseline&HCV&RNA&=&2,506,896&IU/mL&
– Week&4&=&36&IU/mL&
– Week&12&=&not&detected&
– Week&16&=&Detected&<&43&IU/mL&
– Week&24&=&2,119&IU/mL&(onDtreatment)&despite&100%&adherence&
&&

48. Courtesy of Dr. Stuart Ray

49. Challenges&to&HCV&cure&in&HIVDinfected&
pa0ents&
• Cirrhosis&&
– Lower&SVR&with&interferon&and&with&oral&DAA&
therapy&
• Resistance&to&HCV&DAA&
– Baseline&resistant&variants&–&impact&on&HCV&cure&
– Selected&resistant&variants&–&persistence?&
• &Access&to&drugs/cost&
&

50. Degree&of&liver&disease&impacts&HCV&
eradica0on&from&infected&hepatocytes&
Stage&0&–&No&fibrosis& Stage&4&–&Cirrhosis&&

51. 84%##
No#NS5A#Variants#
at#baseline#
10%#
NS5A#Variant#
&
n=178/195&
91%#SVR#
Rela0onship&of&baseline&NS5A&Variants&and&
HCV&cure&(10%&cutDoff)&
ION&Phase&3&Program&(IOND1,&IOND2,&IOND3)&
50&
n=195#
n=1752*#
*5&Subjects&not&successfully&sequenced&
&&
DvoryDSobel&H&et&al.&&HepDART&2013&
www.informedhorizons.com/resistance2014/
presenta0ons.html&
97%#SVR#
n=1702/1752#
• HCV failure associated with NS5A resistant variants
• No S282T (SOF) resistance detected

52. Pa0ents&with&HCV&relapse&following&LDV/SOF&
(IOND2))&
12#Week#
Treatment#Group#
Age# Race# Sex# GT# IL28B# Cirrho>c#
Prior#Rx#
(PegCIFN+RBV)#
Prior#Treatment#
Response#
NS5A#RAVs#at#BL#
NS5A#RAVs#at#
Relapse#
SOF/LDV+RBV# 63# B# M# 1a# CT# Yes# +PI# NonCResponder# None# Q30K(>99%)
SOF/LDV+RBV# 60# W# M# 1a# CT# Yes#
Relapse/#
Breakthrough#
Y93H(1.20%)##
Q30L(76.43%)
Q30R(22.94%)
Y93H(>99%)
SOF/LDV+RBV# 60# W# M# 1a# TT# Yes# +PI# NonCResponder# L31M(>99%)##
Q30H(>99%)
L31M(>99%)
SOF/LDV+RBV# 65# W# M# 1a# CT# Yes#
Relapse/#
Breakthrough#
None#
M28T(>99%)
Q30R(>99%)
SOF/LDV# 62# W# M# 1b# CT# Yes# Null#Responder# None# L31V(>99%)
SOF/LDV# 64# W# M# 1b# CT# Yes# +PI#
Relapse/#
Breakthrough#
None#
L31M(96.81%)
Y93H(>99%)
SOF/LDV# 64# W# M# 1a# CT# Yes# +PI#
Relapse/#
Breakthrough#
None#
Q30H(9.80%)
Y93H(93.93%)
SOF/LDV# 61# W# M# 1b# CT# No# Null#Responder# Y93H(59.82%)## Y93H(>99%)
SOF/LDV# 58# W# F# 1a# CT# No# +PI# NonCResponder#
Q30R(1.43%)#
Y93N(97.60%)##
Y93N(>99%)
SOF/LDV# 57# W# F# 1a# CT# No# +PI#
Relapse/#
Breakthrough#
M28T(1.03%)#
Q30R(>99%)#
L31M(>99%)##
Q30R(>99%)
L31M(>99%)
SOF/LDV# 54# W# M# 1a# CT# No#
Par>al#
Responder#
Q30H(98.76%)#
Y93H(98.07%)##
Q30H(98.92%)
Y93H(>99%)

53. Pa0ents&with&HCV&relapse&following&3D&
Failure*# Subgenotype# NS3Cbase# NS3Cfail# NS5BC
base#
NS5BCfail#
BT& 1a& D& R155K&>&
D168[A>V]&
D& G554S&
BT& 1a& D& D168A& D& M414T&
BT& 1a& D& D168V& D& C316Y&>&D559G&
BT& 1a& D& D168[E>Y]& D& G554S&>&S556G&>&
M414V&+&G554S&
BT& 1a& D& D168V& D& S556G&
BT& 1b# D168[E>T]& D168K& D& C316Y&
Rel& 1a& D& D168[Y>V>A]& D& S556G&>&M414T&
Rel& 1a& D& D& D& D&
Rel& 1a& D& D168V& D& S556G&
Poordad&NEJM&2013;&368(1):&45&
*BT&=&breakthrough&
&&Rel&=&relapse&

54. Infec0on&and/or&reinfec0on&with&DAA&
resistant&hepa00s&C&
Franco&et&al.&Gastroenterology&2014&
HIV-infected male partners with
documented infection and re-infection with
telaprevir resistant HCV (V36M)

55. Limited&Access&to&HCV&therapy&

57. HIV/HCV&coinfec0on&DD&s0ll&special&in&2015&
• High&prevalence&of&HCV&infec0on&and&disease&
– Most&pa0ents&are&diagnosed&(~&95%&have&been&tested)&
– Ongoing&incident&acute&HCV&infec0on&
• High&level&of&engagement&in&health&care&for&pa0ents&taking&ART&
– Support&services&(social&work)&
– Pharmacy&benefits&
– Access&to&mental&health/addic0on&care&
– Skilled&clinicians&–&cross&train&
• DAA&efficacy&may&not&be&greatly&impacted&by&HIV&coinfec0on&
– Drug&interac0ons&&
– Cost&
# 56&