RealWorldManagementofHCVinHIV:ApproachtoInitialTherapywithfocus

onnewDAAsKristenM.Marks,MD

AssistantProfessorWeillCornellMedicalCollege

NewYork,NewYork

FinancialRelationshipsWithCommercialEntities

• DrMarkswasawardedresearchgrants,paidtoherinstitution,fromBristol-MyersSquibb,GileadSciences,Inc,andMerck.

LearningObjectives

Afterattendingthispresentation,learnerswillbebetterableto:

� Describe regimens recommended for initial treatment of HCV infection in HIV-infected persons

� Recognize when to do testing for HCV resistance� Identify the advantages and limitations of newly approved HCV

treatment regimens

IDSA/AASLDwww.hcvguidelines.org

EASLhttp://www.easl.eu/research/our-contributions/clinical-practice-guidelines/detail/easl-recommendations-on-treatment-of-hepatitis-c-2016

NewerstrategyforHCVtherapy:Directactingantiviralstargetlifecycle

---PREVIRProteaseinhibitors

e.g.telaprevir,boceprevir,faldaprevir,simeprevir,danoprevir,asunaprevir,paritaprevir,grazoprevir,voxilaprevir,glecaprevir

---BUVIRPolymeraseinhibitors– Nucleos(t)ideanalogs:e.g.

tegobuvir,sofosbuvir,– Non-nucs:e.g.deleobuvir,

dasabuvir---ASVIR

NS5A inhibitorse.g.daclatasvir,ledipasvir,ombitasvir,elbasvir,velpatasvir,pibrentasvir

NUC PI+

NUC NS5A+

PI NS5A+

PI NS5A+ nonNuc+NUC-SPARINGHCVRenalinsufficiencyDrug-druginteractionsDurationAffordability/AccessToxicityResistance

+/-RBV

+/-RBV

+/-RBV

CurrentlyusedcombinationsofDAAclasses

NUC-SPARINGHIVToxicityResistanceRenalinsufficiencyDrug-druginteractionsAffordability

NUC + NS5A+/-RBVPI +

PEGRBVSOF

RBVSOF SOF

RBVSMV

+/-

SOF

RBV+/-

LDV OMVDAS

Interferon PegIFN

Ribavirin ribavirin ribavirin +/-ribavirin +/-ribavirin

Nucs sofosbuvir sofosbuvir sofosbuvir sofosbuvir sofosbuvir sofosbuvir

Proteaseinhibitors

simeprevir Paritaprevir/ritonavir

grazoprevir velpatasvir glecaprevir

NS5A ledipasvir daclatasvir ombitasvir elbasvir pibrentasvir

Non-Nucs dasabuvir

SOFDAC

PTV/r

+/-

G1 X X X X X X X X X

G2 X X X X X

G3 X X X X X

G4 X X X X X X X X X

GZREBV SOF

VEL

ApprovedDrugRegimensforInitialTreatment

GLEPBV

TeamApproachtoHCVTreatmentPre-treatment,Pre-approval

MyContribution• Workwithpatienttopickregimen

• ClearlydescribeinplanANYindicationsfortreatment• E.g.HCVst2fibrosis,womanofchildbearingpotential,

cryoglobulins,DM,etc.

• ClearlydescribeinmyplantheindicationsforthisSPECIFICregimen

• E.g.G1a,Tx-naïve,cirrhosis– LDV/SOFx12wks• Ifunusualchoice- citestudyorguidancedocument

• ClearlydescribeinmyplanthereasonsotherregimensNOTagoodoption

• E.g.currentdarunavir/ruseprecludesuseofPrOD

• Confirmdiscussedmedicationinteractionsandaddressanyspecificones

• DocumentnobarrierstoadherenceevidencedbyHIVcontrol,etc

ContributionofHepatitisNurses+/orPharmacy• Completespecialtypharmacyreferral• Printanyrelevantlab/imagingdocumentation• Faxtospecialtypharmacy

• FileandTrackprogress• HelpdraftlettersforAppeals

• FileandTrackprogress• Stayincommunicationwithpatient• Patientassistanceconnectionswhenneeded

• Copayprograms• Charity

TeamApproachtoHCVTreatmentPre-treatment,Post-approval

MeetwithHepatitisNursesonly• Drugsusuallydeliveredtoourclinic• Reviewanynewmedications• Educationaboutmedications• Discussionofsideeffectsandmanagement

• Createmonitoringplanschedule• Bookappointmentsformonitoringvisits

• Localcommerciallabifcannotmaketoourclinic

• Reviewhowtotakeandusuallytakefirstdose

Which of the following represents the BEST strategy for treating HCV?

1. 3drugsfor8weeks2. 2drugsfor8weeks3. 2drugsfor12weeks4. 3drugsfor12weeks

CASE1– Treatmentduration:whentouse8v.12wks

26y.o.CaucasianWomanwithHCVGeno1b,nocirrhosis,HCVRNA1.2milIU/mL

• HCVHx:• Diagnosedduringlastpregnancy• RiskfactorIVDlastuse26mosago• Treatmentnaïve• FibrosureF0

• OthermedHxincludes:• SeizuredisorderonLevetiracetam(Keppra)

Which of the following regimens would NOT be recommended for this patient with HCV g1b and no cirrhosis?

1. Sofosbuvir/velpatasvir/voxilaprevirx8wks2. Sofosbuvir/velpatasvirx12wks3. Sofosbuvir/ledipasvirx8wks4. Glecaprevir/pibrentasvirx8wks

MinimumtoKnowPre-Treatment• HCVgenotype/subtype• HCVresistance(sometimes)• Stageoffibrosis

• Cirrhosis- yes/no• Ifyes,decompensated?(e.g.,ascites,encephalopathy,etc)

• Ifyes,don’tusePIs!• Method?

• Liverbiopsy• Transientelastography• Laboratorybiomarkers• Imaging

• PriorHCVtreatment?• Response?• DAAused?

HIV/Hepatitis C helpline

1-866-637-2342

• Medications• Tocheckfordruginteractions

• Comorbidities• Renalfunction• HIVstatus• Lifeexpectancy<1yrnon-livercauses?

• Patientpreference• Child-bearingpotentialofpatient/partner

• Ribavirinisateratogen

IDSA/AASLDwww.hcvguidelines.org

NOCIRRHOSIS:• Elbasvir/grazoprevirx12w• Glecaprevir/pibrentasvirx8w• Ledipasvir/sofosbuvirx8*or12w• Sofosbuvir/velpatasvirx12w• Paritaprevir/ritonavir/ombitasvir+dasabuvirx

12w• Simeprevirxsofosbuvir12w• Daclatasvir+sofosbuvirx12w

*8wknotrecommendedforBlackpatientsorHIV-infected.OnlyrecommendedwhenRNA<6millionIU/ml

CIRRHOSIS:

• Elbasvir/grazoprevirx12w• Glecaprevir/pibrentasvirx12w• Ledipasvir/sofosbuvirx12w• Sofosbuvir/velpatasvirx12w• Paritaprevir/ritonavir/ombitasvir+

dasabuvirx12w*

G1b Initial Treatment Recommended Regimens

(BOLDED areregimensapprovedsincelastyear!)

IDSA/AASLDwww.hcvguidelines.org

NOCIRRHOSIS:

• Elbasvir/grazoprevirx12wifnohilevelNS5Aresistance

• Glecaprevir/pibrentasvirx8w

• Ledipasvir/sofosbuvirx8*or12w• Sofosbuvir/velpatasvirx12w

• Paritaprevir/ritonavir/ombitasvir+dasabuvirx12w

• Simeprevirxsofosbuvir12w

• Daclatasvir+sofosbuvirx12w

*8wknotrecommendedforBlackpatientsorHIV-infected

CIRRHOSIS:

• Elbasvir/grazoprevirx12wifnohilevelNS5Aresistance

• Glecaprevir/pibrentasvirx12w• Ledipasvir/sofosbuvirx12w• Sofosbuvir/velpatasvirx12w

G1a Initial Treatment Recommended Regimens

(BOLDED areregimensapprovedsincelastyear!)

PangenotypicGlecaprevir/pibrentasvir Slide 30 of 52

DAA combo naive (TN, PEG/RBV, SOF) & special pops

► ENDURANCE (Phase 3)– GT 1 no cirrhosis (8 vs 12W)– GT 2 no cirrhosis (12W)– GT 3 no cirrhosis (8 and 12W)– GT 4-6 (12W)

► EXPEDITION (Phase 3)– GT 1, 2, 4-6 cirrhosis– GT 1-6 HIV– GT 1-6 Renal impairment

► SURVEYOR (Phase 2)– GT 2, 4-6 no cirrhosis 8 weeks– GT 3 cirrhosis/TE 12 vs 16 W

► Co-formulated – 3 pills once daily► Pangenotypic► Next generation

– Active vs NS3 RAS at 80, 155, 168 and NS5A RAS at 28, Q30, 31, 93

– A30K associated with failure in GT3 infection

► Negligible renal excretion► Contains a protease inhibitor► Has interaction with acid suppressing

meds

G/PSlidescourtesyofS.Naggie

Glecaprevir/pibrentasvir: No Cirrhosis

► 8 (N=828) vs 12 (N=1076) weeks

► TN and TE– PEG, RBV, SOF

– No DAA otherwise

► Relapse <1%

► Tx emergent RAS

99 99 9997

100 100 10099 100 10098

100 100 100

0

10

20

30

40

50

60

70

80

90

100

All GT1 GT2 GT3 GT4 GT5 GT6

8weeks 12weeks

Puoti et al. EASL 2017

Glecaprevir/pibrentasvir:CirrhosisSlide 34 of 52

Forns et al. EASL 2017

► 12 weeks in N=146

►Compensated cirrhosis

► TN or TE (25%) with IFN, P/R or SOF+P/R

► GT1a 33%, GT1b 27%, GT2 23%, GT4 11%, GT5 1%, GT6 5%

► 1 relapse- GT1a

Sofosbuvir/velpatasvirx12wksinHIV/HCVG1-6,Naïve+Rx-exp

Wyles,ClinInfectDis,2017.

N=10629%Rx-exp18%cirrhosis12%NS5aRAVs

Of2relapses:1rx-exp,0cirrhosis,0baselineRAVS

RenalfxnlookedunchangedinptsonboostedTDF

POLARIS-2:8-WkSOF/VEL/Voxilaprevirvs.12-WkSOF/VELNot Non-inferiorforDAA-naïve

8-wkSOF/VEL/VOXdidnotmeetcriteriafornoninferiorityvs12-wkSOF/VEL

Treatmentdifference:-3.4%(95%CI:-6.2%to-0.6%)

Jacobson IM, et al. Gastroenterology. 2017. Slide credit: clinicaloptions.com

InitialTreatmentAlgorithmAlgorithm• HCVgenotype/subtype&resistance• HIVstatus• Cirrhosis- yes/no- duration

• Ifyes,decompensated?(e.g.,ascites,encephalopathy,etc)

– Ifyes,don’tusePIs!• Renalfunction

– AvoidSofifCrCl<30• Medications

– Addressdruginteractions– Ribavirinisateratogen

• Patientpreference(8or12w,#pills,packaging)

OurCasePatient• 1a,startwith4recommendedregimens

• resistancetestingifelbasvir/grazoprevironly• HIVneg• Cirrhosis– no

• Potentiallyeligiblefor 8wkregimens• Renalfunctionnormalsoeligibleall4regimens

• Medications:• ChildbearingpotentialsoavoidRBV• Anti-epilepticsoftenhaveinteractions

• Pillsandpackaging• Elbasvir/grazoprevir– 1pill/dx12wks• Glecaprevir/pibrentasvir3pills/dx8wks• Sofosbuvir/ledipasvirx8wks• Sofosbuvir/velpatasvirx12wks

• (WHATPAYERCOVERS)TestallpregnantwomanforHCV.Remembertodopregnancytestingpriortotreatmentinwomenofchildbearingpotential

CASE2– WhentodoresistancetestingandwhattouseinpatientswithESRD

55y.o.AfricanAmericanMwithHIV(wellcontrolled),HCVGeno1bandcirrhosis,HCVRNA221,000IU/mL,ESRDonhemodialysis

• HCVHx:• Treatmentnaïve• Cirrhoticbasedontransientelastographymeasurementof 17kpa

• Nodecompensationevents• EGDnovarices• SononoHCC

• OthermedHxincludes:• HIV-infectiononTDF,3TC,andDOL• HTN,highcholesterol,ESRDonhemodialysis• MildGERDonPPIqD• HBVsAg- cAb+sAb-,HBVDNAnegative

v

(Slidetobeupdatedlaterthismonthwithguidelinesrelease)

HCVguidlines.orgaccessed9/29/17

Glecaprevir/pibrentasvir:RenalImpairmentSlide 35 of 52

Gane et al. EASL 2017

► GT 1-6 for 12 weeks

► Stage 4 or 5 CKD

– GFR<30 including HD

– 82% on HD

► TN or TE (42%) with IFN, P/R or SOF+P/R

► Including compensated cirrhosis (19%)

► GT1a 22%, GT1b 28%, GT2 16%, GT3 11%, GT4 19%, GT5 1, GT6 11

Testing for HCV resistance (RASs) would be indicated in this patient with HCV geno 1b if…

1. HehadfailedPegIFN+RBVinthepast2. Youplantotreatwith8weeksofglecaprevir/pibrentasvir3. Youplantotreatwith12weeksofgrazoprevir/elbasvir4. Nope!Resistancetestingisnotnecessaryhere5. Hmmm…What’saRAS?

RASTestingpriortoTreatment• NS5ARASsarerelativelycommon(10-15%)• SignificanceofNS5ARASsmaydependontheRAS,thegenotype,theregimenusedandwhetherpriorNS5Atreatment

• Ininitialtreatment,useresistancetestingpriorto:• Treatmentwithgrazoprevir/elbasvirfor1a• TreatmentofG3ifcirrhosis

ImpactofBaselineNS5ARAVs:SV

R12

(%)

GT1a GT1b GT1a, No BL NS5A RAVs

94 99 9990

144/154

129/130

133/135

9/10n/N =

SVR12 With 12 Wks of Grazoprevir/Elbasvir for initial treatment

10080604020

0GT1a, BL

NS5A RAVs With ≤ 5-Fold Shift to EBR

29

GT1a, BL NS5A RAVs

With > 5-Fold Shift to EBR

2/9

Slide credit: clinicaloptions.comZeuzem S, et al. Ann Intern Med. 2015;163:1-13.

IfNS5ARAVsingenotype1a,treatwithEBR/GZR+RBVfor16wks(alternative)

NobaselineRAVtestingneededingenotype1bpts

InitialTreatmentAlgorithmAlgorithm• HCVgenotype/subtype&resistance

• HIVstatus• Cirrhosis- yes/no- duration

• Ifyes,decompensated?(e.g.,ascites,encephalopathy,etc)

• Ifyes,don’tusePIs!• Renalfunction

• AvoidSofifCrCl<30• Medications

• Addressdruginteractions• Ribavirinisateratogen

• Patientpreference(8or12w,#pills,packaging)

Ourcasepatient• 1b,noneedforresistancetesting,startwith4recommendedregimens

• HIVposbutnodrug/druginteractions• Cirrhosis– yes

• No8wkregimens• CompensatedsooktousePIs

• Hemodialysis,noregimensw/sofosbuvir,so2remainingregimens

• Medications:ARVs,PPIqd• Elbasvir/grazoprevir– nointeraction• Glecaprevir/pibrentasvir(limitdoseofPPI)

• Pillsandpackaging• Elbasvir/grazoprevir– 1pill/d• Glecaprevir/pibrentasvir – 3pills/d

• (WHATPAYERCOVERS)HBVtestingpriortotreatmentforallpatients.MonitorforHBVreactivationduringtreatmentifcAb+(withDNAforsAg+orDNA+,lfts/sxforothers)ContinuecirrhosismanagementandHCCscreeningaftercure

CASE3– TreatmentanddruginteractionsinpatientswithHIV

49y.o.MwithHIVandHCVGeno2,HCVRNA120,000IU/mL

•HIVHx:•WellcontrolledonTDF/FTC+BIDdarunavir/ritonavirx10years

•HCVHx:• Treatmentnaïve• Fibroscan6.1kPa• AcquiredHCV2yearsago– RFMSM

• OthermedHxincludes:• HTN,renalinsufficiency(CrCl50)• GERDonPPI

Which of the following regimens are recommended for genotype 2 infection in a person without cirrhosis?

1. Sofosbuvir/velpatasvirx12wks2. Glecaprevir/pibrentasvirx8wks3. Both1and24. Neither1or2

IDSA/AASLD/IAS-USAwww.hcvguidelines.org

NOCIRRHOSIS:• Glecaprevir/pibrentasvirx8w• Sofosbuvir/velpatasvirx12wks

G2 INITIAL TREATMENT RECOMMENDED REGIMENS

CIRRHOSIS:• Glecaprevir/pibrentasvirx12w• Sofosbuvir/velpatasvirx12wks

HCVguidlines.orgaccessed9/29/17

Before administering sofosbuvir/velpatasvir in a patient with renal insufficiency (CrCl 50) on TDF/FTC + darunavir/ritonavir, which of the following should be considered?

1. Changedarunavir/rdosingfromBIDtoQD2. ChangeTDFtoTAF3. Changedarunavir/rtoefavirenz4. NoARVadjustmentneeded

HCVguidelines.org

RTV-BoostedPIsWithout WithLDV/SOF4-9LDV/SOF10

WithSOF/LDVTDFexposuresarehighinthoseonPIs

EFV RPV ATRCPA

NNRTIsWithout With

LDV/SOF1,2LDV/SOF3

• TFVexposuresarehigherwhenTDFiscoadministeredwithLDV/SOFcomparedtowithoutLDV/SOF,but• ComparedtotherangeofTFVexposureswithavailablesafetydata

• ForEFVorRPV:TFVexposuresfallwithintherange1• ForRTV-boostedPIs:TFVexposurespartiallyexceedtherange2

RangeofTFVexposureswithavailablesafety

data

1,DataonFile,GileadSciences.2.HoetelmansRMW,etal.6th IWCPHT2005.QuebecCity,Canada.Poster#2.113.GermanP,etal.ICPHHT2014.#O64.LuberAD,etal.HIVMedicine.2010;11:193-9(FPV+RTV)5.ChittickGE,etal.AAC.2006;50(4):1304-10(SQV+RTV)

6.Zhu.9thIWCPHT.2008.#023(ATV+RTV&LPV/r)7.KearneyB,etal.JAIDS. 2006;43(3):278-83(LPV/r)8.AgarwalaS,etal.6thIWCPHT2005.#16.(ATV+RTV)9.HoetelmansRMW,etal.BJCP. 2007;64(5):655-61(DRV+RTV)10.GermanP,etal.CROI2015

N=3015 1714FPVSQVLPV/rATVDRVATVDRV153519*2417*14122423

SlidecourtesyofJKiser

GuidelinesRecommendationaboutuseofLDVorVELwithTDFSOF/LDV+TDFCrCl<60mL/min:AVOIDCrCl>60:MONITOR

SOF/LDV+TDF+cobi- orritonavir-boostedPIAnyCrCl:AVOIDifpossible,ConsiderTAF

SOF/VEL+TDFCrCl<60mL/min:AVOIDCrCl>60:MONITOR

SOF/VEL+TDF+cobi- orritonavir-boostedPICrCl<60mL/min:AVOIDCrCl>60:MONITORorconsiderTAF

HCVguidlines.orgaccessed9/29/17

10093

0

10

20

30

40

50

60

70

80

90

100

8weeknocirrhosis 12weekcirhosis

Glecaprevir/pibrentasvir:HIV Slide 36 of 52

136/13614/15

Rockstroh et al. EASL 2017

► GT 1-6► Primarily an 8 week study► 12 weeks in 16 patients with

cirrhosis► TN or TE (19%) with IFN,

P/R or SOF+P/R► VBT on treatment – GT3

with cirrhosis

HCVguidelines.org

Drug-Drug Interactions with DAAS

•Acid-reducingdrugs

•Anti-epileptics

•Antiretrovirals

•Amiodarone

•Lipid-loweringdrugs

http://www.hep-druginteractions.org/https://www.hep-druginteractions.org/

Marks,CROI,2018 Marks,CROI,2018

InitialTreatmentAlgorithmAlgorithm• HCVgenotype/subtype&resistance

• HIVstatus• Cirrhosis- yes/no- duration

• Ifyes,decompensated?(e.g.,ascites,encephalopathy,etc)

• Ifyes,don’tusePIs!• Renalfunction

• AvoidSofifCrCl<30• Medications

• Addressdruginteractions• Ribavirinisateratogen

• Patientpreference(8or12w,#pills,packaging)

Ourcasepatient• 2,noneedforresistancetesting,startwith2recommendedregimens

• HIVpos– watchfordruginteractions• Cirrhosis– no• CrCl50,sofosbuvirokbutCrCl>30butassessifTDF

• Medications:TDF,HIVPI,PPIqdneedtobeaddressed

• ARVadjustmentneeded

• Pillsandpackaging• Sofosbuvir/velpatasvir– 1pill/d• Glecaprevir/pibrentasvir3pills/d

• (WHATPAYERCOVERS)MonitorMSMforreinfectionatleastannually.ConceptofHCVtreatmentaspreventionhasbeenprovenforHIV+MSMinNetherlands&Switzerland.

CASE4– Genotype3management

71y.o.WwithHCVGeno3,HCVRNA950,000IU/mL

HCVHx:• Treatmentnaïve• Fibroscan14.2kPa(c/w)cirrhosis• Nosymptomsdecompensation• RAStesting:nomutations

• OthermedHxincludes:• DM• CrCL55

Which of the following is recommended for initial treatment of HCV G3 in a patient with cirrhosis?

1. Sofosbuvir/ledipasvirx12wks2. Sofosbuvir/velpatasvirx12wks3. Elbasvir/grazoprevirx12wks4. Glecaprevir/pibrentasvirx8wks

IDSA/AASLD/IAS-USAwww.hcvguidelines.org

NOCIRRHOSIS:• Glecaprevir/pibrentasvirx8w• Sofosbuvir/velpatasvirx12w• Sofosbuvir+daclatasvirx12w

G3 INITIAL TREAMENT RECOMMENDED REGIMENS

CIRRHOSIS:• Glecaprevir/pibrentasvirx12w• Sofosbuvir/velpatasvirx12w*• Sofosbuvir+daclatasvir+/-RBVx24w*

*RAVtestingforY93HandaddRBVifpresentorusesofosbuvir/velpatasvir/voxilaprevir

Glecaprevir/pibrentasvirinGT3Treatment-naïvewithoutCirrhosis

Foster et al. EASL 2017

Slide 32 of 52

►Non-inferiority– 12W vs DAC/SOF X12W– 12W vs 8W

►Viral Failure 3% G/P– 4 in 12W (3 relapse, 1 VBT)– 1 in DAC/SOF– 6 in 8W (5 relapse, 1 VBT)

►BL Y93H: 5/5 SVR►BL dual NS3/NS5A

– 71-86% SVR►Tx emergent RAS

– 50% failures with A30K BL– A30K+Y93 (69-fold R

SURVEYOR-II– G3withCirrhosis48patientsreceivedG/P+/- RBVx12w=100%SVR

Glecaprevir/pibrentasvirandRASs-- A30Keffect?

Foster et al. EASL 2017 Krishnan et al. EASL 2017

Slide 32 of 52

►Non-inferiority– 12W vs DAC/SOF X12W– 12W vs 8W

►Viral Failure 3% G/P– 4 in 12W (3 relapse, 1 VBT)– 1 in DAC/SOF– 6 in 8W (5 relapse, 1 VBT)

►Tx emergent RAS– 50% failures with A30K BL

• 6% patients overall had a BL A30K

SURVEYOR-II– G3withCirrhosis48patientsreceivedG/P+/- RBVx12w=100%SVR

Sofosbuvir/velpatasvirx12wksforG3(ASTRAL-2)

Foster,NEJM,2015,hcvguidelines.org

Mostofthis3%w/failurehadcirrhosis

InitialTreatmentAlgorithmAlgorithm

• HCVgenotype/subtype&resistance

• HIVstatus

• Cirrhosis- yes/no- duration• Ifyes,decompensated?(e.g.,ascites,encephalopathy,etc)

• Ifyes,don’tusePIs!

• Renalfunction• AvoidSofifCrCl<30

• Medications• Addressdruginteractions• Ribavirinisateratogen

• Patientpreference(8or12w,#pills,packaging)

Ourcasepatient• Geno3,2regimens,noA30KorY93Hpresent

• HIVneg• Cirrhosis– yes

• CompensatedsoPIsok

• CrCl55,sofosbuvirok• Medications:nodruginteractions• Pillsandpackaging

• Sofosbuvir/velpatasvir– 1pill/dx12wks

• Glecaprevir/pibrentasvir3pills/dx12wks

• (WHATPAYERCOVERS)

• RemarkableadvancesintermsofHCVtreatmenttolerability&efficacyforpatientswithHIV

• RecentadvancesinG2,G3,ESRD

• SVRsforHIV/HCVveryclosetomonoinfection

• Stilldruginteractionissues,butvaluableresourcestohelpmanage

• RAStestingpriortoinitialtreatmentif:• G1aandplannedgrazoprevir/elbasvir• G3&cirrhosisandplannedsofosbuvir/velpatasvir

• Successfultreatmentpreventscirrhosis,endstageliverdisease,andhepatocellularcancer

• PostSVR– continueliverdiseasemanagement/HCCscreening,monitorHBVreactivation,andprovideHCVRNAtestingifongoingrisk

It’stime!CureEveryonewithHCV

• HCVguidelines.org• nynjaetc.org• http://www.hep-druginteractions.org

THANK YOU

Thankyou

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