Most patients with HIV who become infected with hepatitis C will not clear the infection spontaneously and face a chronic course, according to a study presented at the Conference on Retroviruses and Opportunistic Infections, also known as CROI. The researchers advocate for amended direct-acting drug labels and guidelines to allow usage of DAA therapy during the acute phase of HCV in high-risk individuals.
“We currently do not have any DAAs being licensed for the acute phase ... and the drug prices are still high, at least in my resource-rich country, and that makes physicians hesitant to prescribe it in the acute phase,” Christoph Boesecke, MD, from the University of Bonn, Germany, said in his presentation. “The question then is which patient will clear spontaneously and which are the patients I should talk to and refer to early treatment to not waste any more time and money.”
Boesecke and colleagues designed the PROBE-C study to evaluate the rates of spontaneous clearance of acute HCV in patients with HIV coinfection. Between 2007 and 2016, the investigators documented 465 acute HCV episodes in patients with HIV and at least 12 months of follow-up from Austria, Denmark, France, Germany, Italy, the Netherlands, Switzerland and the United Kingdom.
Median patient age was 41 years (range, 38-46 years), most were men (98%) and the main route of transmission was between men who have sex with men (98.9%). Median baseline HCV RNA was 230,000 IU/mL, median CD4+ T cell count was 574 cells/L and median maximum alanine aminotransferase was 445 U/L. Most patients received combination antiretroviral therapy (92%) and 91% had suppressed HIV RNA at baseline.
Fifty-five patients achieved spontaneous clearance of acute HCV, while 325 patients with persistent viremia initiated treatment with either pegylated interferon and ribavirin or interferon-free DAAs (n = 61) within 48 weeks of acute HCV diagnosis. Sustained virologic response was 75.6%.
Fifty-one patients became reinfected with HCV and 85 developed chronic infection. The researchers observed no significant association between spontaneous clearance and HCV transmission risk, HCV genotype, HCV RNA levels or baseline ALT or HIV parameters.
Patients who achieved more than a 2-log decline in HCV RNA by week 4 were significantly more likely to clear infection spontaneously (OR = 1,115.3; 95% CI, 225.5-5,515.3).
“We can say that spontaneous clearance of acute HCV in the HIV coinfection setting is a rare event,” Boesecke concluded. “Almost 90% in this cohort of patients were facing a chronic course. A 2-log drop might be the most helpful tool and the strongest predictor of a chronic course that allows identification of patients early on.”
According to Boesecke, the European AIDS Clinical Society recently amended their guidelines to support the early use of DAAs in patients coinfected with HIV and HCV. – by Talitha Bennett
Reference: Boesecke C, et al. Abstract 129. Presented at: Conference on Retroviruses and Opportunistic Infections; March 4-7, 2018; Boston.
Disclosure: Boesecke reports he is a consultant and on the speakers bureau for AbbVie, Gilead, Janssen, Merck Sharp & Dohme and ViiV Healthcare.