A Decade of Treating HCV in Patients with Ongoing Barriers to Care

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

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&&

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&

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"

HCV&incidence&in&HIV&MSM&in&relaHonship&to&calendar&year&

Rate/&100UPY&

MetaUregression&Polynomial&fit&&&&&&&&&&(with&95%&CI)&

Year&of&esHmate&

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) &&

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."

&

Thinking&of&HCV&treatment&opHons&in&2007,&was&Tim&a&good&candidate&for&HCV&therapy?&&

1. Yes&2. No&&

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…”&

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

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%&

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&

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&subUspecialty&clinic&

Too&much&paper&work:&A.  PaHent&access&&B.  Underinsured&

Low&reimbursement&incenHve&

Adapted from Grebely et al. 2013. JID; 207 (Suppl 1)

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"

Incide

nce&pe

r&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.

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..."


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.&

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

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"

Percen

tage"with

"con

di(o

ns"

HIV&monoinfected&

HIV/HCV&

Goulet'et'al.'AIDS'2005;'19'(suppl'3):'S99:S105'Copyright © Edward Cachay MD, MAS.

n=&25,116&&

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

HIV

control

BA

RR

IER

S

LIV

ER

status

Co-m

orbidities The Owen Hepatitis Co-Infection staging table of HCV among HIV-infected patients

Lesson"#1:"More"than"assessing"liver"fibrosis…


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’.&


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&

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!

!

Homeless1!

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&


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”&


06/2008& 06/2008& 07/2008&07/2008&

Call"to"reGschedule"

07/2008& 08/2008& 08/2009&09/2008&

02/2010&

‘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&

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.&&

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"

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&

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.&

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

&treatm

ent&u

ptake&pe

r&100P

YFU&


2013&

Mean&

95%&&CI&

2014&

May"2013:

&

• We&advocated&for&IFNUfree&DAA&combinaHons&for&our&paHents,&before&any&professional&guideline&was&available.&

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&SV

R"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’&

We"were"looking"forward"to"the"exci,ng",mes"coming"ahead!

IFN& pegIFNURBV& Triple& All&oral&DAA&

Sustaine

d&viral&respo

nse&(cure)&&

1990s& 2000s& 2011& 2014&

10%&

35%&

65%&

>&90%&

No.&

Adapted from Expert Opin Pharmacother. 2013;14:1161-70


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&

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

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&

• 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.&

The"HCV"market"running"and"their"impact"on"lowering"the"prices"

Gilead"

AbbVie"

BMS"

Janssen"

Merck"

&&&&&&&&&

Roche&Boehringer&

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”&

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&&

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

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

""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?&

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:&

Where"do"we"stand"in"this"fight?" MedicaHon&manufacturer& InsurancesU&

Health&payees&

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

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

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&


"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&&


0

75 83.34

SMV + SOF± RBV x 12 Wks

Real"world

. 1Dieterich D, et al. AASLD 2014. Abstract 46.

n =

UCSD

SV

R 4

(%)

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

Northwest

HIV&cohorts&

90

80


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&)&

Cachay et et al. IDweek 2015- abstract 1672

Cachay et et al. IDweek 2015- abstract 1672

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.&

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

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.&&

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&

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&

A Decade of Treating HCV in Patients with Ongoing Barriers to Care

Health & Medicine