Coinfection

AASLD 2013: High Response Rates with Telaprevir Triple Therapy for HIV+ Men with Acute Hepatitis C

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Adding telaprevir (Incivek) to pegylated interferon and ribavirin shortens the duration of treatment and improves sustained response rates for HIV positive men with acute hepatitis C virus (HCV) infection, according to a presentation yesterday at the at the 64thAASLD Liver Meeting in Washington, DC.

Since the early 2000s, researchers have reported outbreaks of apparently sexually transmitted HCV infection among HIV positive gay and bisexual men, first in the U.K. and continental Europe and later in Australia and the U.S.

Because acute hepatitis C is often asymptomatic or causes only non-specific flu-like symptoms, most people do not recognize and seek treatment when they become infected. But HIV positive people on antiretroviral therapy (ART) generally receive regular liver function tests to monitor for drug toxicity and unexplained liver enzyme elevations may signal recent HCV infection.

Treating acute hepatitis C, rather than waiting until it becomes chronic (after 6 months), leads to high rates of sustained virological response (SVR), essentially doubling the cure rate in half the time (24 rather than 48 weeks for HCV genotype 1). However, people with HIV do not respond as well as HIV negative individuals, and they are more likely to need treatment as they less often spontaneously clear HCV.

Daniel Fierer from Mt. Sinai Medical Center and fellow investigators with the New York Acute HCV Surveillance Network conducted a pilot study to evaluate whether adding the HCV protease inhibitor telaprevir to interferon-based therapy could increase the likelihood of sustained response and further shorten duration of treatment for acute hepatitis C in people with HIV. Fierer's team has been following HIV positive gay and bisexual men with presumed sexually transmitted HCV for a decade, reporting that some have experienced unusually rapid liver disease progression.

This open-label study included 34 patients consecutively enrolled at a single clinical practice between July 2011 and September 2012. Participants were sexually active HIV positive men who have sex with men (MSM) with genotype 1 acute HCV infection, as indicated by new alanine aminotransferase (ALT) elevation or newly detectable HCV viremia.

Patients were first observed for several weeks to see if they would spontaneously clear HCV. Those who did not were treated with a triple regimen of 750 mg 3-times-daily telaprevir, 180 mcg once-weekly pegylated interferon alfa-2a (Pegasys), and twice-daily weight-based ribavirin for 12 weeks, starting within 6 months of their first recorded ALT elevation.

If necessary, participants modified their antiretroviral regimen before starting hepatitis C treatment to replace agents known to interact with telaprevir. Permitted antiretrovirals included ritonavir-boosted atazanavir (Reyataz), raltegravir (Isentress), rilpivirine (Edurant), or efavirenz (Sustiva), all with tenofovir/emtricitabine (the drugs in Truvada).

Of the 34 men initially enrolled, 7 could not receive telaprevir (due to HCV genotypes other than 1, lack of insurance coverage, or other reasons) and were included in the comparator group, 5 people spontaneously cleared HCV before starting therapy, and 3 declined treatment, leaving 19 men who started triple therapy.

Most of the treated participants (84%) were white and the median age was 44 years. All but 2 (89%) had the more difficult-to-treat HCV subtype 1a and 63% had the favorable IL28B CC gene pattern associated with good interferon response.

A comparator group consisted of 48 HIV positive MSM with genotype 1 acute hepatitis C who were treated with pegylated interferon and ribavirin alone between January 2008 and September 2012. This group was 58% white and the median age was 42 years; 90% had HCV 1a and 42% had the CC gene variant.

Results

Fierer also reported data from an additional 14 HIV positive men treated with telaprevir triple therapy after the initial study ended, between October 2012 and October 2013. In this group 71% were white, 93% had HCV subtype 1a, and 36% had the CC variant -- closer to the proportion in the comparator group.

At the end of treatment 93% had undetectable HCV RNA, and 6 out of 7 men (86%) with sufficient follow-up achieved SVR12 -- very similar to the rate in the pilot study despite the lower proportion with favorable IL28B status. The 1 person who experienced treatment failure stopped therapy at week 6. Again, there were no relapses among those who completed therapy.

Combining this group with the earlier patients treated with telaprevir, the overall SVR12 rate for triple therapy was 85%, which fell just short of a statistically significant difference from the 63% SVR12 rate in the standard therapy comparator group (P=0.06).

Adding telaprevir to pegylated interferon improves cure rates and cuts treatment duration in half again, to 12 rather than 24 weeks, Fierer concluded. Triple therapy was well-tolerated and study participants said they were pleased with the short course of treatment.

Fierer acknowledged that telaprevir is on the way out, given the pending approval of next-generation direct-acting antivirals such as sofosbuvir that are more effective, better tolerated, and have less potential for interaction with HIV drugs.

But whatever regimen is used, he added, providing treatment now will prevent further HCV infections, and he strongly encouraging "thinking of treatment as prevention."

11/4/13

Reference

DS Fierer, DT Dieterich, MP Mullen, et al. Telaprevir in the Treatment of Acute HCV Infection in HIV-infected Men: SVR 12 Results.64th Annual Meeting of the American Association for the Study of Liver Diseases (AASLD 2013). Washington, DC, November 1-5, 2013. Abstract 40.