HIV/HCV Cases

Case #1
53 y/o man with HIV/HCV, chronic GT1b infection.
-Liver bx 2009 stage 1-2 of 4
-Treated with PEG/RBV, failed to achieve >2log10
decline in viral load by W12
-HIV well controlled, RNA <LLOQ TND
CD4 38%/1374
-On Darunavir/r + tenofovir/emtricitabine
 Case #1

Labs: Albumin 4.0

Tbili 0.6
AST/ALT 120/69
INR 1.0
Plat 140
Cr 0.7
Hgb 14
 Case #1: What to do next?

1. Start LDV/SOF X 12 weeks

2. Start DAC + SOF X 12 weeks
3. More testing needed
4. Start LDV/SOF X 12 weeks + WB ribavirin
5. Start DAC + SOF X 24 weeks
6. SOF + RBV X 24 weeks
 AASLD/IDSA Recommendations: Initial
Therapy for Genotype 1 HCV Infection

* Only if no baseline NS5A RAS for GT1a, if NS5A RAS present for GT1a, EBR/GZR NOR RECOMMENDED
Ϯ 8 Weeks of LDV/SOF only if non black race, no HIV, and HCV RNA < 6million IU/mL
AASLD/IDSA. HCV guidance. September 2017.
 Calculating APRI

• APRI: AST to platelet ratio index

• Formula: (AST / upper limit of normal) X 100
Platelet count per mm3 / 1000

Lin ZH Hepatology 2011

 Case #1

APRI (120/41)/140=0.020 X 100 = 2.0

SPIN – rules in cirrhosis

 Case #1: What to do next?
1. Start LDV/SOF X 12 weeks
2. Start DAC + SOF X 12 weeks
3. More testing needed
4. Start LDV/SOF X 12 weeks + WB
ribavirin
5. Start DAC + SOF X 24 weeks
6. SOF + RBV X24 weeks

Option
 LDV/SOF ± RIB for 12wks
 SOF + VEL for 12wks
 Change of ART regimens:
DAA/ARV Interaction Score Card: Ethiopia Specific
Standard dose of DCV is
Sofosbuvir Ledipasvir Daclatasvir
60mg daily
Inhibitor of
*Decrease DCV dose to
Substrate of Inhibitor/ OATP1B1/3, BCRP, 30mg daily
DDI Substrate of P-gp
P-gp and BCRP Substrate of P-gp and
and BCRP
CYP3A4 **Increase DCV dose to
90mg daily
ATV/r No data LDV ↑; ATV ↑ DCV ↑*
LPV/r No data No data ALLY-2 ↔ Combination of LDV and TDF
EFV SOF ↔; EFV ↔ ION-4 ↔ DCV ↓** is safe with all antiretrovirals
except boosted protease
NVP SOF ↔; EFV ↔ ION-4 ↔ No data**
inhibitors (ex. ATV/r).
TDF SOF ↔; TFV ↔ LDV ↔; ↑TFV DCV ↔; TFV ↔
Renal monitoring is
ABC No data No data ALLY-2 ↔
recommended for all LDV +
3TC/FTC ↔ ↔ ALLY-2 ↔ TDF dosing
Slide courtesy of Jennifer Kiser
 Post-SVR management

What do you tell the patient about their risk of liver death, HCC?
What do you tell the patient about their need for follow-up?
What additional testing will you do for this patient?
What education will you provide this patient?
 Case #2

50 y/o man with HIV/HCV, mixed GT1a/1b without prior staging of liver
disease prior to referral. He had been treated with PEG/RBV in 2005 in
NYC when he had a “flare” of his LE in setting of active drug use.
Relapse per his history, records are spotty.

Now clean of drugs and ETOH X 2 years. Doing well with HIV, on salvage
regimen of Raltegravir + RPV/TDF/FTC and has had suppressed HIV for
>2 years.
 Case #2

Labs: CD4 25%/778

HIV RNA <LLOQ TND
Albumin 4.2
AST/ALT 49/54
Tbili 0.6
INR 0.9
Plat 220
 Case #2: What to do next?

1. Start LDV/SOF X 12 weeks

2. Start DAC + SOF X 12 weeks
3. More testing needed
4. Start LDV/SOF X 12 weeks + WB ribavirin
5. Start DAC + SOF X 24 weeks
6. SOF + RBV X 24weeks
 Calculating APRI

• APRI: AST to platelet ratio index

• Formula: (AST / upper limit of normal) X 100
Platelet count per mm3 / 1000

Lin ZH Hepatology 2011

 Case #2

APRI (49/41)/220=0.005 X 100 = 0.5

SNOUT – rule out

US with fatty liver

 Case #2

Other medications: H2blocker BID

Advair discus
 Case #2: What to do next?

1. Start LDV/SOF X 12 weeks

2. Start DAC + SOF X 12 weeks
3. Start LDV/SOF X 12 weeks + WB ribavirin
4. Start DAC + SOF X 24 weeks
5. More to do…
DAA/ARV Interaction Score Card: Ethiopia Specific
Standard dose of DCV is
Sofosbuvir Ledipasvir Daclatasvir
60mg daily
*Decrease DCV dose to
Inhibitor of
Substrate of Inhibitor/ OATP1B1/3, BCRP, 30mg daily
DDI Substrate of P-gp
P-gp and BCRP Substrate of P-gp and **Increase DCV dose to
and BCRP
CYP3A4
90mg daily
ATV/r No data LDV ↑; ATV ↑ DCV ↑*
LPV/r No data No data ALLY-2 ↔ Combination of LDV and TDF
EFV SOF ↔; EFV ↔ ION-4 ↔ DCV ↓**
is safe with all antiretrovirals
except boosted protease
NVP SOF ↔; EFV ↔ ION-4 ↔ No data**
inhibitors (ex. ATV/r).
TDF SOF ↔; TFV ↔ LDV ↔; ↑TFV DCV ↔; TFV ↔
Renal monitoring is
ABC No data No data ALLY-2 ↔
recommended for all LDV +
3TC/FTC ↔ ↔ ALLY-2 ↔ TDF dosing
Slide courtesy of Jennifer Kiser
 Case #2

H2blocker was discontinued.

Patient started on started LVD/SOF.

BL HCV RNA 8.08 million IU/mL

W6 HCV RNA 102 IU/mL
W8 HCV RNA 26 IU/mL
W10 HCV RNA <LLOQ TD
W12 HCV RNA <LLOQ TND

Treatment extended to 24 weeks and he achieved SVR24

 Case 3
A 63 year old man with HIV/HCV coinfection, ESRD on HD,
compensated cirrhosis, HCC diagnosed in 2013 with recurrence
in 2014, is on an ARV regimen including atazanavir/ritonavir and
lamivudine. He has long-standing HIV viral suppression and CD4+
count of 466 (29%). His HCV is GT1a. He was treated previously
in 2002 with standard IFN-α for about 6 weeks, but treatment
was discontinued due to relapse of illicit drug use. EGD shows no
varices or gastropathy.
His albumin is 3.6, T. bili 1.3, platelet count 290,000, INR 1.0
HCV RNA level is 2.5 million. He is Child Pugh A (5) Concomitant
meds include famotidine 40mg QHS and prilosec 20mg QHS

Would you treat?

A 63 year old man with HIV/HCV coinfection, ESRD on HD,
compensated cirrhosis, HCC diagnosed in 2013 with recurrence
in 2014, is on an ARV regimen including atazanavir/ritonavir and
lamivudine. He has long-standing HIV viral suppression and CD4+
count of 466 (29%). His HCV is GT1a. He was treated previously
in 2002 with standard IFN-α for about 6 weeks, but treatment
was discontinued due to relapse of illicit drug use. EGD shows no
varices or gastropathy.
His albumin is 3.6, T. bili 1.3, platelet count 290,000, INR 1.0
HCV RNA level is 2.5 million. He is Child Pugh A (5) Concomitant
meds include famotidine 40mg QHS and prilosec 20mg QHS

Which DAA regimen would you choose?

A 63 year old man with HIV/HCV coinfection, ESRD on HD,
compensated cirrhosis, HCC diagnosed in 2013 with recurrence
in 2014, is on an ARV regimen including atazanavir/ritonavir and
lamivudine. He has long-standing HIV viral suppression and CD4+
count of 466 (29%). His HCV is GT1a. He was treated previously
in 2002 with standard IFN-α for about 6 weeks, but treatment
was discontinued due to relapse of illicit drug use. EGD shows no
varices or gastropathy.
His albumin is 3.6, T. bili 1.3, platelet count 290,000, INR 1.0
HCV RNA level is 2.5 million. He is Child Pugh A (5) Concomitant
meds include famotidine 40mg QHS and prilosec 20mg QHS

Is his HIV regimen compatible with DAA

regimens, or does it need to be
changed?
 Follow-up
The patient was started on LDV/SOF daily with dosing prior to
HD on HD days. ARV regimen is not changed, but PPI and H2
blocker were stopped 2 weeks earlier. He developed recurrent
GERD, so he was started on a low dose H2 blocker at night.
At week 2 HCV RNA was below the lower limit of
quantification with target detected, but by week 4 target
was not detected. He is receiving 24 weeks of therapy.