HCV Disease Pathway Acute infection 20-30% Spontaneous cure 70-80% ?? Chronic Hepatitis 20-100%!!! Cirrhosis 1- 4%/annum Hepatocellular carcinoma Modelled prevalent number of HCV infected IDUs in Scotland according to stage of HCV disease, 1960-2030 Recovered from HCV 50 Cleared HCV from treatment 40 Mild disease Moderate disease 30 2008 Living IDUs (thousands) 60 Cirrhosis 20 10 0 1960 1980 2000 Calendar year 2020 Hutchinson et al. Hepatology 2005 Modelled number of IDUs with cirrhosis in Scotland by different uptake rates of HCV antiviral therapy, 2008-2030 2010 2020 2030 0 1,000 2,000 3,000 0 1,000 2,000 3,000 2,000 1,000 0 Living IDUs with cirrhosis Uptake of therapy by (up to) 2,000 IDUs per year 3,000 Uptake of therapy by 1,000 IDUs per year Uptake of therapy by 225 IDUs per year 2010 2020 2030 2010 Cirrhosis prevented Compensated Decompensated from antiviral therapy* cirrhosis cirrhosis * Excludes those prevented from antiviral therapy prior to 2008 2020 2030 HCC Hutchinson, SJ. et al 2008 J Hepatol. 48 (Suppl 2):S297 UPTAKE OF TREATMENT In Scotland, 2002-2012: (a) the number of chronic HCV persons commencing a course of therapy each year, and (b) the cumulative number of patients attaining SVR Number treated. 800 3000 600 2000 400 1000 200 0 2002 Key points: Cumulative SVR 4000 1000 2003 2004 2005 2006 2007 No persons commencing treatment 2008 2009 2010 2011 2012 Cumulative number of known SVR •1052 patients treated in 2012/13 (marginally below the national target of 1,150) •In the last three years, more than 1,000 patients per year commencing treatment in Scotland •The number of persons known to have attained a SVR, now exceeds 3000 McDonald et al. J Viral Hep; in press (1b) UPTAKE OF TREATMENT (1a) ATTENDANCE AT SPECIALIST SERVICES 50 50 40 40 % Treated % Attended Proportion commencing treatment within 12 months of attendance, by calendar period, in Scotland. 30 20 30 20 10 10 0 0 96-98 99-01 02-04 05-07 08-09 96-98 PERIOD OF DIAGNOSIS 99-01 02-04 05-07 08-09 PERIOD OF ATTENDANCE Pre phase II Phase II McDonald et al. J Viral Hep; in press (4) IMPACT OF SVR (I) LIVER DEATHS (II) FIRST-TIME ADMISSION FOR LIVER FAILURE Number of admissions Number of deaths 150 100 50 150 100 50 0 0 98 00 02 04 06 Year Death 08 10 98 00 02 04 06 08 10 Year Admission McDonald et al. J Viral Hep; in press Estimated uptake of HCV antiviral therapy, by selected country Estimated number living with chronic HCV (N) Annual number initiated on HCV therapy (Rx) Annual treatment uptake (Rx/N) 38,000 1,052 2.8% ~500,000 ~13,500 ~2.7% USA (2008-2012)2 ~3,200,000 65,000 ~2.6% Australia (2006)3 202,400 2900 ~1.4% Scotland (2012) France (2000-2005)1 1Lettmeier 2Volk 3Gidding et al. J Hepatol. 2008;49(4)528-36 et al. Hepatology. 2009; 50:1750-1755 et al. J Gastroenterol Hepatol. 2009; 24(10)1648-54 Excess risk of a liver and an alcohol related hospital episode post treatment (in SVR & non-SVR patients) AND post diagnosis (in spontaneously resolved patients), compared to the general population 50.0 53.2 Excess risk* 26.8 Liver 10.5 10.0 5.0 5.9 4.5 2.0 1.0 7.4 Alcohol 1.3 0.5 Non-SVR (N=638) * Age, sex & year standardised SVR (N=560) Non-cirrhotic Spontaneous SVR resolved (N=503) (N=3,690) Innes et al. Hepatology, 2011. HCV treatment the state of the art Feb 2014 Interferon Based Tailored to Genotype Duration 24-48 weeks Scotland Genotype 1&3 SVR G1 70%, G3 75% Boceprevir dose must not be reduced or restarted once stopped STOP Treatment-naïve without cirrhosis who achieve undetectable HCV RNA at Weeks 8 and 24 PR lead-in BOC + PR PR BOC + PR* Non-cirrhotic treatment-naïve with detectable HCV RNA at Week 8 but undetectable at Week 24* Non-cirrhotic relapsers and partial responders HCV RNA 0 4 8 If ≥100 IU/mL discontinue all drugs If detectable discontinue all drugs 12 24 28 28 BOC + PR Null responders Patients with cirrhosis 36 48 Weeks *This regimen has only been tested in patients who have failed previous therapy who were late responders Boceprevir EU SmPC Telaprevir dose must not be reduced orrestarted stopped Non-cirrhoticonce naïves and relapsers achieving undetectable HCV RNA at Week 4 and 12 (eRVR) STOP Telaprevir + PR PR PR Non-cirrhotic naïves and relapsers without eRVR Partial and null responders Patients with cirrhosis Weeks 0 HCV RNA 4 12 If >1000 IU/mL at Week 4 or 12: discontinue all drugs 24 36 If detectable at Week 24 or 36: discontinue PR 48 100 80 SVR (%) 63 * 66 * 60 38 40 20 0 n/N = PR48 BOC RGT BOC44/PR48 137/363 233/368 242/366 *p<0.001 for both boceprevir arms versus PR48 Adapted from Poordad F, et al. N Engl J Med 2011;364:1195–206 100 SVR (%) 80 72–75* 60 44 40 20 0 n/N = *p<0.001 vs PR48 in ADVANCE (75% versus 44%) PR48 T12PR 158/361 659/903 Sherman KE, et al. Hepatology 2010;52(Suppl.):401A Jacobson IM, et al. N Engl J Med 2011;364:2405-16; Sherman KE, et al. CROI 2011. Abstract 957 Has changed drug habit to get HCV treatment No Contact/harm reduction Needle exchange On or off opiate substitution therapy? Methadone/ opiate substitution RCTs: randomized control trials PWID: not a barrier to SVR in OST therapy SVR achieved (%) 80 70 60 50 40 30 20 10 0 19/36 12/39 11/31 56/86 33/43* 33/43* G1 Non-IDU *ex-IDU vs active IDU; P=0.02 Non-G1 Ex-IDU Active IDU Jafferbhoy H, et al. J Viral Hepat. 2012:19(2):112–9 The Future HCV Antivirals in Development ANA773 PhI Miglustat Clemizole AVL-181 RG 7348 NIM-811 MK-1220 Other HCV Compounds MK5172 CF-102 Golotimod (SCV 07) sc NA-808 PRO 206 ITX 5061 VBY376 BI-201335 PhIII GS 9256 TMC435350 ACH-1095 Taribavirin Celgosivir ITMN-191/R7227 Telaprevir TaigGen Bio ACH-1625 Boceprevir IPH 1101 IMO-2125 PHX-1766 IDX-320 BIT-225 PF 4878691 IDX-136 and IDX-316 BMS-650032 Nitazoxanide SCY-635 VX-985 MK-7009 GI-5005 CYT-107 ACH 2928 SCH 900518 Debio025 CB-5300 FGI 103723 Nov-205 PhIIb BMS-791325 ATI-0180 PIs VX-813 ABT 450 IDX-375 SPC-3649 BMS-824393 PhIIa R7128 BMS 790052 PPI-461 EDP-239 Nuc polymerases PSI-7977 BMS AZD-7295 Albuferon IDX-184 NS5As PSI-879 PSI-7851 HDV-IFN (Hepasome) Locteron CR MK3281 AZD 2795 ITCA-638 ABT-072 ANA598 BI-207127 IFN-alpha-2b-medtronics ABT-333 IFN-alpha-2b-XL VCH-222+ Telaprevir Interferon-alpha (buccal lozenge, Amarillo) RG7227+RG7128 VCH-222 VCH 916 GS9190+GS9256 IF's Belerofon Changed/additional info Suspended / Discontinued IDX-189 VCH 759 PEG-IL-29 P-1101 IDX-102 PF868554 sr-IFN-alpha (LG Life Sciences) IFN alpha, Medgenics (Biopump SR) PSI-938 GS 9190 BMS-790052 + BMS-650032 IDX184+IDX320 Sources: GBI Analysis (August 4, 2010), Pipeline Sources, Company Press Releases, Reuters Knowledge Analyst Reports BI-201335+BI20127 Combination Products Non-nuc polymerases SOF Phase 3 Analysis in Patients with Traditional Negative Factors ‡ Virologic Response: SVR12 in NEUTRINO GT 1,4,5,6 Race (Non-Black vs. Black) Non-Black SVR12 (%) 100 91 Obesity (BMI < vs. ≥ 35 kg/m2) < 35 kg/m2 Black 100 87 90 IL28B GT (Non-TT vs. TT) ≥ 35 kg/m2 91 Non-TT 100 80 80 80 60 60 60 40 40 40 20 20 20 248/273 0 47/54 254/282 0 Mangia A, et al. AASLD 2013. Washington, DC. #1115 TT 91 251/276 41/45 86 44/51 0 22 NUC NS5B inhibitor sofosbuvir & Daclatasvir ± Ribavirin (geno 1, n =45) % undetectable HCV RNA GS7977/daclatasvir 100% 80% 93% 79% GS7977/daclatasvir/RBV 100% 93% 100%100% 100%100% 77% 67% 60% 40% 20% 0% 2 weeks On Rx 4 weeks On Rx 12 weeks 24 weeks 12 weeks On Rx End of Rx post-Rx Sulkowski M, et al. J Hepatol 2012; 56: S1422 QUEST-1: Phase 3 trial of Simeprevir + PR in G1 treatment-naive patients Response Guided Therapy criteria met by 85% SVR in 91% of RGT patients No incremental rash/anemia Hyperbilrubinemia A NS3a PI a replacement for Boceprevir or telaprevir Jacobson IM et al, EASL 2013, Amsterdam, #1425 24 AbbVie Phase III Clinical Program Results fixed-dose combination of ABT-450/ritonavir (150/100mg) co-formulated with ABT-267 (25mg), dosed once daily, and ABT-333 (250mg) twice daily Study PEARL-II (12 weeks) PEARL-III (12 weeks) PEARL-IV (12 weeks) TURQUOISE-II (12 & 24 weeks) SAPPHIRE-I (12 weeks) SAPPHIRE-II (12 weeks) Patients Treatment Regimen AbbVie regimen + RBV GT1b treatment(n=88) experienced AbbVie regimen only (N=179) (n=91) AbbVie regimen + RBV GT1b treatment-naive (n=210) (N=419) AbbVie regimen only (n=209) AbbVie regimen + RBV GT1a treatment-naive (n=100) (N=305) AbbVie regimen only (n=205) GT1 treatment-naive AbbVie regimen + RBV, 12 and treatment-experienced weeks (n=208) with AbbVie regimen + RBV, 24 compensated cirrhosis weeks (n=172) (N=380) GT1 treatment-naive AbbVie regimen + RBV (N=631) (n=473) GT1 treatment-experienced AbbVie regimen + RBV (N=394) (n=297) SVR12 97% (85/88) 100% (91/91) 99% (209/210) 99% (207/209) 97% (97/100) 90% (185/205) 92% (191/208) 96% (165/172) 96% (455/473) 96% (286/297) • In developed country settings, people who inject drugs (PWID) contribute to the majority (>80%) of HCV transmission • Pooled UK evidence for impact of harm reduction on HCV incidence1 • Opiate substitution therapy (OST) or high coverage needle and syringe programmes (NSP) alone reduces an individual’s HCV risk by ~50% • In combination, reduces HCV risk by ~80% • Modelling indicates OST and NSP likely important in preventing very high HCV prevalences in UK, BUT insufficient to reduce HCV to very low levels2 [1] Turner K et al. Addiction 2011; 106:1978-88 [2] Vickerman P et al. Addiction 2012;107:1984-1995. Relative prevalence reduction (%) at 15 years (2027) 100 90 80 Annually 70 No scale-up 60 Scale-up to 10/1,000 PWID 50 Scale-up to 20/1,000 PWID 40 Scale-up to 40/1,000 PWID 30 Scale-up to 80/1,000 PWID 20 10 0 Edinburgh 25% baseline chronic prevalence Melbourne 50% baseline chronic prevalence Vancouver 65% baseline chronic prevalence Bars indicate the mean relative prevalence reductions; whiskers represent the 95% credibility interval for the simualtions Martin NK, et al. J Hepatol 2011;54:1137–44 DYNAMIC HCV TRANSMISSION MODEL Non-SVR infected PWID Allow for re-infection New PWID Antiviral treatment Uninfected PWID Spontaneous clearance Cease/die Infection Acutely infected PWID Chronically infected PWID ADDITIONAL RISK HETEROGENEITY High risk, Off OST High risk, On OST Low risk, Off OST • PWID cycle through various risk and intervention states, associated with different risks of HCV acquisition • Allows for examination of targeting strategies Low risk, On OST Martin NK, Vickerman P, Grebely J, Hellard M, Hutchinson SJ, Lima VD, Foster GR, Dillon J, Goldberg DJ, Dore G, and Hickman M. HCV treatment for prevention among people who inject drugs: modeling treatment scale-up in the age of direct acting antivirals. Hepatology 2013 RESULTS: EDINBURGH IFN-free DAAs Martin NK, Vickerman P, Grebely J, Hellard M, Hutchinson SJ, Lima VD, Foster GR, Dillon J, Goldberg DJ, Dore G, and Hickman M. HCV treatment for prevention among people who inject drugs: modeling treatment scale-up in the age of direct acting antivirals. Hepatology 2013 SENSITIVITY ANALYSIS • Delaying initiation of IFN-free DAA scale-up by 4 yrs reduces impact by over 20% • Less impact seen with shorter injecting duration • Impact not sensitive to changes in assumptions regarding population heterogeneity and treatment targeting (low risk or on OST) because of movement/cycling between risk states Martin NK, Vickerman P, Grebely J, Hellard M, Hutchinson SJ, Lima VD, Foster GR, Dillon J, Goldberg DJ, Dore G, and Hickman M. HCV treatment for prevention among people who inject drugs: modeling treatment scale-up in the age of direct acting antivirals. Hepatology 2013 Effect Estimates AOR1 95% CI >100%NSP 0.48 0.3 0.9 OST 0.41 0.2 0.8 OST and >100%NSP 0.21 0.1 0.5 1 adjusted for: gender, crack, homeless, injecting duration 100%NSP is defined as exchanging more syringes than you inject Turner K et al. Addiction 2011; 106:1978-88 NECESSARY DAA TREATMENT RATES TO HALVE CHRONIC PREVALENCE IN 10 YRS WITH HARM REDUCTION Martin NK, et al.. CID 2013 Tayside NESI: Needle Exchange Surveillance Initiative 6 months into project Success of HCV Therapy Triple Rx 100% Protease inhibitor + PEG/RBV 24 weeks Cure rate 75% 50% HCV a disease that need not 75% kill anyone HCV a disease we can kill in our life time PEG/RBV 48 weeks IFN/RBV 48 weeks 25% 0% Combo DAA Nuc + 2nd DAA 12 wks No IFN No RGT IFN-α 24 weeks 4% 1985 IFN-α 48 weeks 45% 27% 9% 20yrs 2004 2011 2013 95-100%