Comment: Abstract follows.
Modelling studies presented at CROI in 2016 predicted that prompt treatment of Hepatitis C with direct acting antivirals (DAAs) may substantially decrease the incidence of acute Hepatitis C in HIV + MSM. This study applies modelling to assess the impact of the rapid uptake of Hepatitis C DAA therapy on the incidence of acute Hepatitis C infection among HIV+MSM in the Netherlands.
In November 2014, all oral DAA therapy became available for F3-4 fibrosis and from September 2015 for F0-2 as well, resulting in rapid DAA uptake in Dutch HIV+MSM with chronic HCV. 65% were cured or on DAA therapy 6 months after unrestricted DAA availability (CROI 2017 Boerekamps et al). Also, in 2014 and again in 2016, individuals with acute Hepatitis C were offered immediate therapy in DAHHS study centres across the Netherlands.
In 2014, 93 acute infections occurred in 8290 PYFU while in 2016, 49 acute cases were diagnosed in 8961 PYFU. The incidence in 2014 of 11.2/1000 showed a continuous decline to 6.9/1000 and 4.0/1000 within the first and second half of 2016. 1 year after unrestricted DAA availability in the Netherlands, the incidence of acute HCV in HIV+MSM decreased by 52%.
A delegate enquired whether this reduction may be due to a change in sexual practices of the participants with increased condom use in the era of sexual transmission of Hepatitis C. Review of syphilis and gonorrhoea rates in study participants however, showed a rise in these STIs and would suggest otherwise. Further, next door neighbours Belgium are yet to gain unrestricted access to DAAs and their incidence of acute hepatitis C remains unchanged in recent years. Although the presenter indicated that this modelling study doesn’t provide proof, it strongly suggests that for the first time, real-life data shows that “HCV treatment as prevention” averts new HCV infections in HIV+MSM.
Exciting to document what we think we know! This strengthens the argument to treat acute Hepatitis C in high risk MSM and injecting drug users. The last word went to an American delegate who posed the question to the Dutch presenter: Does this mean you should build a wall between the Netherlands and Belgium?
137LB SUBSTANTIAL DECLINE IN ACUTE HCV INFECTIONS AMONG DUTCH HIV+MSM AFTER DAA ROLL OUT
Anne Boerekamps et al
1Erasmus Univ Med Cntr, Rotterdam, Netherlands,
Background: The incidence of acute HCV (AHCV) among Dutch HIV+MSM has been high for >10yrs. Recent modelling studies predict that prompt treatment with direct acting antivirals (DAA) may decrease this incidence substantially (CROI2016 A536) but confirmation from real-life data is awaited. In 11/2014 all oral DAA therapy became available for F3-4 fibrosis and from 09/2015 for F0-2 as well, resulting in rapid DAA uptake in Dutch HIV+MSM with chronic HCV with already 65% cured or on DAA therapy 6 months after
unrestricted DAA availability (CROI 2017 Boerekamps et al). Also, in 2014 (in DAHHS1 study NCT01912495) as well as in 2016 (in ongoing DAHHS2 study NCT02600325) patients with AHCV were offered immediate therapy in DAHHS centers across the Netherlands. We hypothesized that this rapid treatment uptake will result in a lower incidence of AHCV among HIV+MSM.
Methods: AHCV was defined as HCV-RNA positivity, preceded by a negative HCV-RNA or HCV-IgG within 12 months. When stored plasma could not be retested, a normal ALT preceding the first positive HCV-RNA test together with a negative IgG any time in the past or a positive HCV-RNA and a simultaneous negative IgG was also considered diagnostic for AHCV. The incidence of AHCV was calculated by dividing the cases by the patient years of follow-up (PYFU). Data were available from 18 HIV treatment centers, geographically
spread across the Netherlands having +/-80% of Dutch HIV+MSM in care. We compared the incidence in 2014 (year preceding DAA availability) to 2016 incidence (first year after DAA availability).
Results: In 2014, 93 AHCV infections occurred in 8290 PYFU (=11.2/1000 PYFU, 95% CI 9.1-13.7). In 2016, 49 AHCV were diagnosed in 8961 PYFU (=5.5/1000 PYFU, 95% CI 4.1–7.2, p<0.001). The incidence in 2014 of 11.2/1000 showed a continuous decline to 6.9/1000 and 4.0/1000 within the first and second half of 2016. A relative increase in genotype 4 infections was observed from 19% (n=18) to 31% (n=15) (p=0.02). The absolute number of AHCV infections decreased both in patients with a first AHCV infection as well as in
patients that had an AHCV reinfection (=patients previously cured of an AHCV infection), while the proportion of reinfections remained constant: 21/93 in 2014 and 12/49 in 2016 (p=0.8).
Conclusion: 1 year after unrestricted DAA availability in the Netherlands, the incidence of acute HCV in HIV+MSM decreased by 52%. For the first time, real-life data show that “HCV treatment as prevention” averts new HCV infections in HIV+MSM.