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  Conference on Retroviruses
and Opportunistic Infections
Seattle, Washington
March 4-7, 2019
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Sharp drop in acute HCV among London
MSM with HIV after DAAs arrived
  Conference on Retroviruses and Opportunistic Infections (CROI), March 4-7, 2019, Seattle
Mark Mascolini
New acute cases of HCV infection dropped steeply among HIV-positive men who have sex with men (MSM) in London after direct-acting antivirals (DAAs) become available, during a period when HCV screening practices did not change [1]. Overall newly detected acute HCV toppled 68% from a peak in 2015.
High cure rates with DAAs have encouraged ambitious HCV elimination targets, such as the British HIV Association's aim to cure HCV in 100% of HIV/HCV-coinfected people by 2021. London researchers set out to track progress so far by charting trends in acute HCV incidence among HIV-positive MSM at three large London clinics caring for more than 6000 MSM with HIV. DAA therapy became available in England in 2015, with gradually widening access criteria since then. But National Health Service guidelines do not yet sanction DAAs for HCV reinfection, and acute infection cannot be treated until after 6 months of detectable HCV load.
The study period for the new-HCV analysis ran from July 2013 (before DAA availability) through June 2018. During that time researchers charted the number of acute HCV episodes--both first infections and reinfections. They calculated the number of HIV-positive MSM under active follow-up as the denominator to figure acute HCV incidence. And they recorded the type of HCV therapy selected and when treatment began relative to acute HCV diagnosis.
During the study period the investigators counted 256 acute HCV infections, including 211 first infections and 45 reinfections. Median age at diagnosis of acute HCV stood at 43 years, 90% of men were taking antiretroviral therapy at acute HCV diagnosis, and 85% had an HIV load below 50 copies.
The number of new acute infections rose steadily from the 2013 start of observation until the second half of 2015 then fell sharply through 2016-2018. Acute HCV incidence climbed from 8 per 1000 person-years in 2013, peaked at 17 per 1000 in the second half of 2015, fell to 11 per 1000 in late 2016, and dwindled to 6 per 1000 in 2018. Since the late 2015 incidence peak, new acute HCV infections fell 68% overall, while incidence of first acute infections plummeted nearly 80%.
Reinfections with HCV make up a growing proportion of all new acute infections. While reinfections represented only 9% of new infections in 2013, that rate rose to 18% in 2016, to 43% in the second half of 2017, and to 47% in 2018.
Most people newly infected with HCV from 2013 to 2016 put off treatment as they awaited DAA availability from the National Health Service. In this period men began therapy an average 23 months after acute HCV diagnosis. From 2016 through 2018 most newly infected people began DAA treatment in a clinical trial and started therapy an average 10 months after acute HCV diagnosis. Over the whole study period, average time between acute HCV diagnosis and starting therapy slipped from 41 to 3 months.
Despite the dramatic drop in acute HCV incidence since 2015, the researchers observed that the decline falls short of the World Health Organization target of slicing new infections by 90%. In England reaching the 90% goal will require an incidence of 1.7 per 1000 person-years, less than one third the current incidence. Unless the National Health Service expands DAA access to include early months of infection and reinfection, the researchers warned, "progress in reducing incidence may plateau and the opportunity for HCV micro-elimination in HIV-positive MSM may be lost."
1. Garvey LJ, Smith CJ, Stingone C, et al. Fall in HCV incidence in HIV+ MSM in London following wider access to DAA therapy. Conference on Retroviruses and Opportunistic Infections (CROI). March 4-7, 2019. Seattle. Abstract 85.
CROI: Fall in HCV incidence in HIV+ MSM in London following expansion of access to DAA therapy - (03/12/19)