Summary of the pre-conference clinical course

A pre-conference clinical course on the morning of the first day of the conference included five expert overviews.

The first presentation was from Carlo-Federico Perno from the University of Rome on the history and virology of HCV. [1]

This highlighted key differences with HCV compared to either HIV or HBV. Because HCV replicates without integration into human DNA, unlike HIV or HBV, HCV treatment can cure HCV infected hepatocytes, allowing the cells to actively continue reversing liver damage for several weeks. Before treatment, a single cell might be supporting up to 40 cycles of HCV replication, running simultaneously at different stages in the viral life cycle. In advanced liver disease, the restricted blood flow in the liver, resulting from cirrhosis, is a rate-limiting step by preventing optimal intracellular drug levels. The lecture also reviewed HCV drug resistance, concluding that baseline genotypic testing is not only important but cost effective.

In the second talk, Karine Lacombe from Hôpital Saint-Antoine, Paris, gave an overview of tests and algorithms for diagnosis and management. [2]

Sanjay Bhagani, from the Royal Free Hospital, London, reviewed the data supporting increased risk of serious complications for patients with coinfection together with the importance of early HCV treatment (contrary to the indications for delayed access to new direct acting antiviral [DAA] drugs). [3]

In the fourth talk, Patrick Ingiliz from Medical Centre for Infectious Diseases, Berlin, reviewed the data on new HCV drugs from the perspective of limited access to DAAs. [4]

Although current European guidelines have important differences across countries, none of these documents will last longer than 6-12 months because of the rapid advances in drug development. The talk highlighted rates of 25% HCV reinfection in the NEAT centres. In an overview of latest treatment, including complex cases and drug interactions, Dr Ingiliz concluded that future treatment uptake will mainly be driven by cost: “we will treat who the payers are willing to pay for”.

In the final talk, Graham Foster from the Queen Mary University of London presented an overview of the management of end-stage liver disease and its complications, again from the perspective of limited access to new treatment. [5]

In the UK, 10,000 people already have HCV-related cirrhosis, with approximately 4-5% people each year likely to progress to decompensated disease, and 4-5% to hepatocellular carcinoma (HCC), with some overlap between these groups. By 2020, without new treatment, more than 11,500 people in the UK will have cirrhosis and 4,200 will have progressed to decompensated disease or HCC. Old drugs are hard to use, have a high failure rate, and a high risk of serious toxicity. This demands the use of new drugs.

Early UK data was presented from the first 250/700 patients with decompensated cirrhosis who have been treated with sofosbuvir plus either ledipasvir or daclatasvir with ribavirin, and HCV relapse was only seen in seven cases.

All references relate to the pre-conference clinical course for the Five Nations Conference on HIV and Hepatitis 8-9 December 2014, London. Webcasts and PDF slides from all sessions are online.