Anu Osinusi

Sofosbuvir and Velpatasvir for HCV Genotype 2 and 3 Infection

BACKGROUND In phase 2 trials, treatment with the combination of the nucleotide polymerase inhibitor sofosbuvir and the NS5A inhibitor velpatasvir resulted in high rates of sustained virologic response in patients chronically infected with hepatitis C virus (HCV) genotype 2 or 3. METHODS We conducted two randomized, phase 3, open-label studies involving patients who had received previous treatment for HCV genotype 2 or 3 and those who had not received such treatment, including patients with compensated cirrhosis. In one trial, patients with HCV genotype 2 were randomly assigned in a 1:1 ratio to receive sofosbuvir-velpatasvir, in a once-daily, fixed-dose combination tablet (134 patients), or sofosbuvir plus weight-based ribavirin (132 patients) for 12 weeks. In a second trial, patients with HCV genotype 3 were randomly assigned in a 1:1 ratio to receive sofosbuvir-velpatasvir for 12 weeks (277 patients) or sofosbuvir-ribavirin for 24 weeks (275 patients). The primary end point for the two trials was a sustained virologic response at 12 weeks after the end of therapy. RESULTS Among patients with HCV genotype 2, the rate of sustained virologic response in the sofosbuvir-velpatasvir group was 99% (95% confidence interval [CI], 96 to 100), which was superior to the rate of 94% (95% CI, 88 to 97) in the sofosbuvir-ribavirin group (P=0.02). Among patients with HCV genotype 3, the rate of sustained virologic response in the sofosbuvir-velpatasvir group was 95% (95% CI, 92 to 98), which was superior to the rate of 80% (95% CI, 75 to 85) in the sofosbuvir-ribavirin group (P<0.001). The most common adverse events in the two studies were fatigue, headache, nausea, and insomnia. CONCLUSIONS Among patients with HCV genotype 2 or 3 with or without previous treatment, including those with compensated cirrhosis, 12 weeks of treatment with sofosbuvir-velpatasvir resulted in rates of sustained virologic response that were superior to those with standard treatment with sofosbuvir-ribavirin. (Funded by Gilead Sciences; ASTRAL-2 ClinicalTrials.gov number, NCT02220998; and ASTRAL-3, NCT02201953.).

Virologic Response Following Combined Ledipasvir and Sofosbuvir Administration in Patients With HCV Genotype 1 and HIV Co-infection

IMPORTANCE There is an unmet need for interferon- and ribavirin-free treatment for chronic hepatitis C virus (HCV) infection in patients co-infected with human immunodeficiency virus (HIV). OBJECTIVE To evaluate the rates of sustained virologic response (SVR) and adverse events in previously untreated patients with HCV genotype 1 and HIV co-infection following a 12-week treatment of the fixed-dose combination of ledipasvir and sofosbuvir. DESIGN, SETTING, AND PARTICIPANTS Open-label, single-center, phase 2b pilot study of previously untreated, noncirrhotic patients with HCV genotype 1 and HIV co-infection conducted at the Clinical Research Center of the National Institutes of Health, Bethesda, Maryland, from June 2013 to September 2014. Patients included those receiving antiretroviral therapy with HIV RNA values of 50 copies/mL or fewer and a CD4 T-lymphocyte count of 100 cells/mL or greater or patients with untreated HIV infection with a CD4 T-lymphocyte count of 500 cells/mL or greater. Serial measurements of safety parameters, virologic and host immune correlates, and adherence were performed. INTERVENTIONS Fifty patients with HCV genotype 1 never before treated for HCV were prescribed a fixed-dose combination of ledipasvir (90 mg) and sofosbuvir (400 mg) once daily for 12 weeks. MAIN OUTCOMES AND MEASURES The primary study outcome was the proportion of patients with sustained viral response (plasma HCV RNA level <12 IU/mL) 12 weeks after end of treatment. RESULTS Forty-nine of 50 participants (98% [95% CI, 89% to 100%]) achieved SVR 12 weeks after end of treatment, whereas 1 patient experienced relapse at week 4 following treatment. In the patient with relapse, deep sequencing revealed a resistance associated mutation in the NS5A region conferring resistance to NS5A inhibitors, such as ledipasvir. The most common adverse events were nasal congestion (16% of patients) and myalgia (14%). There were no discontinuations or serious adverse events attributable to study drug. CONCLUSIONS AND RELEVANCE In this open-label, uncontrolled, pilot study enrolling patients co-infected with HCV genotype 1 and HIV, administration of an oral combination of ledipasvir and sofosbuvir for 12 weeks was associated with high rates of SVR after treatment completion. Larger studies that also include patients with cirrhosis and lower CD4 T-cell counts are required to understand if the results of this study generalize to all patients co-infected with HCV and HIV. TRIAL REGISTRATION clinicaltrials.gov Identifier:NCT01878799.

Endogenous intrahepatic IFNs and association with IFN-free HCV treatment outcome

BACKGROUND. Hepatitis C virus (HCV) infects approximately 170 million people worldwide and may lead to cirrhosis and hepatocellular carcinoma in chronically infected individuals. Treatment is rapidly evolving from IFN-α-based therapies to IFN-α-free regimens that consist of directly acting antiviral agents (DAAs), which demonstrate improved efficacy and tolerability in clinical trials. Virologic relapse after DAA therapy is a common cause of treatment failure; however, it is not clear why relapse occurs or whether certain individuals are more prone to recurrent viremia. METHODS. We conducted a clinical trial using the DAA sofosbuvir plus ribavirin (SOF/RBV) and performed detailed mRNA expression analysis in liver and peripheral blood from patients who achieved either a sustained virologic response (SVR) or relapsed. RESULTS. On-treatment viral clearance was accompanied by rapid downregulation of IFN-stimulated genes (ISGs) in liver and blood, regardless of treatment outcome. Analysis of paired pretreatment and end of treatment (EOT) liver biopsies from SVR patients showed that viral clearance was accompanied by decreased expression of type II and III IFNs, but unexpectedly increased expression of the type I IFN IFNA2. mRNA expression of ISGs was higher in EOT liver biopsies of patients who achieved SVR than in patients who later relapsed. CONCLUSION. These results suggest that restoration of type I intrahepatic IFN signaling by EOT may facilitate HCV eradication and prevention of relapse upon withdrawal of SOF/RBV. TRIAL REGISTRATION. ClinicalTrials.gov NCT01441180.

Ledipasvir and sofosbuvir for hepatitis C genotype 4: a proof-of-concept, single-centre, open-label phase 2a cohort study

BACKGROUND Worldwide, although predominantly in low-income countries in the Middle East and Africa, up to 13% of hepatitis C virus (HCV) infections are caused by HCV genotype 4. For patients with HCV genotype 1, the combination of ledipasvir and sofosbuvir has been shown to cure high proportions of patients with excellent tolerability, but this regimen has not been assessed for the treatment of HCV genotype 4. We assessed the efficacy, safety, and tolerability of 12 weeks of combination therapy with ledipasvir and sofosbuvir for patients with chronic HCV genotype 4 infections. METHODS In this single-centre, open-label cohort, phase 2a trial, patients with HCV genotype 4 who were treatment naive or interferon treatment experienced (HIV-negative) were sequentially enrolled at the Clinical Center of the National Institutes of Health, Bethesda, MD, USA. We gave patients 12 weeks of ledipasvir (90 mg) and sofosbuvir (400 mg) as a single combination tablet once per day. The primary efficacy endpoint was sustained viral response at 12 weeks (SVR12), as measured by the proportion of patients with HCV RNA concentrations less than the lower limit of quantification (COBAS TaqMan HCV test, version 1.0, 43 IU/mL). The primary safety endpoint was the frequency and severity of adverse events. We did our analyses on an intention-to-treat basis. This study is registered with ClinicalTrials.gov, number NCT01805882. FINDINGS Between Sept 16, 2013, and Nov 2, 2014, we recruited 21 patients. 20 (95%) of 21 patients completed 12 weeks of treatment and achieved SVR12 (95% CI 76-100), including seven patients with cirrhosis. One patient was non-adherent to study drugs and withdrew from the study, but was included in the intention-to-treat analysis. No patients discontinued treatment because of adverse events and no grade 3 or 4 adverse events occurred that were related to study medications. The most common adverse events were diarrhoea (two patients), fatigue (three patients), nausea (two patients), and upper respiratory infections (two patients). INTERPRETATION Ledipasvir and sofosbuvir treatment for 12 weeks was well tolerated by patients with HCV genotype 4 and resulted in 100% SVR for all patients who received all 12 weeks of study drugs, irrespective of previous treatment status and underlying liver fibrosis. This is the first report of a single-pill, all-oral, interferon-free, ribavirin-free treatment for patients with HCV genotype 4. FUNDING NIAID, National Cancer Institute and Clinical Center Intramural Program. The study was also supported in part by a Cooperative Research and Development Agreement between NIH and Gilead Sciences.

Dysregulation of innate immunity in hepatitis C virus genotype 1 IL28B‐unfavorable genotype patients: Impaired viral kinetics and therapeutic response

Recent studies have shown that a single‐nucleotide polymorphism upstream of the interleukin‐28B (IL28B) gene plays a major role in predicting therapeutic response in hepatitis C virus (HCV)‐infected patients treated with pegylated interferon (PEG‐IFN)/ribavirin. We sought to investigate the mechanism of the IL28B polymorphism, specifically as it relates to early HCV viral kinetics, IFN pharmacokinetics, IFN pharmacodynamics, and gene expression profiles. Two prospective cohorts (human immunodeficiency virus [HIV]/HCV‐coinfected and HCV‐monoinfected) completing treatment with IFN/ribavirin were enrolled. Patients were genotyped at the polymorphic site rs12979860. In the HIV/HCV cohort, frequent serum sampling was completed for HCV RNA and IFN levels. DNA microarray of peripheral blood mononuclear cells and individual expression of IFN‐stimulated genes (ISGs) were quantified on IFN therapy. The IL28B‐favorable (CC) genotype was associated with improved therapeutic response compared with unfavorable (CT or TT) genotypes. Patients with a favorable genotype had greater first‐ and second‐phase viral kinetics (P = 0.004 and P = 0.036, respectively), IFN maximum antiviral efficiency (P = 0.007) and infected cell death loss (P = 0.009) compared with unfavorable genotypes. Functional annotation analysis of DNA microarray data was consistent with depressed innate immune function, particularly of natural killer cells, from patients with unfavorable genotypes (P <0.004). Induction of innate immunity genes was also lower in unfavorable genotypes. ISG expression at baseline and induction with IFN was independent of IL28B genotype. Conclusion: Carriers of the IL28B‐favorable genotype were more likely to have superior innate immune response to IFN therapy compared with unfavorable genotypes, suggesting that the unfavorable genotype has aberrant baseline induction of innate immune response pathways resulting in impaired virologic response. IL28B genotype is associated with more rapid viral kinetics and improved treatment response outcomes independent of ISG expression. (HEPATOLOGY 2012)

Utility of Hepatitis C Viral Load Monitoring on Direct-Acting Antiviral Therapy

BACKGROUND Hepatitis C virus (HCV) RNA loads serve as predictors of treatment response during interferon-based therapy. We evaluated the predictive ability of HCV RNA levels at end of treatment (EOT) for sustained virologic response (SVR12) during interferon-sparing direct-acting antiviral therapies. METHODS HCV genotype 1-infected, treatment-naive patients were treated with sofosbuvir and ribavirin for 24 weeks (n = 55), sofosbuvir and ledipasvir for 12 weeks (n = 20), sofosbuvir, ledipasvir, and GS-9669 for 6 weeks (n = 20), or sofosbuvir, ledipasvir, and GS-9451 for 6 weeks (n = 19). Measurements of HCV RNA were performed using the Roche COBAS TaqMan HCV test and the Abbott RealTime HCV assay. Positive predictive value (PPV) and negative predictive value (NPV) of HCV RNA less than the lower limit of quantification (<LLOQ) at EOT for SVR12 were calculated. RESULTS All 55 patients treated with sofosbuvir and ribavirin had HCV RNA <LLOQ at EOT by the Roche and Abbott assays, but only 38 achieved SVR12 (PPV, 69%). Among patients treated with sofosbuvir and ledipasvir with or without GS-9669 or GS-9451, 100% (59/59) had HCV RNA <LLOQ by the Roche assay and 1 relapsed (PPV, 98%). By the Abbott assay, 90% (53/59) had HCV RNA <LLOQ, of whom 1 patient relapsed (PPV, 98%). Notably, 6 patients with HCV RNA ≥LLOQ at EOT (range, 14-64 IU/mL) achieved SVR12 (NPV, 0%). Quantifiable HCV RNA (range, 15-57 IU/mL) was measured 2 weeks posttreatment in 4 individuals, and 4 weeks posttreatment in 1 patient (14 IU/mL). CONCLUSIONS Contrary to past experience with interferon-containing treatments, low levels of quantifiable HCV RNA at EOT do not preclude treatment success.

Effect of sofosbuvir and ribavirin treatment on peripheral and hepatic lipid metabolism in chronic hepatitis C virus, genotype 1-infected patients.

Hepatitis C virus (HCV) modulates intrahepatic cholesterol biosynthetic pathways to promote viral replication. Chronic HCV infection is associated with altered metabolism, including dyslipidemia and insulin resistance (IR), which contributes to disease progression and influences response to therapy. To further understand the impact of HCV infection on host metabolism, we examined changes in serum lipid profiles and intrahepatic expression of lipid‐related genes during interferon (IFN)‐free treatment of chronic HCV, genotype 1 infection with sofosbuvir and ribavirin (RBV), and explored associations with treatment outcome. Serum lipids (total cholesterol, low‐density lipoprotein [LDL], high‐density lipoprotein [HDL], and triglycerides [TGs]) and hemoglobin A1C (HbA1C) were measured during treatment, while gene expression of lipid‐related genes was assessed using paired pre‐ and end‐of‐treatment (EOT) liver biopsies from 8 patients (n = 7 sustained virologic response [SVR]; n = 1 relapse) and unpaired EOT liver biopsies from 25 patients (n = 17 SVR; n = 8 relapse). Serum LDL concentration and particle size increased early in therapy, whereas TG concentration and very‐low‐density lipoprotein particle size decreased concomitantly, irrespective of treatment outcome. Whereas LDL increased in patients regardless of treatment outcome, average LDL concentration was lower at baseline and post‐treatment in patients who relapsed. Analysis of paired liver biopsies revealed altered expression of genes associated with lipid transport, assembly, and signaling. In unpaired EOT liver biopsies, intrahepatic expression of fatty acid metabolism and lipid transport genes was lower in patients who experienced treatment relapse. Conclusion: Clearance of HCV using an IFN‐free antiviral regimen results in rapid changes in peripheral and intrahepatic metabolic pathways, implicating a direct effect of HCV replication on lipid homeostasis. (Hepatology 2015;61:790–801)

Re-treatment of chronic hepatitis C virus genotype 1 infection after relapse: an open-label pilot study.

Context The treatment of hepatitis C virus is changing rapidly with the introduction of interferon-free regimens that include direct-acting antiviral drugs, such as sofosbuvir. Although treatment generally results in sustained viral response, some patients have relapse after initial treatment. Contribution In a small, nonrandomized study, 14 patients who had relapse after treatment with sofosbuvir plus ribavirin were re-treated with sofosbuvir plus ledipasvir for 12 weeks. All patients, including those with advanced liver disease, achieved a sustained virologic response. The combination was generally well-tolerated. Implication Treatment with sofosbuvir plus ledipasvir may be efficacious in patients who have relapse after initial therapy for hepatitis C virus. Larger randomized studies of this promising combination are warranted. The Editors Chronic hepatitis C virus (HCV) infection is a major cause of chronic liver disease and hepatocellular carcinoma and the leading indication for liver transplantation in Western countries (1, 2). Until recently, HCV treatment consisted of combination therapy with pegylated interferon (IFN) and ribavirin, with the addition of an HCV protease inhibitor (boceprevir or telaprevir) in recent years. In 2013, the U.S. Food and Drug Administration approved sofosbuvir plus ribavirin as the first IFN-free treatment of HCV genotype 2 or 3 and for patients with genotype 1 (GT-1) who are IFN-ineligible (37). Although sofosbuvir (an NS5B inhibitor) plus ribavirin is well-tolerated and effective with sustained virologic response (SVR) rates from 68% to 76% in patients with HCV GT-1 (8, 9), modest rates of relapse in patients with advanced liver disease and transplant recipients have been seen (8, 10, 11). Recent studies using sofosbuvir combined with ledipasvir (an NS5A inhibitor) for 12 weeks demonstrated high SVR rates (95% to 99%) in treatment-naive patients with HCV GT-1 (1215). Ledipasvir has potent antiviral activity against the S282T resistance-associated variant, known to reduce susceptibility to sofosbuvir in vitro (16). As previously reported, 17 of 54 patients treated with sofosbuvir plus ribavirin for 24 weeks in the National Institute of Allergy and Infectious Diseases (NIAID) SPARE study had relapse after treatment (8). We hypothesized that the combination of a second potent direct-acting antiviral agent (DAA) with sofosbuvir could result in SVR, even in patients with relapse after sofosbuvir plus ribavirin therapy and who may harbor the S282T mutation. To test this hypothesis, we re-treated those patients with sofosbuvir plus ledipasvir for 12 weeks. Methods Design Overview All patients who had relapse after 24 weeks of treatment with sofosbuvir plus ribavirin in the NIAID SPARE study (8) were offered re-treatment with sofosbuvir plus ledipasvir in the ongoing, phase 2a, open-label NIAID SYNERGY study (ClinicalTrials.gov: NCT01805882). Of the 17 eligible patients, 3 did not participate in the study. Fourteen patients enrolled and were treated with 400 mg of sofosbuvir and 90 mg of ledipasvir, administered daily as a single combination tablet, for 12 weeks. Setting and Patients The trial was conducted at the National Institutes of Health (NIH) in Bethesda, Maryland, and at community clinics that are part of the District of Columbia Partnership for HIV/AIDS Progress in Washington, DC. Written informed consent, which was approved by the NIAID Institutional Review Board, was obtained from all study patients. Eligibility criteria included documented HCV GT-1 infection and relapse in the NIAID SPARE study (8). Liver fibrosis stage was determined by biopsy within 3 years of enrollment in the NIAID SPARE study. The study was approved by the NIAID Institutional Review Board. It was conducted in adherence to the Good Clinical Practice guidelines and with regulatory requirements consistent with the Declaration of Helsinki. Outcomes and Follow-up Efficacy Assessments Plasma HCV RNA levels were measured using the Abbott RealTime HCV assay, with a lower limit of quantification of 12 IU/mL and a lower limit of detection of 3 IU/mL, or the Roche Cobas TaqMan HCV assay, version 2.0, with a lower limit of quantification of 43 IU/mL and a lower limit of detection of 15 IU/mL. Safety Assessments Patients were closely monitored for adverse events. Clinical laboratory results were assessed while receiving therapy (4, 8, and 12 weeks) and afterward (2, 4, 8, and 12 weeks after treatment). Adverse events were graded from 1 (mild) to 4 (severe), according to the NIAID Division of AIDS Toxicity Table (version 1.0). Interleukin-28B Genotyping Interleukin-28B genotype (rs12979860) was determined as previously described (8). Clinical End Points The primary end point was the proportion of patients with unquantifiable plasma HCV viral load 12 weeks after treatment completion. Safety end points included frequency and severity of adverse events, discontinuations due to adverse events, and safety laboratory changes. Statistical Analysis Primary safety and efficacy data were analyzed by intention-to-treat (all patients who initiated study medication). Missing virologic data were imputed if data from preceding and succeeding time points were obtained. Baseline demographics were described using frequency statistics. Comparisons were calculated using either nonparametric tests or t tests with GraphPad Prism, version 6.0 (GraphPad Software). Role of the Funding Source This study was funded in part by the National Cancer Institute, the intramural programs of the NIH Clinical Center and NIAID, and a Collaborative Research and Development Agreement between the NIH and Gilead Sciences. The study sponsor was the Regulatory Compliance and Human Participants Protection Branch of the NIAID. The sponsor reviewed the study and provided oversight. However, it did not play a role in designing the study; collecting, analyzing, or interpreting the data; or the preparation, review, approval, or submission of the manuscript for publication. All study medications were provided by Gilead Sciences, which did not have a role in the design or conduct of the study, writing of the manuscript, or the decision to submit the manuscript for publication. Results Baseline Characteristics of Patients Most study patients were black men with an unfavorable interleukin-28B non-CC genotype (Table 1). There was a high representation of patients with HCV GT-1a infection, increased baseline HCV viral load (>800000 IU/mL), increased body mass index (>30 kg/m2), and advanced liver disease (Knodell Histology Activity Index score of 3 or 4) (17). Table 1. Baseline Characteristics of Study Patients Presence of S282T Mutation At the time of relapse after sofosbuvir plus ribavirin treatment in the SPARE trial, 13 of 14 patients had wild-type virus by population sequencing (Supplement). The 1 exception achieved unquantifiable HCV RNA levels by week 2 of therapy in SPARE and the virus remained undetectable through the end of treatment. He missed his visit at 26 weeks (2 weeks after treatment), but at 28 weeks (4 weeks after treatment), his HCV viral load was 374 IU/mL and the S282T mutation was readily detected by population sequencing. By 36 weeks (12 weeks after treatment), his HCV viral load was 81286 IU/mL and the S282T mutation was no longer detectable. He initiated sofosbuvir plus ledipasvir treatment 50 weeks after relapse. Supplement. HCV Resistance Mutations Virologic Response Each of the 14 patients treated with sofosbuvir plus ledipasvir had HCV RNA levels below the lower limit of quantification by 4 weeks (Roche Cobas TaqMan HCV Assay, version 2.0), which was maintained through the end of treatment (12 weeks). All patients achieved SVR 12 weeks after completion of treatment. Changes in Hemoglobin Levels No significant change in hemoglobin levels during sofosbuvir plus ledipasvir treatment was seen, in contrast to the decrease seen with sofosbuvir plus ribavirin. The mean hemoglobin level change was 0.07 g/L versus 11.70 g/L at 4 weeks (P=0.01), 0.5 g/L versus 12.6 g/L at 8 weeks (P=0.01), and 3.1 g/L versus 12.1 g/L at 12 weeks (P=0.06) with sofosbuvir plus ledipasvir and sofosbuvir plus ribavirin, respectively. No participant had a decrease in hemoglobin level of 15.0 g/L or greater with sofosbuvir plus ledipasvir compared with 8 of 14 (57%) with sofosbuvir plus ribavirin. Changes in Renal Function Renal variables did not change significantly over the course of treatment, although a single participant with grade 2 renal insufficiency at baseline (estimated glomerular filtration rate, 54 mL/min/1.73 m2) developed a grade 3 event. After 6 weeks of receiving study medications, he had received amoxicillin in the context of a dental procedure and continued preenrollment medications (benazepril, telmisartan, and simvastatin). In this context, his estimated glomerular filtration rate decreased to 29 mL/min/1.73 m2 (grade 3 toxicity); however, it improved (grade 2) within 1 week of withdrawing amoxicillin, returned to baseline within 3 weeks, and remained stable thereafter. He received study drugs without interruption. Safety All patients completed treatment, and no grade 4 adverse events or laboratory abnormalities occurred. The most common adverse events were myalgia and hypophosphatemia, and most adverse events were mild (Table 2). Four grade 3 events occurred (increased creatinine levels described above [n=1], hypercholesterolemia [n=1], and hypophosphatemia [n=2]). Table 2. Treatment Discontinuations, Adverse Events, and Laboratory Abnormalities Discussion In this study, we demonstrate that patients with HCV GT-1 who have viral relapse after sofosbuvir plus ribavirin therapy can be successfully re-treated with sofosbuvir plus ledipasvir. Seven (50%) of the patients in this study had advanced liver disease, which has been shown to be associated with relapse after sofosbuvir plus ribavirin therapy (8, 10, 11). In addition to having a high prevalencBackground The interferon (IFN)-free regimen of sofosbuvir and ribavirin for 24 weeks was recently approved to treat chronic hepatitis C virus (HCV), genotype-1 (GT-1) infection for interferon-ineligible patients . However, sofosbuvir/ribavirin therapy is associated with treatment relapse in 15-30% of HCV GT-1 study subjects. Neither the mechanism of relapse nor the optimal retreatment strategy for these subjects is defined.

Successful Retreatment of Chronic HCV Genotype-1 Infection With Ledipasvir and Sofosbuvir After Initial Short Course Therapy With Direct-Acting Antiviral Regimens

BACKGROUND The optimal retreatment strategy for chronic hepatitis C virus (HCV) patients who fail directly-acting antiviral agent (DAA)-based treatment is unknown. In this study, we assessed the efficacy and safety of ledipasvir (LDV) and sofosbuvir (SOF) for 12 weeks in HCV genotype-1 (GT-1) patients who failed LDV/SOF-containing therapy. METHODS In this single-center, open-label, phase 2a trial, 34 participants with HCV (GT-1) and early-stage liver fibrosis who previously failed 4-6 weeks of LDV/SOF with GS-9669 and/or GS-9451 received LDV/SOF for 12 weeks. The primary endpoint was HCV viral load below the lower limit of quantification 12 weeks after completion of therapy (sustained virological response [SVR]12). Deep sequencing of the NS3, NS5A, and NS5B regions were performed at baseline, at initial relapse, prior to retreatment, and at second relapse with Illumina next-generation sequencing technology. RESULTS Thirty-two of 34 enrolled participants completed therapy. Two patients withdrew after day 0. Participants were predominantly male and black, with median baseline HCV viral load of 1.3 × 10(6) IU/mL and Metavir fibrosis stage 1 and genotype-1a. Median time from relapse to retreatment was 22 weeks. Prior to retreatment, 29 patients (85%) had NS5A-resistant variants. The SVR12 rate was 91% (31/34; intention to treat, ITT) after retreatment. One patient relapsed. CONCLUSIONS In patients who previously failed short-course combination DAA therapy, we demonstrate a high SVR rate in response to 12 weeks of LDV/SOF, even for patients with NS5A resistance-associated variants. CLINICAL TRIALS REGISTRATION NCT01805882.

Two independent epidemics of HIV in Maryland.

Background:HIV-1 subtype B virus is the predominant subtype in HIV-infected individuals in the United States. However, increasing evidence suggests that prevalence of non-B subtypes may be on the rise in the West, and this may have implications for HIV-1 disease surveillance and treatment. The state of Maryland currently has the fourth highest AIDS case report rate in the United States. The goal of this study was to evaluate the prevalence of HIV-1 non-B subtypes in Maryland. The study population included individuals diagnosed with HIV in 2007 through the voluntary counseling and testing sites at the Maryland Department of Health and Mental Hygiene and HIV-infected patients who had genotyping performed at the University of Maryland Medical Center. Results:At the Department of Health and Mental Hygiene sites, 47 unique non-B subtype strains were identified representing a non-B prevalence of 12.9%. These non-B subtypes included CRF02_AG (n = 20), C (n = 11), A (n = 7), G (n = 5), D (n = 1), and unique recombinant forms (n = 3). The non-B patients were predominantly non-Hispanic black (95.7%) with 63.8% female. Although the majority of the HIV subtype B cases (65.3%) were identified from the Baltimore metropolitan area, most (80.9%) of the non-B cases were from the Maryland suburbs of Washington, DC. Among University of Maryland Medical Center patients, there were 30 non-B subtypes, representing a non-B prevalence of 1.9%. The non-B subtypes detected were CRF02_AG (n = 14), C (n = 6), A (n = 6), G (n = 2), D (n = 1), and unique recombinant forms (n = 1). Phylogenetic analysis of the non-B subtypes revealed that viral sequences from both sources were intermixed, confirming that both sampling frames were drawing from the same overall population. Conclusions:Multiple HIV-1 subtypes exist in the Baltimore-Washington metropolitan area with a significant non-B-infected population in the Maryland suburbs of Washington, DC, suggesting 2 independent epidemics of HIV in Maryland. Population-based surveillance inclusive of groups at higher risk of non-B strains is essential to monitor the prevalence and variations of HIV subtypes in Maryland and the United States.