Several clinical trials have shown comparable SVR rates in the treatment of acute hepatitis C (AHC) coinfection with direct acting antivirals (DAA) compared with chronic hepatitis C (HCV) coinfection. In addition, data from modelling and real life cohorts have shown a reduction in AHC incidence when DAA are used to treat acute HCV coinfection. However, with no DAA currently being licensed for the treatment of AHC and with the high drug prices the question becomes eminent which patients will resolve their AHC infection spontaneously and which patients should be offered timely treatment. Here we evaluate rates of spontaneous clearance of acute HCV coinfection in a large European cohort.
The PROBE-C study is an observational European cohort on AHC in HIV coinfection. Between 2007 and 2016 465 AHC episodes were documented in HIV-infected patients with at least 12 months of follow-up from Austria, Denmark, France, Germany, Great Britain and Spain. Fisher’s exact, chi-square and Mann-Whitney U test were used for statistical analysis.
457/465 (98%) patients were male, median age was 41 years (IQR 38-46). Main routes of HCV transmission were MSM (98.9%) and IVDU (1.1%). 78.3% of patients were infected with HCV genotype (GT) 1, 2.6% with GT3 and 18.6% with GT4. Median baseline HCV-RNA was 230,000 IU/mL (135,000-474,432) and median CD4+ T cell count 574 cells/µL (547-604). 92% of all patients received cART, 91% had baseline suppressed HIV-RNA (<200 copies/mL). Median maximum ALT was 445 U/l (402-522). Overall, in 55/465 (11.8%) AHC resolved spontaneously. In 325/465 (69.9%) treatment was initiated within 48 weeks of AHC diagnosis, in 61 cases with interferon-free DAA regimen 24 weeks after acute HCV diagnosis. SVR rate was 75.7%. 51/465 (11%) patients were HCV reinfected. 85/465 (18.3%) developed chronic HCV infection. There was no statistically significant association between spontaneous clearance and HCV transmission risk, HCV GT, HCV RNA levels nor baseline ALT or HIV parameters.
Spontaneous clearance of acute HCV infection in the setting of HIV coinfection is a rare event. Almost 90% of acutely infected patients face a chronic course. Therefore treatment initiation needs to be considered early on to prevent onward transmission to sex partners. As a result DAA drug labels as well as clinical guidelines need to be amended to allow usage of DAA during the acute phase of HCV infection in a high-risk population.