MSF Diagnosis and Treatment of Hepatitis C: A technical landscape by MSF Access Campaign

DIAGNOSIS AND TREATMENT OF HEPATITIS C: A technical landscape

Opportunities to Revolutionise Care in Developing Countries This report provides an overview on the current state of play and a framework for action with regards to hepatitis C diagnostics and treatment in resource-poor settings.

April 2014 MSF Access Campaign MĂŠdecins Sans FrontiĂ¨res Rue de Lausanne 78, CP 116 CH-1211 Geneva 21 Tel: + 41 (0) 22 849 84 05 Fax: + 41 (0) 22 849 84 04 access@msf.org www.msfaccess.org www.facebook.com/MSFaccess twitter.com/MSF_access

SUMMARY AND STATEMENT OF PRIORITY Hepatitis C (HCV) has been a silent killer among people living with HIV around the world. Factors including lack of epidemiologic data, poorly tolerated treatment with low success rates, and cost and complexity of care have all contributed to a vicious cycle of neglect that has allowed a growing syndemic of HCV and HIV to blossom unchecked. But recent advances in both diagnosis and treatment, as well as new data on prevalence in low- and middle-income countries, provides an unprecedented opportunity to take the lead in turning back the growing tide of HCV and dramatically improving the wellbeing of people co-infected with HIV and HCV. New all-oral regimens offer the potential of being robust, well-tolerated and pan-genotypic. Thus, not only improving cure rates, but also simplifying diagnosis and management requirements. Advances in, and scale up of, molecular testing in low-resource environments will facilitate the diagnosis and monitoring of HCV. Taken together, these new tools open the door to managing this deadly co-infection in low- and middle-income countries. The simplified package of care may also enable decentralization of diagnosis and treatment as well as paving the way for eventual task-shifting to less specialized cadres of health workers. However, several key interventions are required in order to spark this revolution in HCV care: • Proactive normative guidelines at the WHO and country level are needed • Regular screening of patients at high risk for HCV, including those infected with HIV, is critical • Access to appropriate diagnostics, including molecular tests, is of utmost importance, and can be facilitated by utilizing the same platforms currently being rolled out for HIV • Prices of both interferon-based therapy, as well as new all-oral therapy, must be affordable to facilitate scale up in low- and middle-income countries, and biosimilar and generic competition is required in order to reach a fair price. • Access to new oral therapies depends not only on price but also on registering of these new medications in key countries, as well as the WHO or other normative bodies signaling their importance by inclusion in the model Essential Medicines List. There is no time like the present to rapidly address this hidden and ignored epidemic. The benefits of new tools and data will not be realized without key market interventions as well as prioritization of this disease at the WHO and at country level. But if the choice is made to invest now in the tools needed to fight HCV in low- and middle-income countries, the potential benefits are vast. Co-Infections of HIV including HCV Co-infections and co-morbidities of HIV remain critical issues in low- and middleincome countries, even in the age of antiretroviral therapy. Many of these diseases are under-diagnosed and access to treatment may be poor. There are significant opportunities to improve care for HIV co-infections, and such opportunities must be actively exploited by appropriate actors in order to ensure the best possible health and wellbeing for all people living with HIV. Many of the traditional co-morbidities of greatest concern fall into the category of opportunistic infections – meaning that one’s immune system must be severely

compromised before one becomes at risk for these diseases. Co-infections such as pneumocystis jiroveci (formally carinii) pneumonia (PCP) typically occur at a CD4 T cell count of <200 cells/µl and others, including cryptococcal meningitis, cytomegalovirus (CMV) retinitis, Kaposi’s sarcoma and cerebral toxoplasmosis, tend to occur at a CD4 T cell count of <100 cells/µl. Thus, there is evidence that the burden of these diseases is decreasing in the era of ART. Furthermore, early ART will significantly help to prevent the development of these opportunistic infections. However, other co-infections, such as hepatitis B and C, are not affected by CD4 count, and thus their attributable mortality and morbidity may not significantly change in the era of ART without specific treatment for these diseases (Table 1). Table 1: The burden and attributable mortality, and a brief description, of the diagnosis and treatment of co-infections of HIV. Disease Hepatitis C

Burden 150-180 mn; 4-5 mn co-infected

Mortality >360,000/year

Hepatitis B

2 bn; approx 10% HIV coinfected (3-3.5 million) 958,000 cases annually (720,000 in SSA)

600,000/year

2nd leading cause of blindness in some high HIV burden countries; 4 cases per 100 person years for patients with CD4<50 In 2006 in SA, 19.1 cases/100,000 in men; 4th most common cancer in Africa

N/A

Poorly documented

Dx: clinical, pathology of biopsies Tx: ART (small lesions), radiation, chemotherapy (pegylated liposomal doxorubicin)

Wide estimation: 4-33% of patients hospitalized with respiratory complaints Lack of epidemiologic

Poorly documented; potentially as high as 40% case fatality

Dx: clinical and radiographic, sputum for silver stain, fluorescence or PCR Tx: septrin, steroids

Poorly documented

Dx: clinical picture and head CT findings

Cryptococcal Meningitis

CMV Retinitis

Kaposi’s Sarcoma

PCP

Cerebral Toxoplasmosis

500,000600,000 deaths annually

Diagnosis and Treatment Dx: serology, viral load, genotype, staging Tx: pegylated interferon alfa+ribavirin Dx: serology, antigen, viral load Tx: tenofovir, lamivudine, entecavir Dx: CSF: india ink, crypto antigen LA or LFA; serum: LA or LFA Tx: amphotericin B+flucytosine or fluconazole Dx: indirect ophthalmoscopy Tx: IV or intraocular ganciclovir; oral valganciclovir

data; Tx: seroprevalence sulfadiazine+pyramethamine 1%-40% Dx=diagnosis; Tx=treatment; CSF=cerebrospinal fluid; LA=latex agglutination; LFA=lateral flow assay For all the key co-infections, better surveillance and diagnosis is needed. For several of these co-infections, improved tools for diagnosis exist, including the LFA for cryptococcal meningitis and task shifting to train primary HIV providers in indirect ophthalmoscopy for CMV retinitis. Similarly, for HCV and HBV, simplification and scale out of molecular testing platforms will allow for improved diagnosis. For other co-infections, such as PCP, potential molecular diagnosis is currently being developed and tested for accuracy. The market-readiness of molecular testing for HCV and HBV make them attractive in terms of investigating and identifying optimal platforms, as well as supporting competition among platforms, including open platforms. The fact that molecular testing can also be polyvalent, and be used for HIV, TB and HCV etc, also creates synergy with other key diagnostic projects. While the LFA for cryptococcal meningitis does represent a breakthrough technology, this test is relatively inexpensive (USD 2/test) and the manufacturer, Immy, reports that they can meet demand. In the future, competing tests will be important to ensure a dependable supply as single source products are, by definition, vulnerable, but this does not appear to be an imminent threat. There are also new opportunities in treatment for certain co-infections. While coinfections, such as PCP and toxoplasmosis, are effectively treated with older drugs that are available generically, optimal treatments for other co-infections are not widely available because of price or patents. New guidelines for cryptococcal meningitis suggest treatment with a combination of amphotericin B injectable and flucytosine. While both medicines are older and not patented, quality-assured generic producers of both amphotericin B injectable and flucytosine are limited, and these medicines remain costly. Further, flucytosine is not widely registered in sub-Saharan Africa. Barriers also exist for scaling up treatment for CMV and Kaposiâ&#x20AC;&#x2122;s sarcoma. CMV is treated with intravenous or intra-ocular ganciclovir, or oral valganciclovir. Oral valganciclovir has several advantages, including the ability to decentralize and simplify care and improve patient comfort. However, while injectable ganciclovir is off-patent and affordable, valganciclovir is still patented in the United States and is expensive. Generic producers exist in India, but these producers are either not pre-qualified or waiting to start commercial production for patent expiry in the United States (by 2015). Finally, the most effective and best-tolerated treatment for Kaposiâ&#x20AC;&#x2122;s sarcoma is pegylated liposomal doxorubicin (PLD). This medicine is costly and not widely available in generic form. However, there is now a potential to improve generic competition, given that a shortage of the originator product in the US has allowed for tentative FDA approval of a generic product. However, nowhere are the opportunities to dramatically transform treatment as great as they are for HCV. Current standard therapy with pegylated interferon alfa and ribavirin is expensive (USD 2,000-30,000 per treatment course), poorly tolerated (with significant adverse events), long (24-48 weeks of therapy), complex (requiring weekly injections) and not optimally effective (with a sustained virologic response of only an average of 30-50% for HIV co-infected patients with genotype 1). However,

new all-oral regimens hold the promise of short course (12 week), well-tolerated therapy with dramatically improved cure rates (84-100%). Some regimens may also be pan-genotypic. These medicines are likely to be widely patented and thus significant market and IP interventions are needed to ensure rapid access to all who need these drugs. In summary, while it is important to increase attention and treatment for all coinfections, only certain of these require strong IP and market interventions for access to treatment and care. Of these, HCV may present the largest amount of gain and the most dramatic shift in care, as well as require the most intensive market interventions, in order to realize these potential benefits.

TABLE OF CONTENTS 1. INTRODUCTION

2. GLOBAL BURDEN OF HCV

2.1 Overview 2.2 HCV and HIV co-infection

8 9

3. GUIDELINES

4. CURRENT AND PIPELINE TREATMENTS

4.1 Current Treatment 4.2 Complications in the use of biosimilars 4.3 The lack of competition from biosimilars 4.4 Current market trends 4.5 HCV treatment pipeline

13 16 17 18 21

5. CURRENT AND PIPELINE DIAGNOSTICS

5.1 Serological rapid diagnostic tests 29 5.2 Confirmation of active infection 30 5.3 Genotyping 31 5.4 Fibrosis staging and the need for non-invasive tests 31 5.5 Prognostic markers that predict response to HCV IFN-based treatment 35 5.6 Safety and monitoring 36 5.7 Viral load for treatment monitoring 36 6. HCV MARKET SHORTFALLS

7. EMERGING OPPORTUNITIES AND STEPS FORWARD

8. ANNEX 1: THE MOST PROMISING PIPELINE HCV DRUGS

1. INTRODUCTION Worldwide, there are between 150 and 180 million people living with hepatitis C virus (HCV) infection, with the majority of affected individuals unaware of their infection. Referred to as the “silent epidemic”1, a lack of reliable data means that the extent of the global epidemic remains unclear. Furthermore, it is estimated that between 6 and 10 million people living with HIV are currently co-infected with HCV or hepatitis B virus (HBV). They risk dying from HCV-related complications - such as liver cirrhosis or hepatocellular carcinoma - if they are not treated. Between 4 and 5 million people globally are estimated to be co-infected with HCV and HIV. Unfortunately, in resource-poor settings, very few HCV infected individuals have access to standard treatments and diagnostics, because treatment is administered only in specialised referral centres and remains extremely costly. The HCV drug pipeline is robust, however, with many new drugs showing promising results and entering Phase II and III clinical trials; and two drugs, sofosbuvir and simeprevir already approved by stringent regulatory agencies. This means that we will soon be able to take advantage of the new HCV treatment opportunities for both mono-infected and HCV/HIV co-infected individuals. These drugs will ensure better, safer, and shorter treatments. Some of the most advanced once-daily oral regimens, which are interferon-sparing or interferon-free, offer treatment across all the HCV genotypes for 12 weeks with an improved drug side-effect profile and a sustained virological response of 90%-100%. This will allow for a simplification of both the diagnosis and monitoring of patients. The challenge now will be to ensure that infected individuals living in low and middle-income countries also have access to these new and improved diagnostic and treatment options. However, access to antivirals in low- and middle-income countries is far from secure. In this report, Médecins Sans Frontières (MSF) has compiled an independent technical HCV landscape analysis to map the current and future trends in disease burden and product development, and we explore market evolution for diagnostics and medicines for HCV diagnosis and treatment. The aim of this report is to establish a prioritisation framework for researchers, civil society, and policy makers so that steps can now be taken to address gaps in research and development, as well as outlining a strategy to ensure that patients in resource-poor settings gain access to promising new products.

Economist Intelligence Unit. The silent pandemic. Tackling hepatitis C with policy innovation. Economist: London, UK; 2012.

2.GLOBAL BURDEN OF HCV 2.1 Overview Between 150 and 180 million people live with HCV infection globally and - together with HBV infection – these infections cause 1 million deaths each year. The infection is often asymptomatic, but when the virus persists in the liver (so-called chronic HCV infection) it can cause long-term damage that may only manifest after several years. Indeed, HCV and HBV infections account for 57% of all cases of liver cirrhosis and 78% of hepatocellular carcinoma, and remain a leading cause of liver transplantation2. Most people who develop acute hepatitis C have no symptoms. It is estimated that as many as 70%-90% of infected people fail to clear the virus during the acute phase of the disease and become chronic carriers. Of those with chronic liver disease, 5%20% may develop cirrhosis. About 5% of infected persons may die from the consequences of long-term infection (liver cancer or cirrhosis)3. The transmission of HCV infection occurs via blood-to-blood contact. In resource-rich countries, over 90% of chronic HCV infections are attributed to contaminated blood, organs, tissues, and blood products, or via the sharing of unsterilised injection equipment among injecting drug users. Less commonly, HCV is transmitted sexually - particularly among HIV-infected men who have sex with men - or at birth via mother-to-child transmission. In resource-poor countries, the primary sources of HCV infection are unsterilised injection equipment and other medical and dental equipment, extra-medical transmission (barbers and traditional circumcision practices), and via infusion of inadequately screened blood or blood products. There are eleven major genotypes of HCV – genotype 1 [GT1] to genotype 11 [GT11] – and many subtypes (designated a, b, c, etc). Genotypes 1-6 are by far the most common. Genotypes 1-3 have a worldwide distribution. Types 1a and 1b are the most common, accounting for about 60% of global infections. They predominate in Northern Europe and North America, and in Southern and Eastern Europe and Japan, respectively. In the United States, most cases are caused by GT1. GT2 is less frequently represented than GT1. GT3 is endemic in south-east Asia and is variably distributed in different countries. GT4 is principally found in the Middle East, Egypt, and central Africa. GT5 is almost exclusively found in South Africa, and GT611 are distributed in Asia3. The HCV epidemic is now described as a dual epidemic, which researchers and policy makers have referred to as “the silent pandemic”1. First, there is a concentrated epidemic affecting high-risk vulnerable groups situated predominantly in Eastern Europe and Asia. Second, there is a generalised epidemic in areas where HIV is highly prevalent, including countries in Africa such as Egypt, Nigeria, and Cameroon. In many countries globally, however, no reliable epidemiological data are available, and so the extent of the HCV epidemic remains unclear. Health authorities, particularly in resource-poor settings, need urgent access to reliable data in order to 2

Brown RS. Hepatitis C and liver transplantation. Nature 2005;36:973-978. WHO. Hepatitis C.(Available at: http://www.who.int/csr/disease/hepatitis/whocdscsrlyo2003/en/index.html [page 13]) 3

measure the magnitude of their domestic and regional disease burden and to prioritise the response accordingly. 8

MOHD HANAFIAH ET AL.

HEPATOLOGY, Month 2012

Fig. 3. Map of1: estimated seroprevalence by GBD region,of 2005. Note: Includes data published up to 2007 in peer from review andMohd U.S. Figure Theanti-HCV global prevalence HCV infection. Reproduced NHANES data up to 2010. 4

Hanafiah K, et al . GBD=global burden of disease.

high-prevalence settings. Conversely, lower-income quality would be covered by the uncertainty interval countries known to have high seroprevalence may surrounding the point estimates. Finally, for regions with less data, borrowing seem have lower because published studies 2.2toHCV and estimates HIV co-infection mainly sample urban affluent populations. Further- strength from other regions may have hidden patterns more, it must be noted that seroprevalence data are of transmission between years and sex amid the pooled Although their paucity of datadata. on Although the prevalence of HIV and HCV cothe data may be analyzed correctly generally derived fromremains adult and aolder age samples, infection, is estimated that inbetween 4 and 5 million people are the currently using the hierarchical model, problem co-infected with metaand may not beit representative samples regions with 5 with HCV HIV (5-15% of 33 million infected people HCV co-infected) analysis being used to makeare causal inferences has been . majority youngerand populations. These limitations in the HIV i.e., the studies included areand observational literature underscore the challenge estimating global highlighted, Little is yet known aboutofthe contribution of HCV infection to morbidity mortality 6representative and ‘‘group-level correlations may be mistakenly attribprevalence in the absence of nationally in the antiretroviral (ART) era . uted to individual-level causes.’’24,25 age-specific databases such as the NHANES U.S. Fourth, methodological limitations also apply. False Three distinct epidemiological profiles of HCV HIV has a strong impact on HCV progression, causing higher rates of chronicity and positivity rates, although not a concern in enzyme im- transmission have been described and can be used as a accelerated disease progression andin mortality. In the era ART, HIV/HCV comunoassay (EIA) testing for adults, is relatively high basis for interpreting the of age-specific seroprevalence infected patients are at increased risk of morbidity and mortality compared with children, particularly in first-generation test kits, and curves in this meta-analysis. In the first transmission 7 patients with HIV infection and withtype, chronic HCVis alone . Without this may be among the reasons behindalone the high prevaprevalence low among younger highly persons,active and lence seen in children age 1-4 years old in Central then rises steadily or sharply through middle age. After 4 Europe in Hanafiah 1990.22,23 Type prevalence is reached, theofseroprevalence declines of diagnostic test and qualMohd K, Groeger J, Flaxman AD, etpeak al. Global epidemiology hepatitis C virus in older ages.seroprevalence. The peak prevalence seen in type 1 ityinfection: of test kitsNew wereestimates not considered, because informaof age-specific antibody to HCV Hepatol tion on the test used were at times not included in the transmission is commonly referred to as the ‘‘cohort 2012;57(4):1333-1342. 5 In priorities type 2 transmission, prevalence isoflow in description of methods, which it difficult to effect.’’and Easterbrook P, Sands A, makes Harmanci H. Challenges in the management appropriate bias indicators in instances where this in- younger populations but increases dramatically and is HIV/HBV and HIV/HCV coinfection in resource-limited settings. Sem Liver Dis formation was not present. To exclude studies without sustained in older populations as a reflection of a past 2012;32(2):147-157. details on the testing kit would further shrink the high risk of infection that is no longer present. Type 3 6 Nelson P, Mathers B, et al. Global epidemiology of viral hepatitis among people who inject amount of studies that could be included, and further- transmission is seen in areas where there was a higher drugs: of that global reviews. risk of2011;378:571-583. infection in the distant past yet a high risk of more it wasresults expected any systematic influence of poor testingLancet 7

Lo Re V, et al. Increased risk of hepatic decompensation and hepatocellular carcinoma in HIV/HCV-co-infected patients compared to HCV-mono-infected patients despite combination th antiretroviral therapy [Oral Abstract number 17867]. 19 International AIDS Conference. Washington DC, USA: July 22-27, 2012.

antiretroviral therapies (HAART), HIV accelerates HCV disease progression, resulting in death, histological fibrosis/cirrhosis, and decompensated liver disease.8 A recent cohort study analysis among 4286 ART-treated HIV/HCV coinfected and 6639 HCV-monoinfected patients in the veterans Aging Cohort Study showed that compared to HCV mono-infected patients, ART-treated HIV/HCV coinfected patients had a higher cumulative incidence and risk of hepatic decompensation (303 of 4286 [7.1%] versus 370 of 6639 [5.7%] adjusted odds ratio: 1.76 [95% CI=1.50-2.06]) and hepatocellular carcinoma (50 of 4286 [1.2%] versus 60 of 6639 [0.9%], adjusted odds ratio: 1.69 [95% CI= 1.14-2.49]). After decompensation, mortality was higher in coinfected people (228 of 303) [75.2%] vs 210 of 370 [56.8%]; p <0.001). In HCV mono-infected people, a systematic review and meta-analysis showed that duration of HCV infection was the most consistent factor significantly associated with progression of fibrosis.9 The stage of hepatic fibrosis in co-infected patients is also independently associated with composite outcome of end-stage liver disease, hepatocellular carcinoma, and death10. In co-infected people, a low CD4 count is associated with higher liver fibrosis progression rate11. Increasing, morbidity is observed from chronic liver disease as patients survive longer on ART. HIV patients continue to have five-fold greater mortality than nonHIV-positive patients; it has been shown that chronic HCV infection is independently associated with a 50% increase in mortality among patients with a diagnosis of AIDS12. Consequently, experts recommended treating HIV early in HCV/HIV co-infected people. These patients are 66% less likely to experience end-stage liver disease, hepatocellular carcinoma, or liver-related deaths13. 8

Deng LP. Impact of human immunodeficiency virus infection on the course of hepatitis C virus infection: A meta-analysis. World J Gastroenterol 2009;15(8):996-1003. 9 Thein HH. Yi Q, Dore GJ, Krahn MD. Estimation of stage â&#x20AC;&#x201C;specific fibrosis progression rates in chronic hepatitis C virus infection: a meta-analysis and meta-regression.Hepatology 2008;48(2):418-431. 10 Berkeley N, Limketkai MD, Shruti H Mehta, et al. Relationship of liver disease stage and antiviral therapy with liver-related events and death in 638 adults coinfected with HIV/HCV. JAMA2012;308(4):370-378. 11 Benhamou Y.Liver fibrosis progression in human immunodeficiency virus and hepatitis C virus coinfected patients. Hepatology 1999;30(4):1054-1058. 12 Branch AD, Van Natta ML, Vachin ML, et al. Mortality in HCV-infected patients with a diagnosis of AIDS in the era of combination anti-retroviral therapy. Clin Infect Dis 2012;55:137-144. 13 EASL. EASL Clinical Practice Guidelines: 2013 revised version. Clinical practice guidelines to optimize the management of hepatitis C virus infection. Available at: http://www.easl.eu/_clinical-practice-guideline/issue-5-2013-revised-version-clinical-practiceguidelines-to-optimise-the-management-of-hepatitis-c-virus-infection 2011;55:245264.Accessed April 2, 2014.

3. GUIDELINES The World Health Organisation (WHO) HCV guidelines will be released in April 2014, including an update for the management of HIV co-infected patients being treated with anti-retroviral therapy. Diagnosis involves a serologic test, confirmation with a viral load test, and, for certain genotypes, subsequent staging to identify candidates for treatment who have evidence of significant liver fibrosis. Liver fibrosis stage is assessed by calculating what is called a METAVIR score. To be able to calculate this score, a liver biopsy or transient elastography ultrasound is performed, or a biomarker score is used. More details are available in the diagnosis section. A number of other expert bodies have developed evidence-based guidelines on the diagnosis and treatment of HCV-infected individuals, based on the GRADE methodology, including the European Association for the Study of the Liver (EASL)13 and the American Association for the Study of Liver Disease (AASLD)14. The primary goal of HCV therapy is to cure the infection, which results in eliminating detectable HCV after cessation of treatment. Sustained virological failure (SVR) is defined as an undetectable HCV RNA level (<50 IU/mL) 24 weeks after treatment withdrawal. SVR is generally associated with resolution of liver disease in patients without cirrhosis. Patients with cirrhosis remain at risk of life-threatening conditions like hepatocellular carcinoma. Treatment should be initiated in patients with advanced fibrosis (METAVIR score F3- F4 compensated), and strongly considered in patients with moderate fibrosis (F2)13. The current standard of care for chronic HCV infection is to treat with pegylatedinterferon alpha plus ribavirin (peg-IFN-riba) for a period of 24-48 weeks according to genotypes. According to these guidelines standard of care for chronic GT1 HCV infection includes the addition of a direct acting first generation anti-HCV protease inhibitor antiviral (telapravir or boceprevir). However, because of the high cost of these drugs and the monitoring required because of their toxicity, the use of these drugs is not feasible in resource-poor settings. However, with the entry of new direct acting antivirals, this standard of care is rapidly changing. According to these guidelines13,14, for HIV/HCV co-infected individuals, earlier treatment is recommended due to rapid disease progression.In case of HIV/HCV coinfection, it is recommended that HIV ART be initiated early: at CD4 counts â&#x2030;¤500cells/ÂľL. Indications for HCV treatment are identical to those for patients with HCV mono-infection. A recent survey has highlighted the lack of country specific guidance for management of HIV/HCV co-infection in resource-poor settings, and lack of consensus, on how to test for and treat HCV infection. Only 32 (34%) of 93 resourcepoor countries surveyed by WHO in 2012 provided guidance on various aspects of HIV/HCV co-infection management. The major shortfalls identified were: staging of liver disease, HCV diagnosis and timing of the initiation of HIV treatment, and choice of HCV treatment. The major area of discordance identified was: timing of ART in 14

American Association for the Study of Liver Diseases (AASLD)/ Infectious DiseasesSociety of America ( IDSA). Recommendations for Testing, Managing, and Treating Hepatitis C: American Association for the Study of Liver Diseases (AASLD)/ Infectious Diseases Society of America ( IDSA). January 2014. Available at: http://www.hcvguidelines.org/full-report-view. nd Accessed April 2 2014.

HIV/HCVco-infection (4 of 8 countries recommended early ART, and 4 of 8 recommended deferral of treatment)15.

HeenanRC, WiersmaST, VitoriaM. Significant variation in recommendations for management of HIV-hepatitis B and C (HIV-HBV and HIV-HCV) co-infection: a survey of th national guidelines from resource-limited settings (RLS). [Abstract number THPE682]. 19 International AIDS Conference. Washington DC, USA: July 22-27, 2012.

4. CURRENT AND PIPELINE TREATMENTS 4.1 Current Treatment The goal of the treatment is to eradicate HCV infection in order to prevent the complications of HCV-related liver disease, including inflammation, fibrosis, cirrhosis, hepatocellular carcinoma, and death13. The standard of care for HCV treatment is injectable pegylated-interferon-alpha (pegIFN-alpha) 2a or 2b combined with ribavirin oral therapy – so-called peg-IFN-riba. Treatment duration varies according to genotype: GT1 and GT4 require up to 48 weeks of treatment, whereas GT2 and GT3 require 24 weeks of treatment. Treatment outcomes in HCV mono-infected individuals and HCV/HIV co-infected individuals vary considerably. Treatment efficacy data are as follows: • • • • •

GT1 (treated with peg-IFN-riba, boceprevir, or telaprevir): ~70% GT1 HCV/HIV co-infected (treated with peg-IFN-riba): ~15-35% GT2 and GT3 (treated with peg-IFN-riba): ~80% GT2 and GT3 HCV/HIV co-infected (treated with peg-IFN-riba): ~55-73% GT4 (treated with peg-IFN-riba): 60-70%

Treatment failure occurs most often in those patients who are most in need of treatment, such as those with liver cirrhosis and HCV/HIV co-infection, or in posttransplant patients. Treatment with peg-IFN-riba is long and complicated. Adverse events are common and not always easy to manage, especially in resource-poor settings. Current shortfalls of existing drugs include: 1. Treatment availability: drugs are only in tertiary specialised referral centres. 2. Length of treatment: 24 to 48 weeks. One injection of peg-IFN-alpha per week plus daily doses of oral ribavirin. Weekly medical consultation by trained personal is needed to check that treatment is well enough tolerated and to detect and treat complications as they arise. 3. Regular HCV RNA PCR is needed to calculate SVR and therefore check treatment efficacy at weeks 4, 12, 24, 48, and 12 weeks post treatment, rarely available in resource-poor settings. 4. Management of peg-IFN-riba related side-effects is needed, especially acute anaemia, low neutrophil count, low platelets count, psychiatric disorders (especially depression) and co-morbidities like thyroid disorders, hypertension, diabetes, HIV and ART, excessive alcohol consumption. Such management can be difficult in resource-poor settings13. A systematic review and meta-analysis on treatment outcomes in chronically infected HCV patients in low and middle-income countries16, which included 12213 patients from 93 studies across 17 countries, showed a pooled SVR of 49% for GT1 and GT4, and 59% for GT2 and GT3. Factors associated with successful outcomes included treatment with peg-IFN-riba, infection with HCV GT2, GT3, the absence of 16

Ford N, Kirby C, Singh K, et al. Chronic hepatitis C treatment outcomes in low and middle income countries: a systematic review and meta-analysis. Bull World Health Organ 2012;90:540-550.

liver damage, and HIV infection at baseline. However, treatment side-effects were a limiting factor, with 17% of adverse events resulting in a treatment interruption or dose modification and 4% of adverse events resulting in treatment discontinuation. The authors concluded that treatment outcomes in low and middle-income countries were similar to those reported in high-income countries. These findings show that it is feasible to successfully treat HCV-infected individuals in resource-poor settings with peg-IFN-riba. Treatment outcomes in HCV/HIV co-infected people are less promising, however. A recent systematic review and meta-analysis of observational cohorts of treatment outcomes of treatment naïve hepatitis C patients co-infected with HIV showed that the pooled proportion of patients achieving SVR was 38%. Significantly poorer outcomes were observed for patients infected with GT1 or GT4 (pooled SVR 24.5%), compared to GT2 and GT3 (pooled SVR 59.8%).17

Increasing access to peg-IFN-riba in resource-poor settings is important to our ability to treat patients with HCV infection Very few people have access to peg-IFN-riba in resource-poor settings. The treatment is administered only in specialised referral centres and remains extremely costly. The burden of HCV infection is a sensitive issue for many resourcepoor settings. A strong civil society and considerable political will are needed to confront the reality of this “silent pandemic” and take the necessary steps towards universal access for all to treatment and diagnostics. Adding boceprevir and telaprevir to peg-IFN-riba can improve treatment outcomes for patients with HCV/HIV co-infection: approximately 30% improvement of SVR with HCV protease inhibitor regimen in naïve GT1 patients18. However, treatment management is highly complex, requires frequent and expensive monitoring, and the management of adverse events is so difficult that this treatment option is not an option as yet for resource-poor settings19. 17

Davies A. Singh KP, Shubber Z, et al. Treatment outcomes of treatment–naïve hepatitis C patients co-infected with HIV: A systematic review and meta analysis of observational cohorts. PloS One 2013;8(2):e55373. 18 Poordad F, McCone J, Bacon BR, et al. Boceprevir for Untreated Chronic HCV Genotype 1 Infection. N Engl J Med 2011;364:1195-1206. 19 JM Pawlovsky. (National Center for Viral Hepatitis B, C, delta. Department of Virology and INSERM U 955. Henri Mondor Hospital. University Paris-Est).“Current standard of care and a 5–year perspective”. Personal communication. MSF-TAG-OSI HCV Meeting: Paris, France, September 24-25, 2012.

Important steps that must now be taken by WHO The global community is beginning to mobilize to provide guidance for the diagnosis and management of HCV. The WHO HCV guidelines, expected in April 2014, the World Health Assembly viral hepatitis resolution planned for May 2014, and the integration of the Global Hepatitis Programme into the HIV WHO Department, all represent important opportunities to set a new agenda for the diagnosis and treatment of HCV and HCV/HIV co-infection in low and middle income countries*. We recommend that the target population for improved access to treatment includes all people with chronic HCV infection, regardless of genotype, transmission mode, or stage of fibrosis. People with more unfavourable prognostic factors (for example, GT1 HCV disease) and little evidence of liver damage, however, may elect to defer therapy while awaiting newer drugs. The WHO plans to release a list of newly pre-qualified HCV rapid diagnostic tests in 2014. We recommend that the WHO also ensures timely inclusion of the new direct acting antivirals on the Essential Medicines List following the evolution of the WHO guidelines. *WHO Executive Board viral hepatitis resolution available at: th http://apps.who.int/gb/ebwha/pdf_files/EB134/B134_R18-en.pdf/. Accessed March 11 , 2014.

Surveys carried out by MSF and other non-governmental organisations have highlighted that the price of peg-IFN-alpha-2a and 2b are often listed as between USD 100 and USD 400 per vial, in countries in which generic or biosimilar competition does not exist. The price structures offered by Roche and Merck, the two existing originator manufacturers, are aligned in the countries in which the two products are registered. Egypt is a notable exception, because the national Hepatitis C programme has reached an agreement to procure peg-IFN-alpha-2a (Pegasys) and peg-IFNalpha-2b (PEG-Intron) at USD 41 per vial, including a weekly supply of ribavirin20,21. In Egypt, competition through manufacturers offering biosimilars or originator peg-IFN products has reduced the price of both originator products for a 48-week treatment course of peg-IFN-riba from USD 10,000-20,000 to less than USD 2,00022. However, due to negotiations, competition of other PEG-IFN products 20

Esmat G, Fattah S. Evaluation of a novel pegylated interferon alpha-2a (Reiferon Retard) in Egyptian patients with chronic hepatitis C-genotype 4. Dig Liver Dis 2009 (Suppl 2009) 3:1. 21 El Sayed N, Kandeel A, Genedy M, et al. Progress towards prevention and control of hepatitis C virus infection â&#x20AC;&#x201C; Egypt, 2001-2012. Centers for Disease Control and Prevention.MMWR 2012 (July 27); 61: 29.. 22

National Institute for Health and Clinical Excellence. National Institute for Health and Clinical Excellence Technology Appraisal Guidance 106. Peginterferonalfa and ribavirin for the treatment of mild chronic hepatitis C. NICE: London, UK; 2006.

in some countries and the entry of the DAAs, Roche and Merck PEG-IFN prices are decreasing in multiple countries. Table 2: Average price of current treatments

Treatment regimen

Average price per course

Peg-IFN-riba Peg-IFN-riba + boceprevirortelaprevir

USD 10-20,000 USD 60-90,000

30000"

Pegylated"Interferon" 486weeks" Price"(USD)"

25000" 20000" 15000" 10000" 5000" 0"

Figure 2. Average price of peg-IFN-riba in resource-poor settings. (Source: courtesy of Azadeh Momenghalibaf [Program Officer, IHRD & AEMI] and Paul Cawthorne [MSF Access Campaign Coordinator – Asia]; “Global Snapshot: HCV epidemiology & response”, Paris MSF-OSF-TAG Meeting, September 24-25, 2012; Reproduced with permission from the authors)

4.2 Complications in the use of biosimilars Interferons are biological substances (ie, large and complex proteins produced through a biological process in specially engineered living organisms). Both branded and generic biological products (called biosimilars, bio-generics, follow-on biologics, or follow-on-protein products) have a different regulatory pathway than small molecules made through a chemical process. In order for biosimilars to gain approval from the regulators, they must be satisfied that these products are comparable to the reference product in terms of quality, safety, and efficacy. They must undergo an extensive (although less so than the originator product) development process, including comparative pre-clinical and comparative clinical trials to establish safety and efficacy. These studies are not required for approval of generic drugs (small molecules), in which the process is based on demonstrating bioequivalence.

WHO has a limited set of standards for biosimilars, called the “Guidelines on Evaluation of Similar Biotherapeutic Products”, which were only issued in 2009. Furthermore, WHO has not established any prequalification system for biological products beyond the category of vaccines. One problem associated with the development of a biosimilar is that it requires a large investment of time and money as opposed to generic small molecules. It takes approximately 8 years to develop a biosimilar, far longer than the development of a generic small molecule product (approximately 2 years). Development is also extremely expensive, requiring an investment of USD 10–140 million compared with USD 1–5 million for a generic product.

In the short-term, MSF has called for Merck and Roche to increase access to the preferential prices that have been available in Egypt. Both companies have established tiered pricing policies that require many lowand middle-income countries, including India, to pay unaffordable prices for peg-IFN-alpha. In the long-term, it calls for alternative sources to the originator drugs. Even if Roche and Merck agree to decrease their prices to the level negotiated in Egypt (USD 41 per weekly treatment of pegIFN-alpha), scale up will only be possible with safe and quality-assured alternative sources of this treatment. It is therefore crucial that a system is created that enables proper evaluation of the quality, safety, and efficacy of the existing alternative peg-IFN-alpha products to the originator products. 4.3 The lack of competition from biosimilars23 Peg-IFN-alpha-2a and 2b are being developed and marketed in a number of low and middle-income countries, including Egypt, Vietnam, Iran, Cuba, and India. Some of these products include a different size and form of peg (polyethylene glycol) branches and linker, and so do not fall under the category of biosimilars to the originator products. Others have been developed as biosimilars. However, none of these products have gained approval from a stringent regulatory authority either as a new biologic or a biosimilar because competition is currently blocked by the existence and the enforcement of patents in these countries, as well as the emerging use of lengthy terms of data exclusivity to prevent approval of biosimilar medicines. On the other hand, there is no WHO prequalification scheme that can ensure quality, and safe and effective alternative products to the innovators, in order to foster competition and obtain decreases in prices that allow for affordable treatment in developing countries.

Milani B, Gaspani S. Pathway to affordable, quality-assured sources of pegylated interferon alpha for treating hepatitis C. Generics and Biosimilars Initiative Journal 2013; 2(4):194-203.

Governments need to play a greater role in ensuring a lowering of the price of peg-IFN-alpha. It is crucial to have quality assured alternatives to the originator products available to foster competition and decrease prices, and governments must play a role in registering and using originator products and biosimilars. Compulsory licences and patent oppositions may also be necessary to ensure production or importation and use of a biosimilar, as well as measures to avoid introduction of lengthy terms of data exclusivity. 4.4 Current market trends Access to testing 59% of the world’s population has no access to HCV diagnostics. This finding correlates to the wealth of the country: serological diagnostic testing for the presence of primary infection is available to more than half of the population in 93% of highincome countries, 77% of upper-middle-income countries, 53% of lower-middleincome countries, and 11% of low-income countries. 84% of the population in lowermiddle-income countries and 96% of the population in low-income-countries live in areas where testing is not widely accessible24. In this report, although the full diagnostic package is discussed in section 5, this market analysis refers only to serological screening tests. Access to treatment Standard treatment for HCV infection is extremely expensive, severely limiting its use in low and middle-income countries. The availability of full or partial government funding for treatment of HCV infection depends heavily on the income status of that country. According to the latest World Hepatitis Alliance report23, any funding to support viral hepatitis is available in 83% of high-income countries, 77% of middleincome countries, and 33% of low-income countries. This report highlights that in all WHO regions, except for the African region, the majority of countries provide domestic funds that partially or completely fund HCV care and treatment programmes. Global sales • Peg-IFN-alpha-2a (Pegasys): o 1.655 billion Swiss Francs (CHF) in 2009, an increase of 5% from 200825 o 441 million CHF in the first quarter of 2010, a 15% increase from the first quarter of 200926 o Pegasys, for HCV and HBV infection, fell 11% to 695 million CHF for the first 6 months of 201127 o Pegasys sales growth: + 11% in 201228 24

World Hepatitis Alliance. Viral hepatitis: global policy. World Hepatitis Alliance: London, UK; 2011. Available from:http://www.worldhepatitisalliance.org/Policy/2010PolicyReport.aspx 25 Roche. Strong operating performance for Roche. Roche: Basel, Switzerland; 2009. 26 Roche. Excellent growth in first quarter of 2010. Roche: Basel, Switzerland; 2010. 27 Roche posts healthy financials for first half of 2011”. World news. July 21, 2011. Pharmatimes. 28 ZacksEquityResearch. Roche grows in 2012. Zacks: Chicago, USA; 2012 (www.zacks.com/stock/news/91818/roche-grows-in-2012).

•

Peg-IFN-alpha-2b (Pegintron): o 918 million USD in 200729 o 198 million USD in the third quarter of 200930 o 149 million USD fourth quarter of 2009 (post-merger with Merck)31 o Worldwide sales of Pegintron for the treatment of chronic HCV infection in 2010 were USD 274 million; worldwide sales of Pegintron were USD 319 million for the first 6 months of 2011, a decrease of 14% compared with the same period in 2010. According to Merck, these declines were attributable, in part, to patient treatment being delayed by health-care providers in anticipation of new therapeutic options becoming available.32 o Worldwide sales of Pegintron declined 1% in 2012 to USD 653 million.33

“The hepatitis C market is expected to become one of the fastest growing markets in Pharma over the next decade, given a sizable 170 million patient population, a significant unmet need, and rapid advancements in the clinic. The management of this infectious disease is on the verge of a revolution that will bring considerable changes to the treatment algorithm.” - Global Hepatitis C Market Analyzed & Forecast in New First Word Report available at Market Publishers.com (http://marketpublishers.com/report/pharmaceuticals/drugs/kol-insight-hepatitis-c-race4-first-interferon-free-regimen.html)

In 2011, the HCV therapeutics market was estimated at USD 2.6 billion. From 2004 to 2011, the market grew at the compound annual growth rate of 2.7%, with the launch of Incivek and Victrelisin 2011 (mainly for the treatment of HCV, HBV is a minor market), boosting positive growth34. Since then the market has seen a significant decline in value due to the low uptake of peg-IFN therapies and subsequent reluctance to put patients on peg-IFN-riba in anticipation of more effective drugs being launched. The launch of the two direct acting antiviral (DAA) protease inhibitors – telapravir and bocepravir - added a billion dollars to the market in 2011 and resulted in a positive compound annual growth rate. 29

Pan D, Bronshtein S, Shikani W. Schering-Plough (SGP). 2010; http://www.wikinvest.com/stock/Schering-Plough. 30 Schering-Plough Corporation. Schering-Plough announces 2009 third quarter financial results. Medical News: Macclesfield, UK; 2009. (http://www.newsmedical.net/news/20091022/Schering-Plough-announces-2009-third-quarter-financialresults.aspx?page=2). 31 Merck. Merck Announces Fourth-Quarter and Full-Year 2009 Financial Results [Media Release]. Merck: NJ, USA; 2010 (http://www.merck.com/newsroom/news-releasearchive/financial/2010_0216.html). 32 Tickerpot.com. tickerpot.com/symbol/mrk/310158/topic/pegintron/2011 33 Pegintron mentioned by Merck and Co (MRK) in 2011. Tickerpot.com; 2011 (tickerpot.com/symbol/mrk/310158/topic/pegintron/2011). 34 Hepatitis C Therapeutics Market to 2018. (http://www.researchandmarkets.com/research/ngbvll/hepatitis_c)

Global Business Intelligence (GBI) Research has estimated that the hepatitis C therapeutics market is in the top seven markets and will be valued at USD 14.9 billion by 2018, with a compound annual growth rate of 28.3% over the forecast period. These estimates are based on the continued adoption of the protease inhibitors as the gold standard treatment option for HCV, and the imminent launch of all-oral DAA molecules, the first of which should be in the market in 2014-2015.(GBI. Expected Launch of GS-7977 in 2015 will Pave the Way for an Oral Interferon-free Combination Therapy Hepatitis C Therapeutics Market to 2018. October 15, 2012).

Access to the new generation of DAAs Simeprevir (Olysio) received US Food and Drug Administration (FDA) approval on November 22nd, 2013. Its price on the US market is now USD 56,000 per course. Sofosbuvir (Sovaldi) received FDA approval on December 5th, 2013, and European Medicines Agency (EMA) approval on January 16th, 2014. Its price in the US reaches USD 86,000 per course, or USD 1,000 per pill. Global sofosbuvir sales could reach USD 4.5 billion in 2014 and USD 6.7 billion in 2015. It is estimated that Gilead will see peak hepatitis C sales in 2015 of USD 11 billion, more than half of the global market estimate for that year35. The price structure set by Gilead for sofosbuvir is expected to be USD 900 for a 12 weeks course in 60 low-income countries and three middle-income countries, India, Nepal, and Nigeria. Gilead is also offering a voluntary license to generic manufacturers in India to produce the drug only for 60 low-income countries (the drug cannot be exported to countries outside the 60 identified in Gilead’s access strategy36. The price structure for most middle-income countries - where more than 75% of the world’s HCV infection is found - is not yet known, but is expected to be much higher and unaffordable for patients and governments in those countries. These countries will also be excluded from a voluntary license37. This tiered pricing system will also likely leave out many high-burden middle-income countries, including the Ukraine and China, which will have to pay the “commercial” price – potentially similar to the price in the US and Western Europe. These prices will undermine scale-up of their national response according to need. The pro-public use of all TRIPS flexibilities, including compulsory licences, patent oppositions, public health friendly patent examinations, and transparent, public health driven, voluntary licensing, to eliminate any remaining patent or pricing barrier, in all low- and middleincome countries, are of critical importance to ensure access to new DAAs. 35

Karen Andersen. Gilead’s hepatitis C and oncology portofolio bolster its wide moat. Investment thesis. 03 /25 / 2014. http://analysisreport.morningstar.com/stock/research?t=GILD&region=usa&culture=enrd US&productcode=MLE. Accessed April 3 , 2014. 36 Gilead press release. Expanding access to hepatitis C treatment. February 2014, available th at: www.gilead.com. Accessed February 28 2014. 37 The Pharma Letter. Gilead to offer hepC drug sofosbuvir at greatly reduced price in developing countries. www.thepharmaletter.com/article/gilead-to-offer-hep-c-drug-sofosbuvirth at-greatly-reduced-price-in-developing-countries. Accessed February 7 2014.

Competition in the market, particularly through the entry of generic products, will lower prices, and facilitate further scale-up of HCV treatment and care. Innovative procurement strategies will have a role to play, including parallel importing and pooled procurement. The fixed-dose combination of sofosbuvir-ledipasvir was filed with the FDA in February 2014. High cure rates for this oral therapy may make it the new bar for competition. The price structure for a sofosbuvir and ledipasvir combination is not yet known. Competitors like Abbvie or BMS will launch oral treatments in 2014 too. Daclatasvir, and the combination of ABT 450/ritonavir+ABT 267+ABT 333, with or without ribavirin, are expected to receive FDA approval later this year. It is our view that policy makers and pharmaceutical companies must aim for a price of <USD 500 for the entire diagnostic, monitoring and treatment package in developing countries. Encouragingly, new data show that minimum manufacturing costs of some oral DAAs could be as low as USD 100-200 for a 12 weeks course, which makes <USD 500 a realistic prospect38. 4.5 HCV treatment pipeline The HCV drug pipeline is extremely rich. It is clear that we can anticipate the availability of all-oral DAA regimens by 2014-2015. DAAs act at various levels of viral replication to stop the virus from reproducing with the aim of cure e.g. SVR. These regimens are expected to be potent and simple to administer, have improved safety, tolerability, and efficacy. Some of them are expected to cover genotypes 1-6, and may be compatible with ART. Data have also shown that several of these pipeline regimens may have efficacy in the setting of advanced liver disease or in treatmentexperienced patients. Some recently approved DAA combinations can be used without peg-IFN, others still rely on a peg-IFN and ribavirin backbone. In HCV genotypes 1 and 4, a 12 week regimen of sofosbuvir plus peg-IFN and ribavirin has been FDA approved. With this regimen, SVR rates at 12 weeks were 89% in phase III Neutrino and phase III Atomic trials39,40. Sofosbuvir can be used with ribavirin alone in genotype 2 (for 12 weeks), and genotype 3 (for 24 weeks) and has received FDA approval for this indication. The SVR rates in genotype 2 after 12 weeks of sofosbuvir plus ribavirin was 93%; in HCV genotype 3, SVR was 85%41. 38

Hill A, Khoo S, Fortunak J, Simmons B, Ford N. Minimum cost for providing Hepatitis C direct acting agent for use in large scale treatment access programs in developing countries. Clin Infect Dis 2014 (Jan 6, early online), available at: http://cid.oxfordjournals.org/content/early/2014/01/06/cid.ciu012.full.pdf 39 Kowldey KV, Lawitz E, Crespo I, et al. Sofosbuvir with pegylated interferon alfa-2a and ribavirin for treatment –naïve patients with hepatitis C genotype-1 infection (ATOMIC); an open –label, randomised, multicentre phase 2 trial. Lancet 2013; 381(9883). 40 Lawitz E. Mangia A, WylesD, et al. Sofosbuvir for previously untreated chronic hepatitis C infection. NEJM 2013; 368:1878-1887. 41 Zeuzem S, et al. Sofosbuvir + ribavirin for 12 or 24 weeks for patients with HCV genotype 2 th or 3: the VALENCE trial. 64 Annual meeting of the American Association for the Study of Liver Diseases: Washington DC, Nov 1-3, 2013.

In HIV/HCV co-infected patients, and with genotype 1, 24 weeks sofosbuvir plus ribavirin yielded a 76% SVR rate in the PHOTON trial42. All oral 24 weeks sofosbuvir plus ribavirin is now recommended in the AASLD/IDSA Guidelines for genotype 1 IFN-intolerant patients43. There are 5 drug classes of oral regimens; we will present only the most promising pipeline drugs (Table 3). These drugs were selected for inclusion in this report according to a specific target product profile adapted for resource-poor settings and according to the latest available information (as of March 30th, 2014). For a complete overview of pipeline drugs see Annex 1. It is important to note that these are pipeline drugs and, as such, Phase III trials are not yet finished. Any results or data presented here must be analysed with caution. Large phase III trials are currently ongoing that will improve data regarding the safety and efficacy of these new drugs. More complete information is available in Annex 1 and the Pipeline Report from Treatment Action Group44. Based on MSFâ&#x20AC;&#x2122;s assessment, we believe that, if Phase III trials of these pipeline drugs bear fruit, these all-oral treatment regimens represent appropriate products for resource-poor settings, according to the following criteria: (a) safety; (b) efficacy; (c) simplicity; (d) potential combinations; (e) dose of drug; (f) potency; (g) pan-genotypic coverage; (h) tolerability; (i) robustness; (j) compatibility with ART; (k) compatibility and efficacy with advanced liver disease; (l) absence of interactions with Opioid Substitution Therapy, TB treatment, and other diseases; (m), and performance in treatment-experienced patients. MSF believes the potential utility of new DAA regimens may be judged by these criteria and phase III studies will provide further supporting data. The question now, therefore, is not if these drugs are a breakthrough for treatment of HCV, but whether HCV infected individuals in low and middle-income countries will be able to access these game-changing regimens at an affordable price. 42

Sulkowski M, et al. All-oral therapy with sofosbuvir in patients co-infected with HIV th (PHOTON-1). 64 Annual Meeting of the American Association for the study of Liver Diseases. Washington DC, Nov 1-4 2013. Available at: th http://www.natap.org/2013/AASLD/AASLD 34.htm. Accessed December 6 2013. 43 AASLD Practice Guidelines 2014. Available at: http://www.hcvguidelines.org/full-reportth view. Accessed February 15 2014. 44 Swan T. HIV HCV TB 2013 Pipeline Report. Treatment Action Group: New York, USA; July 2013 (www.pipelinereport.org).

TABLE 3: THE TOP 5 MOST PROMISING PIPELINE REGIMENS FOR HCV INFECTION

1-6

Geno types studi ed

No significant drug-drug interactions related to sofosbuvir

Well tolerated, no need of food intake, no rash, no pancytopenia, improved anaemia compared with interferon-based therapy but is still an issue due to ribavirin.

drug-drug interactions

Major adverse events/safety issues;

GT1 phase III 12 weeks Peg-IFN +SOF+RBV SVR12: 90%

GT1 phase III 24 weeks SOF+RBV SVR12: 76%

GT3 , phase III SOF + RBV 24 weeks : SVR12: 85%

GT2, phase III 12weeks SOF+RBV SVR12: 93%

Treatment duration (weeks), efficacy, and robustness

Simplicity Barrier to resistance

Once daily Fixed dose combination of sofosbuvir and ledipasvir High barrier to resistance

GT2/3 treatmentexperienced SOF+RBV: - 12 week treatment: GT2 SVR12=96% GT3 SVR12=30% . - 16 week treatment: GT2 SVR12 94%; GT3 SVR 62%

GT1 treatmentexperienced, phase III 12 weeks SOF+LDV SVR12 93.6% SOF +LDV+RBV SVR12 96.4%

HCV/HIV, treatment experienced, and advanced liver disease

oral combinations: available in 2014: Sofosbuvir+ribavirin ( genotypes 2,3) Sofosbuvir+simeprevir ( genotypes 1,4) Sofosbuvir+daclatasvi r ( genotypes 1,3,4-6)

Sofosbuvir-ledipasvir expected 2014

Sofosbuvir DFA approved in 2013

Trial status and timeline

This table reviews five of the major direct acting antivirals (DAAs) in later-stage trials and reviews only the all-oral combinations that are being trialled. This table is not exhaustive, but is included as a brief reference for select drugs that are furthest down the pipeline. For further information, please see the Annex table. Drugs name (drug class); manufacturer; combinations being studied Sofosbuvir (Nucleotide NS5B polymerase inhibitor) Manufacturer: Gilead Sofosbuvir+RBV Sofosbuvir+Ledip isvir+/-RBV Sofosbuvir+dacla tasvir+/-RBV

GT1 phase III 12

weeks SOF + LDV(ledipasvir) SVR12 97.7% GT1 phase III SOF+LDV 8 weeks SVR12: 94% GT1 phase II SOF+ LDV+GS 9669 6 weeks SVR12 95% ( N=20) GT1 phase II SOF+LDV+GS 9451 6 weeks SVR12 100% ( N= 20) GT 1phase II 12 weeks SOF+simeprevir SVR12 100% (n=14) SOF+simeprevir + RBV SVR12 100% (n=12) GT1 phase II 12 or 24 weeks SOF+Daclatasvir (DCV) SVR12 100% (

GT1 phase II SOF+simeprevir null responders 12 weeks SVR12 100% (n=7) SOF+ simeprevir + RBV SVR12 93.3% ( n=15) GT1 experienced SOF+DCV SVR12 100% (n=21) SOF+DVC +RBV SVR12 95% (n=20)

Ledipasvir (NS5A inhibitor) Manufacturer: Gilead Ledipisvir+Sofos buvir+/-RBV

Daclatasvir (NS5A inhibitor) Manufacturer: BMS

1,2,3, 4

Safe and well tolerated Fatigue, headache, nausea

Well tolerated, no need of food intake, no rash, no pancytopenia, improved anaemia compared with interferon-based therapy but is still an issue due to ribavirin.

n=14) SOF+DCV+RBV SVR12 95% ( n=15) GT1 SOF +DCV Na誰ve SVR12 98% Experienced SVR12 98% GT2 SOF+DCV SVR12 92% (n=26) GT3 SOF+DCV SVR12 89% (n=18) GT1 phase II 12 weeks sofosbuvir+ledipisvir +RBV: SVR12 100%

GT1 phase II daclatasvir+sofosbu vir+/-RBV: -12 week treatment SVR12=95%

Once daily Fixed dose combination of sofosbuvir and GS 5885 Low barrier to resistances Once daily Medium high barrier to

GT1 treatmentexperienced, phase II 12 weeks Sofosbuvir+ledipisvir+ ribavirin:SVR12 100%

Limited data available in advanced liver disease and HCV/HIV co-infected individuals and treatment-

Sofosbuvir-GS 5885 registration expected 2014

Phase III sofosbuvir+ledipisvir+ RBV currently underway, including HIV co-infected patients

Phase III trials of daclatasvir+asunepra vir+/-BMS 791325 expected 2014

Daclatasvir+sofo sbuvir+/-ribavirin Daclatasvir+Asun apravir+/-BMS 791325

ABT 450/ritonavir

1, 2, 3

Significantly less adverse events without ribavirin

1% discontinuation.

-24 week treatment SVR=93% GT1 phase II daclatasvir+asunepr avir+BMS 791325 -12 or 24 weeks treatment SVR12 94% GT2/3 phase II 24 weeks daclatasvir+sofosbu vir+/-RBV: SVR12 88-100%

DCV 30mg+ simeprevir (SMV)+/- RBV in GT1a and 1b na誰ve an null responders: Overall SVR12= 75-85% in treatment na誰ve Overall SVR 12 = 65-95% in prior null responders. ABT 450/ +-ABT 267+- ABT333+-

Twice daily

resistance

GT1 null-responders phase II 12 weeks

experienced individuals

Phase III underway (started Oct 2012)

studies of daclatasvir+sofosbuvir are ongoing

(Protease inhibitor) Manufacturer: Abbott ABT 450/r+/ABT267+/-ABT 333+/-ribavirin Simeprevir (Protease inhibitor) Manufacturer: Janssen/Tibotec/ Medivir Simeprevir + TMV 647055/ritonavir Simeprevir + sofosbuvir +/ribavirin Simeprevir+Dacl atasvir Simeprevir+ VX135

1, 4

Common adverse events: fatigue, headache, pain, vomiting, hyperbilirubinaem ia Ritonavir=high potential for drugdrug interactions Flu-like symptoms, rash, neutropenia, anaemia, transient elevation of bilirubin Co-administration with efavirenz is not recommended

RBV : phase III, GT1, tt na誰ve, 12 weeks: 3 DAA+ RBV : SVR12: 99.5% 3 DAA: SVR12: 99% ABT/r+ABT 267 formulated in a fixed dose combination Low barrier to resistance Once a day Limited information on resistance

450/r+ABT267+/-ABT 333+ribavirin: 87-93%

GT 1 experienced, compensated cirrhosis: 3 DAAs +RBV 12 weeks : SVR12: 92% 3 DAAs +RBV 24 weeks SVR12: 96% Awaiting results of alloral regimens using this drug

Phase II with simeprevir-containing all oral-therapy underway

Name Class Asunapravir Protease inhibitor BMS 791325 Non-nucleoside NS5B polymeraseinhibitor ABT267 NS5A ABT333 Non-nucleoside polymerase inhibitor TMV 647055 Non-nucleoside NS5B polymeraseinhibitor VX135 Nucleotide polymerase inhibitor BMS=Bristol-Myers Squibb. SVR= sustained virological response. SVR12=sustained virological response at 12 weeks. SVR24=sustained virological response at 24 weeks. RBV=ribavirin.

5. CURRENT AND PIPELINE DIAGNOSTICS â&#x20AC;&#x153;Whenever easy oral treatments will be available, the key issue will be screening. Governments will hate it, because it will mean they will have to pay for itâ&#x20AC;?. JM Pawlotsky, Professor of Medicine at the University of Paris, AgenceNationale de Recherchesur le Sida (Paris MSF-OSF-TAG Meeting, September 24-25)

At present, HCV diagnosis and monitoring is complex, involving multiple steps and resulting in an expensive and resource-demanding process. New treatments that require a much more simplified monitoring algorithm will have a hugely positive impact on the minimum access requirements for HCV monitoring tests.

5.1 Serological rapid diagnostic tests The first step in the diagnostic algorithm is to screen for HCV by measuring whether the person has any antibodies to the virus. However, because cured patients, and patients who are exposed to the virus but clear it naturally, retain antibodies to HCV, an additional molecular test to measure the actual virus must be done to confirm active infection. The easiest way to perform a non-laboratory-based serological testing is by a point-of-care rapid diagnostic test (RDT), a similar diagnostic test kit to a pregnancy test. MSF has spent considerable resources in recent years searching for a good point-ofcare RDT, yet we have not found anything suitable for resource-poor settings that meets all basic requirements. Requirements for such a test are summarised in the Panel below.

Panel 1: Requirements for a point-of-care RDT for HCV infection in resource-poor settings 1. Close to 100% sensitivity and a high negative predictive value 2. Simple procedure 3. No cold chain requirement 4. No additional equipment 5. WHO prequalified, CE marked, or FDA approved (as class I/A product) 6. Good manufacturing practice 7. Low cost 8. No interaction with other co-morbidities (especially HIV/AIDS)

Available products are currently too complex and expensive, have cold chain requirements, do not have good manufacturing practice, are not CE marked, and/or are not approved by the Food and Drug Administration (FDA) (as a class I/A (or high

risk) products). In order to ensure quality, it is important that products are quality approved by a strict regulatory authority. Often there are no good performance evaluation reports or published data, or the evaluation is relatively old (>10 years). The OraQuick test (OraSure, USA) would be the preferred RDT for procurement for resource-poor settings if it was affordable but, at EUR 14 per test, it is 4-12 times more expensive that other HCV RDTs. The test has a good performance (over 99% accurate), especially in patients who have seroconverted (recently become anti-HCV positive), and is made using good manufacturing practice. Unlike other tests that must be done on serum or plasma, the OraQuick RDT can also be done on whole blood (for example, finger-prick) or oral fluid, which is much more convenient for decentralised testing where there is no option of processing blood samples. This test also has no cold chain requirements (although must be kept below 30°C). Table 4 provides an overview of currently available tests; Table 5 provides an overview of pipeline tests. A recent systematic review and meta-analysis of rapid and point-of-care screening tests for HCV revealed that tests done on blood samples have a higher accuracy that those done on oral fluid45, which is to be expected. The review also provides test specifications of products included. One major gap in the evidence base is that there is limited evidence on the accuracy of HCV RDTs in HCV/HIV co-infection. We do know, however, that several HCV screening tests can show false-negative or false-positive results in cases of HCV/HIV co-infection, and this remains a major concern46. Shivkumar S et al36 showed that both HIV infection and ART initiation could influence the immune response sufficiently to alter HCV test accuracy. The researchers conclude that future implementation research studies stratify patients by HCV/HIV co-infection to resolve the issue of test accuracy. 5.2 Confirmation of active infection Once serological positivity has been established, active infection must be confirmed by a nucleic acid amplification test – a molecular test that can measure the presence of the actual virus. This may be done by one of two tests: (1) a qualitative test that provides a “yes/no” answer – much like measuring HIV DNA for early infant diagnosis; or (2) a quantitative test that measures the viral load in international units per millilitre (IU/mL). Qualitative tests are cheaper and easier to perform, however, with current peg-based treatment, a baseline viral load measurement is required before treatment initiation so that the log drop may be measured. Due to the fact that not all patients will respond to the current therapy with peg-IFN-riba, if a patient has not achieved a 2 log IU/mL drop in their viral load by 12 weeks of therapy (termed an early virological response), it is advised that they discontinue treatment as they have a negligible chance of achieving a SVR by the end of therapy (ie, patients will undergo a toxic treatment course without a chance of cure)47. For this reason, if there is a strong 45

Shivkumar S, et al. Accuracy of Rapid and Point-of-Care Screening Tests for Hepatitis C: A Systematic Review and Meta-analysis. Ann Intern Med2012;157:558-566. 46 Smith BD, Drobeniuc J, Jewett A, et al. Evaluation of three rapid screening assays for detection of antibodies to hepatitis C virus. J Infect Dis 2011;204(6):825–831. doi:10.1093/infdis/jir422 47 P Deltenre, V Canva, M El Nady et al. A 2-log Drop in Viral Load at 1 Month is the Best Predictor of Sustained Response in HCV Patients with Normal ALT: A Kinetic Prospective Study. J Viral Hepat2009;16(7):500-505.

suspicion that the patient has an active HCV infection and could start treatment fairly soon, it is better to just do one test - the viral load test - and skip the qualitative test altogether. Furthermore, manufacturers are phasing out their supply of qualitative tests and focusing now on quantitative testing platforms (usually based on real-time PCR). This is evident by the fact that there are only two known suppliers of qualitative tests whereas there are five known suppliers of viral load tests. Table 6 provides an overview of commercially available qualitative HCV tests, and Table 7 an overview of pipeline tests. Viral load tests for the purposes of treatment monitoring will be reviewed later in this report. With the introduction of the new pipeline drugs, it is possible that only qualitative testing may be needed. The use of a newer generation of DAA treatment may require only a binary +/- measurement (to confirm viral replication or suppression, respectively), potentially only pre-treatment and post-treatment (e.g. SVR12) depending on the lower limit of detection of the qualitative assay. 5.3 Genotyping The required length of peg-IFN-riba treatment, the current standard of care, and the expected outcome from treatment, is dependent on the HCV genotype, of which there are 6 main genotypes (GT1-GT6): • GT1, GT4, GT5, GT6: 48 weeks of treatment, worse outcomes • GT2, GT3: 24 weeks of treatment, better outcomes Current genotyping tests are based on four different types of technologies: real-time PCR, line probe assay, and DNA chip or sequencing. The most popular is the line probe assay. Table 8 provides an overview of available tests and Table 9 provides an overview of pipeline tests. When sending a sample to the laboratory for testing, costs can be well over USD 100. Tests are complicated and require well-resourced laboratories with highly qualified staff. The good news is that automated sample preparation platforms have greatly reduced hands-on time and the need for more highly qualified staff. Furthermore, generic options, like the HCV Genotype Plus Real-TM kit (Sacace, Italy) may be used with any real time PCR instrument, obviating the need to invest in additional instrumentation if the laboratory already has the basic devices installed. The same real time PCR machine can also be used for viral load testing. Importantly, because new HCV treatments will be pan-genotypic, genotypic testing may no longer be necessary. 5.4 Fibrosis staging and the need for non-invasive tests As chronic HCV infection often takes years, if not decades, to progress to significant liver damage, and the currently available treatment is relatively toxic, staging should be performed before treatment decisions are made for patients living with chronic HCV48. Depending on HCV genotype and patient factors, including HCV/HIV coinfection and race/ethnicity, the SVR may range from 25%-80%. Thus, in particular for GT1 and GT4, which are associated with a worse treatment response, many clinicians will not initiate IFN-based antiviral therapy until significant fibrosis is demonstrated and the risk-benefit of treatment tips towards initiating treatment. Most clinicians will initiate treatment once significant liver scaring - or fibrosis - is demonstrated. For example, fibrosis - which is divided into 4 levels from F1 (mild) to F4 (severe) - must exceed F2 (METAVIR>/= F2). Importantly, as HCV treatments 48

EASL. EASL clinical practice guidelines: management of hepatitis C virus infection. J Hepatol 2011;55:245–264.

improve in terms of safety and efficacy, these staging procedures may no longer be necessary. Until recently, staging depended exclusively on a liver biopsy to examine the histology of the liver and diagnose the degree of inflammation and fibrosis in a given patient49. Liver biopsies are invasive and carry risks, including risk of internal haemorrhage and infection. Biopsies require a trained individual to perform then and a relatively experienced pathologist to interpret the biopsy. As liver damage does not occur in a uniform pattern throughout the liver, there is also the risk of inappropriate staging because of sampling error50. Thus, there is a need for non-invasive staging tests to help determine candidates for IFN-based HCV treatment. A non-invasive test would ideally be affordable, easy to perform (for example, based on phlebotomy), and accurate for a wide range of patients, including those with co-morbidities such as HIV. Currently, non-invasive tests of liver damage include radiologic and serologic measures. One of the most commonly used radiologic tests is based on transient elastography and measures the liver ‘stiffness’. The more liver fibrosis there is, the stiffer the liver will be. Serologic tests are based on a combination of biomarkers that are correlated with liver disease. The biomarker measurements are put into an algorithm, the score of which may then be interpreted in a standardised way. The question for resource-poor settings is which tool is best in terms of performance and feasibility? Given the expense, maintenance, and need for operator experience involved in transient elastography, this modality, while reasonable for resource-poor settings, should likely be carried out at a higher level health centre or referral centre to ensure that the operators have sufficient experience to provide accurate and reliable results. The other option is using biomarkers. Although many biomarker-based testing algorithms exist, most biomarkers are not able to be measured because the laboratory tests are unavailable, and the calculation of the algorithm is complex. Out of these, two serological tests may be considered feasible for resource-poor settings: APRI and FIB-4. These tests demonstrate acceptable accuracy in diagnosing no or minimal fibrosis or cirrhosis in mono-infected HCV patients. However, as their predictive value at intermediate ranges (F1-F3) is low, these patients may be considered for a confirmatory test, such as transient elastography. Biomarkers are still recommended for all settings where volumes are low and it does not make financial sense to purchase a FibroScan® (to perform transient elastography). While APRI may not be the best possible biomarker test, it is still suitable for use in resource-poor settings and the advantages include the use of a simple formula that is amenable to calculation by hand or with a simple calculator, and the use of laboratory test results that are likely to be routinely available (aspartate transaminase (AST) and platelets). For patients who are HCV/HIV co-infected, if levels of platelets or AST change, the indirect serologic tests are less accurate, and these patients may require transient elastography or liver biopsy. We summarise the performance of the main indirect markers in Panel 2. Further information about the measurement of fibrosis can be found in reference 44. 49

Bravo AA, Sheth SG, Chopra S. Liver biopsy. N Engl J Med 2001; 344:495–500. Regev A, Berho M, Jeffers LJ, et al. Sampling error and intraobserver variation in liver biopsy in patients with chronic HCV infection.Am J Gastroenterol 2002;97:2614-2618. 50

FibroIndex (platelets, AST, GGT)

PGA index: PT, GGT, Apolipoprotein A1

AST to platelet ratio index (APRI): (AST/ULN (upper limit of normal)) / platelet count x 100

Aspartate transaminase (AST)/alanine transaminase (ALT) ratio

Fibrosis Marker

Currently under investigation; prediction of significant fibrosis is 0.8344

Accuracy in detecting cirrhosis: 66-72% in patients with alcoholic liver disease53

A recent meta-analysis of 40 studies revealed that APRI threshold of 0.7 for severe fibrosis showed a sensitivity of 77% and specificity of 72%; for cirrhosis, a cut-off of 1.0 showed a sensitivity of 76% and specificity of 72%; AUROC (area under the receiver operating curve) for significant fibrosis, severe fibrosis and cirrhosis was 0.77, 0.80, and 0.83, respectively52

Not useful on its own51

Performance

Panel 2: Summary of the performance of the main indirect markers

FIB-4 Index (platelets, ALT, AST, age)

Tested in mono-infected HCV patients: AUROC = 0.85 for severe fibrosis; positive predictive value of 82.1% for significant fibrosis (at a cut off >3.25); values of 1.45-3.25 were not very predictive54,55

Imperiale TF, Said AT, Cummings OW, et al. Need for validation of clinical decision aids: use of the AST/ALT ratio in predicting cirrhosis in chronic hepatitis C. Am J Gastroenterol 2000;95(9):2328-2332. 52 Lin ZH, Xin YN, Dong QJ, et al. Performance of the aspartate aminotransferase-to-platelet ratio index for the staging of hepatitis C-related fibrosis: an updated meta-analysis. Hepatol 2011; 53:726-736. 53 Ahmad W, Ijaz B, Gull S, et al. A brief review on molecular, genetic and imaging techniques for HCV fibrosis evaluation.Virol J 2011; 8;8:53.

Hepascore: total bilirubin, GGT, hyaluronic acid, alpha-2 macroglobin, age, & gender

ActiTest: FibroTest with ALT

FibroTest (FibroSure): alpha-2 macroglobulin, haptoglobin, gamma globulin, apolipoprotein A1, GGT, & total bilirubin. Determines fibrosis stage F0/1 vs F2/3/4

Fibrometer: platelets, PT, AST, alpha-2 macroglobulin, hyaluronate, BUN, age

AUROC of this test is 0.85 for significant fibrosis, 0.96 for advanced fibrosis and 0.94 for cirrhosis44

• •

Improves identification of more advanced fibrosis and inflammation May be used for monitoring57

Sensitivity 75% and specificity 85% for determining stage >F2 FibroTest and FibroScan have been combined to improve correct diagnosis: in a recent study of 183 patients with chronic HCV infection, the AUROC was 0.88 for identifying fibrosis state >F2, 0.95 for >F3, and 0.95 for >F456,48

Can differentiate fibrosis progression44

Vallet-Pichard A, Mallet V, Nalpas B, et al. FIB-4: an inexpensive and accurate marker of fibrosis in HCV infection. Comparison with liver biopsy and fibrotest.Hepatol 2007; 46:32-36. 55 Sterling RK, Lissen E, Clumeck N, et al. Development of a simple noninvasive index to predict significant fibrosis in patients with HIV/HCV coinfection. Hepatol 2006;43:1317-1325. 56 Vallet-Pichard A, Mallet V, Nalpas B, et al. FIB-4: an inexpensive and accurate marker of fibrosis in HCV infection: comparison with liver biopsy and fibrotest. Hepatol 2007; 46:32-36 57 Poynard T, et al. Overview of the diagnostic value of biochemical markers of liver fibrosis (FibroTest, HCV FibroSure) and necrosis (ActiTest) in patients with chronic hepatitis C. Comparative Hepatol 2004;3:8.

5.5 Prognostic markers that predict response to HCV IFN-based treatment Once a patient is identified as being a candidate for treatment, a variety of predictive tests may be done to determine their likelihood of responding to IFN-based treatment. The type of IL28B gene (for example, CC, TT, etc] and levels of IP-10 (a measure of inflammation and immune activation) are the most studied predictors of treatment response to IFN-based treatment. These tests are generally done for HCV genotypes that are not as responsive to IFN-based therapy (for example, GT1 and GT4). The likelihood of response for other genotypes is so high that these tests are not considered to be as valuable. For reasons stated below, these tests are not likely to be important in the era of DAAs. IL-28B Polymorphisms of IL28B can predict treatment response and have been shown to be the strongest baseline predictor of SVR in HCV infection with GT158. More favourable genotypes are as follow: CC genotype at rs12979860 (Odds ratio [OR] of SVR 5 vs unfavourable genotypes); TT at rs8099917 (OR 3.7 vs unfavourable genotypes); AA at rs12980275 (OR 8.3 vs unfavourable genotypes). For those with unfavourable genotypes, SVR drops to between 30-35%59. The various polymorphisms of the IL28B gene are strongly associated with race/ethnicity and favourable genotypes are more likely to be found in Caucasian populations. For example the CC polymorphism is found in 30% of Caucasians compared with 15% of African Americans and 20-23% of Asians60. However, rapid virological response (RVR), which is the viral response at 4 weeks into treatment, is as good a predictor of success (OR 5) for GT1 as is the CC polymorphism61. In a study of telapravir, considering RVR after the lead in with pegIFN-riba made the effect of CC non-significant62. Thus, while IL28B CC is the strongest baseline predictor of SVR, RVR is the strongest overall predictor of SVR (when considering CC, race, serum glucose, viral load, METAVIR, and fibrosis stage F0 or F1). IP-10 The other most studied predictor of response to IFN-based therapy in HCV GT1 is IP-10.. As IFN-based treatment is based on activating the immune system to fight HCV, higher baseline levels of IP-10 suggest that additional immune stimulation with IFN might not be useful and in fact, higher levels of IP-10 predict a worse response. 58

Thompson AJ, Muir AJ, Sulkowski MS, et al. Interleukin-28B polymorphism improves viral kinetics and is the strongest pretreatment predictor of sustained virologic response in genotype 1 hepatitis C virus. Gastroenterol 2010; 139:120-129. 59 Grebely J, Petoumenos K, Hellard M, et al. Potential role for interleukin28B genotype in treatment decision-making in recent hepatitis C virus infection.Hepatol 2010;52(4):1216-1224. 60 Gonzalez SA, Keeffe EB. IL-28B asa Predictor of Sustained Virologic Response in Patients with Chronic Hepatitis C Virus Infection.GastroenterolHepatol 2011; 7(6):366-373. 61 Beinhardt S, Rutter K, St채ttermayer AF, et al. Revisiting the predictors of a sustained virologic response in the era of direct-acting antiviral therapy for hepatitisC virus. Clin Infect Dis 2013;56(1):118-122. 62 Pol S, Aerssens J, Zeuzem S, et al. Limited impact of IL28B genotype on response rates in telaprevirtreated patients with prior treatment failure. J Hepatol 2013;58(5):883-889.

IP-10 and unfavourable IL-28B genotypes are not directly related and, thus, these two tests can be considered complementary63. Levels >600 pg/mL (measured by ELISA) had negative predictive values for achieving SVR of 78%64. Thus, levels of >600 pg/mL are considered as a cut-off for predicting poor response. However, in one study, only 14% of patients had IP-10 >600 pg/mL. So, once again, IP-10 and RVR are highly correlated and - when taking into account the predictive value of RVR - IP-10 levels become non-significant and RVR remains the only independent predictor of SVR. Although these markers may be useful for predicting response to IFN-based treatments for patients living in resource-rich countries, these tests are complex and expensive. They also only have moderate predictive value for treatment response. Considering a resource-poor setting, where the only options are peg-IFN-riba treatment or nothing, these markers may hold little added value. Furthermore, investing in infrastructure to test these markers may not produce long-term gains as these markers will no longer be important when we move to DAA, oral HCV drugs.

Implementing HCV treatment programmes in resource-poor settings does not require the use of prognostic marker tests for predicting treatment response; therefore the absence of these tests should not hinder the opening of treatment programmes, even for programmes treating only with peg-IFN-riba.

5.6 Safety and monitoring Due to potential toxicities of peg-IFN-riba, regular laboratory monitoring is required. EASL recommends measuring ALT and complete blood count at baseline, weeks 1, 2, and 4, and then every 4-8 weeks during treatment. TSH (thyroid stimulating hormone) must also be monitored at baseline and every 12 weeks. As both ribavirin and peg-IFN-alpha are renally dosed (dosed according to renal function), most clinicians will also assess creatinine at baseline and during treatment. Due to the teratogenic effects of ribavirin, pregnancy testing is also recommended. A move to new, all-oral HCV treatments may offer an opportunity to also simplify laboratory monitoring. For example, the combination of sofosbuvir-ribavirin may only require ALT, creatinine, and haemoglobin testing at baseline and 3-4 times during treatment. Unlike TSH or even complete blood count, ALT, creatinine, and haemoglobin are regularly available in mid-level health facilities in low and middle-income countries. This decreased need for laboratory monitoring also reduces the laboratory related costs of treatment. 5.7 Viral load for treatment monitoring Viral load testing is required to monitor the effectiveness of treatment. At a minimum the baseline, week 12, week 24, and end of treatment viral loads must be measured, with - where possible - an additional viral load 6 months post-treatment to confirm 63

Darling JM, Aerssens J, Fanning G, et al. Quantitation of pretreatment serum interferon-Îłinducible protein-10 improves the predictive value of an IL28B gene polymorphism for hepatitis C treatment response. Hepatol 2011; 53:14â&#x20AC;&#x201C;22. 64 Lagging M, Romero AI, Westin J, et al. IP-10 predicts viral response and therapeutic outcome in difficult-to-treat patients with HCV genotype 1 infection. Hepatol 2006;44:1617â&#x20AC;&#x201C; 1625.

that there has been no disease reactivation (or reinfection). The use of oral regimens in the future may eliminate the need for on-therapy testing, given high rates of suppression while on therapy. There are currently 6 different commercially available viral loads tests for HCV, described in Table 10, including a cheaper generic version, the HCV Real-TM Quant (Sacace, Italy), which may be run on any real time PCR instrument. This therefore saves the laboratory having to purchase extra instrumentation if they already have a real-time PCR machine in place. These laboratory-based tests are complex, requiring well-resource laboratories and skilled staff. Automated sample preparation instruments have greatly reduced the hands-on time and level of technical skill required, which may allow for greater decentralisation of testing. A number of studies have also looked at the use of dried blood spots for both genotyping and viral load assays. Although further research is required, preliminary results show that dried blood spots (DBS) can be used for transportation of blood samples to laboratories that may be far away from clinics65,57,58,66. DBS are easy to prepare from a finger-stick of blood and are stable at ambient temperatures for a few weeks. Furthermore, a number of point-of-care test manufacturers that are on the cusp of launching viral load tests for HIV (for example, IQuum, Alere, Cepheid, and Wave80) are also planning to release test cartridges for HCV in the more distant future (Table 11). Together this means that, if prices are not too high, viral load testing in resource-poor settings will be possible. An HCV viral load test can cost over USD 100 so pricereducing mechanisms, such as competition and volume price discounts, will be necessary to drive costs down.

Since diagnostic and treatment monitoring costs for HCV are expensive, bringing prices down will be a major step forward. It is estimated that the screening test (1x serological RDT) plus viral diagnostic test (1x viral load + 1x genotype), plus treatment monitoring (2x viral load tests) currently cost in the region of EUR 400-500 per patient.

In summary, current diagnosis and monitoring algorithms - which include staging for patients with GT1 or GT4 HCV disease - are relatively complex and costly, but feasible even in resource-poor settings. With use of DAAs, the diagnostic and monitoring algorithm may be significantly simplified, reducing, or may even eliminate the need for genotyping, staging, and intensive monitoring for drug side-effects (for example, TSH). 65

Tuaillon E, Mondain AM, Meroueh F, et al. Dried blood spot for hepatitis C virus serology and molecular testing. Hepatol 2010; 51(3):752â&#x20AC;&#x201C;758. 66 Solmone M, Girardi E, Pucillo CF, et al. Simple and Reliable Method for Detection and Genotyping of Hepatitis C Virus RNA in Dried Blood Spots Stored at Room Temperature.J ClinMicrobiol 2002; 40(9):3512â&#x20AC;&#x201C;3514.

6. HCV MARKET SHORTFALLS Table 12: HCV commodity market shortfalls Category Affordability

Market shortcoming Current management using standard treatments (PEGRIB) and staging (eg liver biopsy) is prohibitively expensive

New DAAs are projected to be priced at about USD 80,000 in HICs

Quality

Lack of prequalified HCV rapid tests, with questionnable accuracy for co-infected patients

Acceptability/adaptability

Current management is complex, long, and poorly tolerated, with low effectiveness

Delivery

Lack of country guidance and programmes to deliver HCV diagnosis and treatment.

Underlying reason(s) Perceived small markets do not incentivise price reductions. A lack of WHO regulatory guidance for drugs and diagnostics leads to low competition. Staging and genotype are costly, but needed given riskbenefit of standard treatments. Without active negotiation, intellectual property interventions, demand identification, and political/resource mobilisation, the price of DAAs coming to market will put these innovative new out of reach for LMICs Perceived small market does not incentivise development of test for LMICs or for specific patients with comorbidities Use of a weekly injectable and need for biopsy or staging ultrasound makes decentralisation of HCV care difficult. Side-effects make this regimen difficult for patients to take and poor efficacy make this an unattractive investment for governments or donors. Lack of funding and poiltical will due to unrecognised epidemic as well as low incentive to implement current costly, complex, and poorly effective management. Lack of experience diagnosing and treating HCV lead to lack of evidence to contribute to robust guidelines. Regulatory barriers delay access to new drugs, including DAAs

7. EMERGING OPPORTUNITIES AND STEPS FORWARD The burden of HCV and HCV/HIV co-infection in low and middle-income countries is significant and remains largely unaddressed to date. The unprecedented progress in the HCV drug pipeline – with new drugs likely coming onto the market in early 2014 – will radically modify the way HCV care will be provided. Major steps forward in drug development will now mean that we can move from complex treatment requiring specialised centres, to simplified protocols that will allow progressive decentralisation and scale-up in resource-limited settings. At the same time, increased simplification and automation in terms of laboratory technologies will allow development of reliable and simple HCV viral load point-ofcare devices and laboratory-based tests that will be suitable for district level laboratories. These new treatments will also simplify diagnostic and monitoring algorithms. We may need only one viral load test, or qualitative test, prior to treatment, and one after treatment termination. Genotyping and staging may no longer be necessary. Limited side-effects will allow for a simplified monitoring schedule. In order to reduce the barriers to ensuring patients can access HCV diagnosis and care, the following factors have been identified as being in urgent need of addressing: • WHO sentinel epidemiological surveys and data collection systems must be put in place in every country/or globally. • WHO should ensure the pre-qualification of HCV RDTs and virological tests with urgency. • Simple and reliable pre-qualification system for biosimilars needs to be developed by regulators. • Competition between drugs must be encouraged to decrease the price of peg-IFN-riba globally. • Governments and policy-makers should ensure aggressive access policies for the new DAAs, including addressing intellectual property and registration barriers that may exist to block potential for generic competition. • Achieve appropriate and affordable pricing for new DAAs. • Ensure that guidelines – at both WHO and country-level - are developed for diagnosis and treatment of HCV in resource-poor settings and include guidance on new DAAs as evidence becomes available. • Countries should rapidly adapt guidelines and implement use of DAAs that are registered, including sofosbuvir • Companies should register DAAs rapidly and broadly with a focus on high burden countries. • Countries should accelerate registration of key DAA products. • Key DAAs, such as sofosbuvir, should be registered on the WHO model EML. • HCV products should be included in the WHO prequalification programme • Encourage governments to offer increased access to freely available screening for HCV for key populations and in generalised epidemics. • The research community must push for the implementation of real-life treatment feasibility trials and operational research of care simplification in resource-poor settings and among vulnerable groups, including people living with HIV, injecting-drug users, pre-post transplant patients, cirrhotic and fibrosis stage F3-F4 patients, and people who do not tolerate IFN.

• • •

•

Increase public, patient, and professional awareness. Improve the reliability of blood transfusion and ensure adherence to universal hygiene precautions for safe medical procedures. Service-providers should develop new models of care to suit everyone: from centralised to decentralised settings, to families, vulnerable groups, children, and HCV/HIV co-infected people. Create incentives for developers to include access to all-oral HCV drugs for people living in resource-countries in their market strategies, at affordable prices. Unitaid, the Global Fund, PEPFAR, domestic funding etc should urgently set up new funding opportunities to secure treatment for resource limited settings, including middle income countries and emerging markets. Increased political will is a critical next step in this process.

There is now a unique window of opportunity for innovators and policy makers to ensure that people living with HCV in resource-poor settings gain access to new diagnostics and effective and affordable new treatments. Acknowledgments Tracy Swan (Treatment Action Group), Prof Francesco Negro (Geneva University Hospital, Switzerland), Dr Vincent Lo Re (University of Pennsylvania, USA), Dr ValeriannaAmorosa (University of Pennsylvania, USA), Dr Sally Hargreaves (Medical Writer, London, UK), Barbara Milani (MSF Access Campaign, Geneva, Switzerland).

ANNEX 1: THE MOST PROMISING PIPELINE HCV DRUGS

Definitions used for treatment outcomes Sustained virological response (SVR) 24: HCV becomes undetectable during treatment, and remains undetectable for 24 weeks post-treatment completion. Considered as a cure.

SVR12: HCV becomes undetectable during treatment, and remains undetectable for 12 weeks post-treatment. Considered as highly predictive of treatment success. Accepted as co-primary endpoint with SVR24. SVR4: HCV becomes undetectable during treatment, and remains undetectable for 4 weeks post-treatment. Product

Sofosbuvir: Nucleotide analogue NS5B polymerase inhibitor Ledipasvir: NS5a inhibitor GS-9669 NS5b non nucleoside inhibitor GS9451: protease inhibitor GS0938: guanide nucleotide analogue GS-5816: NS5a inhibitor, pan-genotypic in vitro

Drug characteristics

SOFOSBUVIR = SOVALDI Class

Gilead 400mg once daily Phase III. FDA approved December 8, 2013 YES 1, 2, 3, 4, 5, 6 Adults One tablet taken once daily with or without food.

Ex GS-7977 Companion drug: ledipasvir, GS-9669, GS-5816

Company Daily dose Development Potent Genotype Universal Dosage and

Recommended combination therapy

administration

SOF RBV: Well tolerated. Common adverse events: fatigue, headache. In combination with peg-IFN: fatigue, headache, nausea, insomnia, anaemia. No need of food intake. No significant drug-drug interactions, no rash.

HCV mono-infected and HCV Treatment Duration –HIV-1 co-infected123 GT1 or 4 Recommended:Sofosbuvir + peg-IFN-riba 12 weeks Or Suggestion: Sofosbuvir +riba ( if IFN intolerant) 24 weeks GT2 Sofosbuvir+riba 12 weeks GT3 Sofosbuvir+riba 24 weeks Dose: Sofosbuvir (400mg/d single daily dose)+ Ribavirin (weight based - 1,000mg/d if <75Kgs, 1,200mg/d if >75Kgs); Dose: Sofosbuvir ( 400mg/d single dose) +pegylated interferon alpha2a (180 µg/wk) or pegylated interferon alpha 2b ( 1.5 µg/kg/wk) +ribavirin ( < 75kg = 1000 mg, > or = 75 kg = 1200 mg)

Should be used in combination with ribavirin, or in combination with pegylated interferon and ribavirin for treatment of Chronic Hepatitis C (CHC).

It is important to note that the indication in GT1, GT4, GT5, and GT6 includes the addition of 12 weeks of peg-IFNriba, so it is not IFN free (except for IFN intolerant ) . In GT1 , 2, 3 it is possible to use IFN free regimen.

Sofosbuvir-ledipasvir-ribavirin [ Gane ref 3]: (n=34); serious adverse events = 8%; 1 treatment interruption for severe adverse events; common adverse events - anaemia (20%), depression (8%), headache (4%). 44% laboratory abnormalities including anaemia. ION trials: Adverse events: SOF LDV RBV 12 weeks ( n=328): fatigue(37%), headache 22.9%, nausea 17.4%, insomnia 18,.9%, diarrhea 7%, rash 9.8%, irritability 9.1%, cough 11.3%, pruritus 9.8%. SOF LDV 12 weeks ( n=539): fatigue 21.5%, headache 21%, nausea 11.3%, insomnia 7.6%, diarrhea 7.6%, irritability 4.1%, rash 4.3%, arthralgia 5.8%, cough 3.3%, pruritus 3.9%.PHOTON trial: SOF+RBV 24weeks: SAE 6/155, treatment interruption: 3/68. 12 weeks arm: SAE 7/ 155, treatment interruption: 4/68.

Safety /Tolerability/adve rse events

Combinations and SVR

QUANTUM GT1

xxxxx.7 GT1

ATOMIC 4 GT1

Study name

SOF +RBV (weight based or 600mg RBV)

SOF +RBV

SOF+ Daclatasvir +/-RBV

SOF+ Ledipasvir +/-RBV

SOF + pIFN + RBV

SOF+pIFN + RBV

Combination

60 patients, 24% cirrhotics, 29% relapse in the weight-based RBV arm)

Part1: 12 weeks: SVR12: 90% 24 weeks: SVR12: 77% (of 25 participants)

12 vs 24 weeks 12 weeks: SVR: 59% (10/17)

12 or 24 weeks SVR 100%

Ongoing Include cirrhotic patients

SVR 12: 89%

12 or 24 weeks SVR 90%

Outcomes

GT1

NEUTRINO 5 GT1 ION-1.6 GT1

SPARE. 1011

Part 1: n=10, liver fibrosis (stage F0-F2) 24 weeks SOF+ WB RBV (1000mg/day if weight < 75kg or 1200mg/day if =or>75kg). Part 2: n= 50, all stages of liver disease, 1/4 stage F3 or F4. Randomly assigned to receive sofosbuvir +WB RBV or fixed dose 600mg/day RBV.

Sofosbuvir + RBV + Peg-IFN for 12 weeks

SOF+BMS791325+RBV

Results for GT4, 5 and 6?

90% (295/327) GT 1a: 92% GT 1b: 82% Cirrhotic: 81%

12 weeks SVR 100% (25/25)

Sofosbuvir+B MS-791325 12 GT1

GT4:28 cases GT5:1case GT6:6 cases

NEUTRINO

GT1,4,5,6 naive

GT1: 24 weeks: SVR12:76% ( 87/114) GT2: 12 weeks: SVR12: 88% ( 23/26) GT3 : 12 weeks: SVR12:67% ( 28/42)

1314

PHOTON-115

Sofosbuvir+ WB RBV ( 1000 or 1200 mg/day) for 12 weeks or 24 weeks

GT2: 24 weeks: SVR12: 92% ( 24/26) GT3: 24 weeks: SVR12: 88% ( 15/17)

HIV-HCV GT1,2,3

52% (13/25)

56% (14/26)

SOF+RBV for 12 weeks or SOF+RBV for 24 weeks in na誰ve

70% (92/132)

HIV-HCV 98% on ART GT1: n=114, 4%cirrhosis GT2: n=26, 4% cirrhosis GT3: n=42, 14% cirrhosis High mean cd4 cells (>550/mm3)

QUANTUM16 GT1

SOF +RBV for 24 weeks if retreatment Or GS0938 (guanide nucleotide

ELECTRON17

1819

GT1, majority 1a GT 2/3 Difficult to treat

ELECTRON 20

SOF+RBV null responders (n=10) or

SOF+RBV na誰ve (n=25) or

analogue)

10%

84%

GS 0938 arm halted. (ALT elevations)

100% (25/25)

SOF+Ledipasvir+RBV null responders (n=9) or

92%

100%

100% (21/21) 68% (17/25)

SOF+GS 9669 (HCV NS5B nonnucleoside inhibitor) +RBV in na誰ve (n =25) or

100%

GT1, na誰ve, no cirrhosis: SOF+Ledipasvir+RBV na誰ve ( n=25) 12 weeks or 8 weeks or 6 weeks

SOF+GS 9669+RBV in null responders (n =10)

SVR24=100% (n=50)

SVR12=64% (n=25)

SVR24=100% (n=24)

sofosbuvir+/- peg-IFN + ribavirin Group 12 weeks, no peg-IFN Group 8 weeks, with peg-IFN Group 8 weeks, no peg-IFN.

Sofosbuvir+ simeprevir+/- RBV for 12 to 24 weeks

SVR4: 96-100%

SOF+SIM+RBV arm: 96% ( 26/27) SOF+SIM arm: 92% (13/14)

COSMOS2122 GT1 null responders, metavirF0-F2 GT1 naïve and null responders, metavir F3-F4

GT1, Null respondersAll levels fibrosis

SOF + RBV for 12 weeks Or

Pooled analysis of the 12 –week treatment arms in cohorts 1 and 2, SVR4: 96% SOF+SIM with or without ribavirin, in 96% patients with IL28B non CC, 91% if metavir score F4 cohort 1, 100% if metavir score F4 cohort 2 , and 95% of prior null responders. 67% (107/253) GT2: 97% Cirrhotic: 91% Non-cirrhotic: 98% GT3: 56% Cirrhotic: 34% Non cirrhotic: 61%

SVR12: 79-96%

FISSION2425 GT 2/3 treatment naive N= 499 20% cirrhotic

Peg IFN+RBV for 24 weeks

67% (162/243) GT2: SVR12:78% Cirrhotic: 62% Non cirrhotic: 82% GT3:SVR12: 63% Cirrhotic: 30% Non-cirrhotic: 71%

POSITRON21 22 ( same ref as fission)

GT2/3, IFN intolerant, ineligible or unwilling N= 207

FUSION ( same ref as Fission)

GT2/3 treatment experienced N= 201 30% cirrhotic AI 444-040 Treatment na誰ve, non cirrhotic,

Results across GT

SOF+RBV for 12 weeks Or Placebo for 12 weeks

78% (161/207) 0% (0/71)

73% (69/95) GT2: 94% GT3: 62% non cirrhotic: 63%, cirrhotic: 61%

50% (50/100) GT2: 86% GT3: 30% non cirrhotics:37%,cirrhotic: 19%

GT3 12 weeks: SVR12: 30% Cirrhotic: 19% non cirrhotic: 37% GT3 16 weeks: SVR12: 62% Cirrh: 61%, non cirrh. 63%

GT2 12 weeks: SRV12: 96% Cirrhotic. 60% Non- cirrhotic. 96% GT2 16 weeks: SVR12: 94% Cirrhotic: 78%, non-cirrhotic: 100%

SOF+RBV for 12 weeks Or SOF+RBV for 16 weeks

Daclatasvir+sofosbuvir+/ribavirin.GT1 naive

24 weeks, sofobuvir lead in, no ribavirin (n=16): SRV24=88% 24 weeks, no ribavirin (n=14): SRV24=100 % 24 weeks, with ribavirin (n=10): SRV24=93%

NEUTRINO

GT2& GT3.2627

Sofosbuvir+ledipasvir+ /-RBV 12 weeks

12 weeks sofosbuvir=peg-IFN-riba

Daclatasvir+ sofosbuvir+/- RBV TVR/BOC failures, GT1

SVR 12=97% (n=35). Of the 35 patients with GT4, GT5, GT6, 97% achieved SVR12. Break down by GT: GT4: sofosbuvir+peg-IFN-riba : SRV24= Is 10/12 GT6: sofosbuvir+ peg-IFN-riba. SVR24= Is 5/5 No relapses at week 12 and week 24.

SOF+DCV SVR 12: 100% ( n= 21) SOF+DCV+RBV SVR12 : 95% ( n= 20)

LONESTAR28 GT3

SOF+RBV: - 12 weeks in patients with HCV GT 2 ( N=73) TT na誰ve TT na誰ve, cirrhotic TT experienced, no cirrhosis TT experienced, cirrhosis

SVR12: 94% (86/92)

SVR12: 97% (29/30) SVR12: 100% (2/2) SVR12: 91% (30/33) SVR12: 88% (7/8)

TT experienced who failed PIs, 12 weeks With cirrhosis

TT naive, no cirrhosis

SVR12: 83% in treatment experienced patients, both cirrhosis and no cirrhosis SVR12: 97% (58/60) after 8 to 12 weeks treatment 39/40 (98%) SVR 21/22 (95%) SVR

VALENCE29 GT2 GT3

- 24 weeks in patients with HCV GT 3 (N=250) TT na誰ve

ION-1, ION-2. ION-330 GT1 na誰ve & experienced

TT na誰ve, cirrhotic TT experienced + cirrhosis TT experienced no cirrhosis

ION-1 treatment na誰ve

SVR12: 92% (12/13) SVR12: 60% (27/45) SVR12: 87% (87/100)

94% (202/215)

In progress, evaluate 8,12,24weeks of SOF+ ledipasvir /RBV ION-1 GT1 naive 12 weeks FDC FDC RBV 8 weeks FDC FDC RBV 12 weeks FDC ION-2 tt experienced 12 weeks FDC FDC RBV 24 weeks FDC FDC RBV 8 weeks FDC

93.1% (201/216) 95.4% (206/216)

99.1% (108/109) 99.1%(110/111)

93.8% (102/109) 96.4%(107/111)

ION-2 treatment experienced (20% with cirrhosis)

SVR12: 95.4%(206/216)

SVR12: 94.0%(202/215) SVR12: 93.1%(201/216)

SVR12: 97.7% (209/214) SVR12: 97.2%(211/217)

ION-3 8 weeks FDC+RBV 12 weeks FDC

NIAID SYNERGY Trial31 GT1(a) difficult to treat population GT4 Egyptian ancestry32

6 to 12 weeks regimen, RBV free, 12 weeks SOF+LDP (N=20) 6 weeks SOF+LDP+GS9669 (n=20) 6 weeks SOF+LDP+GS9451 (n=20) SOF+RBV 12 weeks TT na誰ve (n=14) TT experienced (n=17) SOF+RBV 24 weeks TT na誰ve (n=14) TT experienced (n=15)

SVR12: 100% (20/20) SVR4: 18/20 SVR4: 100% (20/20) SVR12: 79% SVR12: 59% SVR4: 97% SVR4: 100% SVR4: 93%

Resistances

Currently under study, similar HCV viral kinetic as mono-infected, well tolerated.33,34 Treatment outcomes of sofosbuvir-GS5885 without ribavirin are not yet known.

High genetic barrier to resistance/ GT 1,2,3,4,5,6. (means drug resistance is unlikely)

GT4: Few data for all oral sofosbuvir ribavirin on GT4.Trial ongoing in Egypt. GT4: trial sofosbuvir simeprevir ongoing in Egypt.

HCV/HIV coinfection

PHOTON-1 is an ongoing open-label Phase 3 study being conducted at sites in the United States and Puerto Rico to evaluate the efficacy and safety of 12 or 24 weeks of sofosbuvir 400 mg once-daily plus weight-based RBV (1,000 or 1,200 mg/day) among HCV treatment-na誰ve patients with genotype 1, 2 or 3 HCV infection who are also HIV-positive. Ninety-five percent of PHOTON-1 patients were receiving antiretroviral therapy for their HIV infection. The HIV treatment regimens permitted in the study were based on the results of a separate Phase 2 drug-drug interaction

Treatment experienced

study demonstrating that sofosbuvir did not significantly affect the pharmacokinetic parameters of drugs from various classes of antiretrovirals. The most common HIV treatment regimens taken by patients in PHOTON-1 were emtricitabine/tenofovir disoproxil fumarate administered with efavirenz, atazanavir/ritonavir, darunavir/ritonavir, raltegravir.or rilpivirine. SVR12 rates were similar to those observed in patients with HCV monoinfection. HIV viral breakthrough seen exclusively in the setting of poor ART compliance. No effect on CD4 T 窶田ell percent. No resistance (deep sequencing) was observed in virological failures. Treatment discontinuations due to adverse events were reported in three percent of patients receiving 24 weeks of therapy and four percent of patients receiving 12 weeks of therapy. The most common side effects observed in the study were consistent with the safety profile of RBV and included fatigue, nausea, headache and insomnia. Note: anemia (19/114) with hb<10g/dl in the 24 weeks arm (and 10/68 in the 12 weeks arm) Note: hyperbilirubinemia with atazanavir (20/22) in the 24 weeks arm (and only 6/ 68 in the 12 weeks arm.) GT1 treatment experienced:

ELECTRON: sofosbuvir +ribavirin for 12 weeks. GT1 null responders, SVR12=10% (n=1 of 10). ELECTRON: sofosbuvir+GS5885+ribavirin 12 weeks in 9 GT1 null responders. SVR12= [A: %?] (n=9/9) ( ref 3) See tables for more info GT2& GT3 treatment experienced FUSION: 12 or 16 weeks sofobuvir+ribavirin.35 - Group 12 weeks: SVR12= 50% (n=50/100) - Group 16 weeks: SVR12=73% (n=69/75) Break down by GT: - 12 weeksgroup; GT2 SVR12=86%; GT3 SVR12=30% - 16 weeksgroup; GT2 SVR12= 94%; GT3 SVR12=62%

POSITRON study in GT2 & GT3 intolerant to peg-IFN;sofosbuvir+weight- based ribavirin.36 -GT2: SRV12=93% -GT3: SRV12=61%Studies so far show a better outcome in GT2 treatment- experienced patients than in GT3 treatment-experienced patients with sofosbuvir+ribavirin.

Advanced liver disease

COSMOS trial: Phase IIa in GT1 prior null responders SOFOSBUVIR+SIMEPREVIR Cohort 1:prior null responders, metavir F0-F2, n=80. 77% GT1a, 50% baselines Q80K polymorphism, 70% IL 28B CT, 24% IL 28B TT genotype, 59% metavir F2. SVR12= 93% in GT1 null responders, treated with SOF +SIM for either 12 or 24 weeks. Cohort 2: tt na誰ve and prior null responders, metavir F3-F4, n=87. 78% GT1a subtype, 40% of those with baseline Q80K polymorphism, 56% had IL28B CT genotype and 23% had baseline IL28B TT genotype, 47% metavir F4, 54% prior null responders. Interim analysis cohort 2: SVR4: 100% in both GT1 na誰ve and prior null responders with metavir scores F3-F4 treated with simeprevir and sofosbuvir for 12 weeks. GT 2&3 experienced: PHOTON study: SOF+RBV37 Treatment experienced GT2 24 weeks SVR12 92% ( N=24) Treatment experienced GT3 24 weeks SVR12: 67% ( N= 17) See also FISSION, POSITROM; FUSION and VALENCE tables for more information. Still very few data for cirrhotic patients. Under study in cirrhotic pre- transplant patients.

GT1 NEUTRINO: sofosbuvir+Peg-IFN-riba among patients with cirrhosis, 80% achieved SVR12 SPARE: sofosbuvir+ribavirin: All stage fibrosis (n=50); advanced fibrosis/compensated cirrhosis (n=13/50). 2 subanalysis: - 24weeks, weight-based ribavirin (n=25): SVR12=72% - 24 weeks, low dose ribavirin (n=25): SVR12=56%. Note: relapse rates were 29% with weight-based ribavirin and 45% with low-dose ribavirin. (ref 11) See also COSMOS study results

GT2& GT3 FISSION38: 20 of 100 participants (20%) had compensated cirrhosis. 72% had GT3. Among people with cirrhosis at baseline who received sofosbuvir+ribavirin, 47% achieved SRV12. 38% of cirrhotic patients who received peg-IFN+riba achieved SVR12.

Interest

FUSION: 34% ( N=68)of participants had compensated cirrhosis at baseline. 31%achieved SVR12 in the 12 weeks group, and 66% achieved SVR12 in the 16weekgroup.Break down data by GT not available yet. (ref 20)

POSITRON (ref 20): 207 patients in the sofosbuvir+ribavirin group. 31 of them had compensated cirrhosis, 108 of them had GT2.99 had GT3. In GT2: SVR12= 93% In GT3: SVR 12=61% See tables for more info

HIGH: One tablet taken once daily with or without food. Should be used in combination with ribavirin, or in combination with pegylated interferon and ribavirin for treatment of Chronic Hepatitis C . Very good efficacy and safety profile (SVR12 > 90%), pan-genotypic, easy to use All oral regimen in GT2 (12 weeks SOF+RBV) , GT3 ( 24 weeks SOF+RBV) , GT1: either SOF+pegIFN+RBV 12 weeks ( FDA approved) or SOF+RBV 24 weeks if IFN intolerant GT4: SOF+pegIFN+RBV 12 weeks, encouraging data for all oral SOF+RBV 24 weeks (SVR4: 97%). Very limited data in GT 5 and 6. Limited data in case of liver advanced disease and cirrhosis, but it looks good Limited data in co-infected people, be aware no data with nevirapine and lopinavir-ritonavir Sofosbuvir ledispavir FDC under study: FDA approval expected in 2014.Potential for a shortened treatment regimen for GT1 naive and experienced all oral 12 weeks, or even 8 weeks in na誰ve. No data yet in other genotypes. DAAs should be studied in children Sofosbuvir is renal excreted no data on dose and safety in patients with impaired renal function ! IFN-free regimen available in 201439: Sofosbuvir+ribavirin (genotypes 2,3) Sofosbuvir+simeprevir (genotypes 1,4) Sofosbuvir+daclatasvir (genotypes 1,3,4-6)

Drug characteristics

Product

DACLATASVIR (DCV) Class

Daclatasvir: NS5A Inhibitor Companion drug: Asunaprevir (ASV): NS3 protease inhibitor BMS-791325: non-nucleoside inhibitor of the NS5B polymerase

BMS-790052: NS5a replication complex inhibitor

Company Daily dose

Bristol Myers Squibb DCV: 60 mg once daily ASV: 100mg twice daily, 200 mg tablet or 100mg softgel capsule BMS-791325: twice daily, 75 or 150mg tablet Phase III Yes 1,2,3,4,5,6 in vitro (for each of the three drugs) Adults Yes, no food restriction

Development Potent Genotype Universal Simple to administer Safety/ Tolerable / AE

In study DCV+ asunaprevir in treatment-experienced patients: 5 serious adverse events reported: high fever, gastroenteritis, elevated bilirubin (unrelated study drugs), hypochondria. 2 discontinuations for liver-enzyme elevation, 1 for elevated bilirubin. Other adverse events: headache, cold, diarrhoea, fever, stomach pain, malaise, constipation, back pain, appetite loss. DCV+ asunaprevir+ BMS-791325 study adverse events: headache, diarrhoea, asthenia No safety signal

DVC-ASV study AI447-026, No deaths were reported and the study discontinuation rate was low (12.6%, 28/222). There were low rates of serious adverse events (5.9%, 13/222) and few adverse events were reported in greater than 10% of patients. The most common adverse events reported were nasopharyngitis (30.2%, 67/222), increased ALT (15.8%), increased AST (12.6%), headache (15.8%), diarrhea (9.9%) and pyrexia (12.2%). A limited number of

Combinations and SVR

Grade 3-4 laboratory abnormalities were observed in greater than 3 percent of patients. The most common adverse event leading to discontinuation was ALT/AST elevation, a measure of liver inflammation. Of the 11 patients who discontinued due to an adverse event, 10 discontinued due to ALT/AST elevation. Despite early discontinuation, 80% of these patients achieved SVR24 and all ALT/AST values returned to normal.

GT1 treatment na誰ve AI444-040: DCV-sofosbuvir+/- ribavirin 24 weeks. SVR=100% in GT1, and > 85% in GT2 & GT3 regardless of ribavirin use.40

AI444-040: DCV+ sofosbuvir+/- ribavirin. Population: GT1, non- cirrhotic (n=126), 12 weeks (n= 82): SVR4= 9598%, 24 weeks(n= 44) SVR12= 93-100%.

AI443-014: DCV+ asunaprevir +BMS-791325,41 GT1 treatment naive, non-cirrhotic (n=32), 24weeks (n=16): SVR4=94%. 12 weeks (n=16) SVR24=94%42. Arm BMS 791325 75mg:overall SVR12: 88.8% SVR12 cirrhotics:100% (8/8 ) SVR12 non cirrhotics:91% ( 63/69) SVR12 Gt1a:91% (59/65) SVR12 GT1b: 100% (12/12) Total tt discontinuation:2,1 for adverse event, 1 for other reason.( more discontinuations in the 150mg arm) Arm BMS 791325 150mg:overall SVR 12: 89.5%43

D-LITE: Phase IIbpeg-IFN-lambda+ribavirin+ asunaprevir or DCV in treatment na誰ve, non-cirrhotic, early responders (n=69).44 -24 weeks, 4drugs asunaprevir (n=32). SVR12=75% (GT1a: 67%, GT1b: 91%, IL28b CC: 90%, IL28b non-CC: 68%) - 24-weeks, 4 drugs, DCV (n=37). SVR12=100%, all GT1b, IL28b: no impact.

LEAGUE: DCV+ simeprevir (SMV)+/- RBV 45 in GT1a and 1b na誰ve an null responders: It is important to highlight that DCV dose selection was 30mg, given the PK data showing a 2-fold increase in DCV( 60mg) exposure when dosed in combination with SMV (150mg).

Overall SVR12= 75-85% in treatment naïve Overall SVR 12 = 65-95% in prior null responders. Treatment duration did not have impact on probability of SVR, suggesting 12 weeks to be sufficient.in null responders the addition of ribavirin seems to increase SVR rate.

GT2& GT3 AI 444-040: DCV+sofosbuvir+/-ribavirin, in treatmentnaïvenon cirrhotic patients, GT2& GT3.46 -24 weeks, sofobuvir lead in, no ribavirin, (n=16). SRV24=88% - 24 weeks, no RBV (n=14). SRV24=100 % - 24 weeks, with RBV (n=10). SRV24=93%

HIV-HCV

Resistances

GT1: DCV-Peg-IFN-riba for 24 weeks followed by 24 weeks peg-IFN-riba “tail”. Phase III, recruiting. No clinically significant pharmacokinetic interaction between DCV and tenofovir. DCV dose adjustment with efavirenz and atazanavir/ritonavir may be needed. Well tolerated.48

Low genetic barrier to resistance (class effect)

GT4 DCV + Peg-IFN-ribaSVR12=100% in the 60mg group at week 12.47

Treatment experienced

HCV GT 1b Phase IIa, DCV-asunaprevir 24 weeks among a group of 21 null responders, and 23 IFN-ineligible/intolerant patients.49,50 SVR 24=77%. SVR24 was higher among null responders (91%) than among IFN-ineligible/intolerant people (64%).

AI 447-011: Phase II. HCV GT1, peg-IFN-ribavirin+ DCV+ asunaprevir once or twice daily: null responders (n=41) mostly GT1a, mostly non-CC 2 groups: -24 weeks, 4drugs (asunaprevir once daily) (N=21): SVR24= 95% -24 weeks, 4-drugs (asunaprevir twice daily) (n=20): SRV24=90%

GT1. IFN ineligible/ intolerant ( n=135)or non- responders ( n=87):DVC plus ASV (ribavirin free, IFN free) AI447-026: SVR24: 87.4% in IFN ineligible intolerant patients in Japan, 80.5% in prior non responders. and 91.9%

Advanced liver disease

Interest

SVR24among this population aged 65+, providing potential treatment alternative for many in Japan who currently have no options. In this study, the DCV+ASV regimen had low rates of discontinuation (5%) due to adverse events, and low rates of serious adverse events (5.9%)51

HCV1b, DCV+ asunaprevir, null responders, 16% with advanced fibrosis (n=38): once daily (n=20) SVR12=62%; twice daily (n=18) SVR 12=78%.52

Study AI444-040: GT1, GT2, GT3. 40% had absent to mild fibrosis (Metavir F0-F1), about half had moderate to advanced liver disease (F2-F3), and roughly 15% had cirrhosis (F4).

Note: very limited data in treatment naĂŻve or treatment-experienced patients with cirrhosis

Interest: High DCV: Pan-genotypic BUT: DVC + SOF will not be developed as FDC: access may only be possible for people who can afford to pay for both separate drug components. BMS is seeking approval for DVC in combination with SOF.

DCV+ asunaprevir + BMS 325: only developed for GT1 especially 1b. So limited interest for low and middle income countries as no pan-genotypic potential. DVC+ASV will be registered in Japan for GT1, essentially interesting for GT1b.

Dual DAA: DCV-sofosbuvir SRV=85-100% in GT1, GT2, GT3 treatment naive. Could potentially be a robust treatment option for resource limited settings, regardless of ribavirin use. Regulatory approval in Japan obtained for DCVâ&#x20AC;&#x201C;ASV in 2013.

Product

NS3 / 4 A Protease Inhibitor Companion drugs: ABT 333: NS5B RNA polymerase inhibitor ABT 267: NS5a inhibitor (pan-genotypic)

Drug characteristics

ABT-450/ritonavir Class

Abbott 100/100mg, 200/100mg twice daily Boosting with ritonavir required

(ABT 450/r)

Company Daily dose

Phase III Yes 1,2,3: under study, results pending Potent activity in vitro against GT 1-4 and 6.

Adults FDC ABT 450/ritonavir and ABT 267 co-formulated as 2 tablets once daily plus ABT-333 as 1 tablet twice daily

Development Potent Genotype Universal Simple to administer Safety/ Tolerability/adver se events

AVIATOR: 1% discontinuation 5 serious adverse events: 1 arthralgia possibly drug related Common adverse events: fatigue, headache, nausea, pain, vomiting, hyperbilirubinaemia, less than 2% patients interrupted treatment because of side effects in Aviator trial. No safety issues ABT 450/r â&#x20AC;&#x201C;ABT 267: well tolerated, no discontinuation due to adverse events o laboratory abnormalities.

ABT450/r â&#x20AC;&#x201C;ABT267 Pearl: 10% AE, no TT discontinuation due to AE, but 2 interruptions of study drug due to AE. 2 increase of ALT or ASAT grade 3.

Combinations And SVR

AVIATOR: GT1 non cirrhotic naïve and prior peg-rbv null responders53

ABT 450/r (dose100/100 mg to 200/100 mg) + ABT-267 ( 25mg daily) + ABT-333 (400mg twice daily) + ribavirin SVR 12 in GT1 treatment naïve=97.5% (n=77/79) SVR12 in GT1 null responders=93.3% (n=42/45) SVR12 in GT1a treatment naïve=96% (n=52/54) SVR12 in GT1a null responders=89% (n=25/28) SVR12 in GT1b treatment naive=100% (n=25/25) SVR12 in GT1b null responders=100% (n=17/17) Results from the 12 week triple DAA groups without ribavirin SVR12 in GT1=87.3% (n=69/79) SVR12 in GT 1a=83% (n=43/52) SVR12 in GT1b=96%(n=24/25) Note: cirrhosis excluded.

ABT450/r + ABT 333+ weight-based ribavirin in GT1 and previous non responders to peg-IFN-riba54 SVR12 RNA < 25 IU/mL at weeks 4-12 Treatment naïve ABT450/r 250mg+ABT-333 400mg(n= 19) SVR=95% Treatment naive ABT450/r 150mg+ ABT 333 400mg (n=14) SVR= 93% Previous non-responders ABT450/r 150mg+ ABT 333 400mg (n=17) SVR=47% ABT 450/r + ABT 333 + weight-based ribavirin: under study55 ABT 450/r + ABT 267 for 12 weeks in GT1b56: PEARL study SVR12: 95.2% in TT naïve people SVR12:90.0% in prior null responders

ABT 450/ +-ABT 267+- ABT333+-RBV : SAPPHIRE I, PEARL III, PEARL IV: phase III, GT1, tt naïve, 12 weeks:57 3 DAA+ RBV: Overall SVR12: 99.5%

Resistances

Low barrier to resistance (class effect)

3 DAA: overall SVR12: 99%

HCV/HIV coinfection Treatment experienced

No data yet Drug interactions are expected/Ritonavir ABT 450/r+- ABT 267+-ABT 333+- RBV: SAPPHIRE II, PEARL II, phase III, GT1, tt experienced, 12 weeks:58 SAPPHIRE II: n= 394 • All GT1 DAAs+RBV: SVR12= 96% • GT1 a 3 DAAs+RBV: SVR12 = 96% • GT1b 3 DAAs+RBV: SVR12 = 97% PEARL II: n= 179 • GT1b 3DAAs +RBV: SVR12= 97% • GT 1b 3 DAA: SVR12 = 100%

Advanced liver disease

Under study No data yet in treatment naïve or treatment-experienced cirrhotic patients

TURQUOISE II: phase III, GT1, tt naïve and experienced, compensated cirrhosis: 3 DAAs +RBV 12 weeks: SVR12 92% (n= 208) 3 DAAs +RBV 24 weeks: SVR 12: 96% (n= 172)

Interest

High Ritonavir booster required All-oral combination Results are available for GT1 only. Studies are needed for HCV/HIV co-infected individuals, those living with advanced liver disease, and treatmentexperienced patients. On-going trial in Egypt, in GT4.

Drug characteristics

Product

SIMEPREVIR = OLYSIO Protease Inhibitor Janssen/Tibotec/Medivir Gelule 150 mg once daily with food Phase III completed. FDA approved December 2013. Yes 1,4 Adults No

Simeprevir + Peg-IFN-riba:no increased serious adverse events compared to placebo. Adverse events: fatigue, flu-like symptoms, itching, headache, nausea. No difference in incidence of rash, anaemia, neutropenia by treatment group. Transient elevation in bilirubin levels in Simeprevir patients. SAE leading to treatment interruption: 0.9%. Rifampicine and rifabutine can decrease simeprevir virological response. No data in case of HBV co-infection.

Class Company Daily dose Development Potent Genotype Universal Simple to administer Indication

FDA: genotype 1 only. Need screening for NS3 Q 80 K polymorphism, Photosensitivity: sun block and avoid sun exposure during treatment59. AASLD guidelines: alternative regimen for patients that are interferon-ineligible: â&#x20AC;&#x153;. Daily sofosbuvir (400 mg) plus simeprevir (150 mg), with or without weight-based RBV (1000 mg [<75 kg] to 1200 mg [>75 kg] for 12 weeks is recommended for IFN-ineligible patients with HCV genotype 1 infection, regardless of subtypeâ&#x20AC;?60.

Safety/Tolerable /adverse events

Simeprevir + peg-IFN-ribaSVR24=78% Simeprevir + TMV 647055 (non-nucleoside HCV polymerase inhibitor) boosted ritonavir

France ATU: HCV genotype 4 in combination with peg-IFN and ribavirin for 12 weeks in people with metavir F4 with or without HIV co-infection, failing peg-IFN plus minus ribavirin treatment. Treatment duration and treatment interruption rules are adapted according to early treatment response.61

Combinations & SVR

Resistances Forgiving Genotype 1 naive

HCV/HIV coinfection

Simeprevir + sofosbuvir +/- ribavirin Simeprevir-DCV Simeprevir+ VX 135 Simeprevir + IDX 719

Simeprevir+pegIFN+RBV62: pooled data from QUEST I and II studies: SMV 150mgQD administered for 12 weeks with peg IFN+RBV: overall SVR12 80% rateLimited information available

Study C208: QUEST1 and study C126 QUEST2: compilation intend to treat analysis simerepvir peg-IFN ribavirin (ref 49): SVR12 = 80% (419/521). Results according to fibrosis level: fibrosis F0-2: SVR 12= 84% (317/378), fibrosis F3-4: SVR12 = 68% (89/130), F4: SVR 12 = 60% ( 29/48)

Co-administration with efavirenz is not recommended (efavirenz reduces the dose effect of simeprevir). Co-administration with ritonavir boosted or unboosted protease inhibitors is not recommended: darunavir, atazanavir, fosamprenavir, lopinavir, indinavir, saquinavir, tipranavir. Co-administration with delavirdine, etravirine, and nevirapine is not recommended. Raltegravir, rilpivirine, tenofovir , abacavir, ddi, emtricitabine, lamivudine, zidovudine, can be co-administered without dose adjustment. Co-administration of simeprevir with single dose tacrolimus or cyclosporine appears to be well tolerated with no serious adverse events.63 Co-administration with methadone does not require dose adaptation. See COSMOS trial in the Sofosbuvir section. C212 study: SIM 12 weeks +(peg IFN+RBV) till 48 weeks64: Overall SVR12: 74% Tt na誰ve: SVR12: 79% Relapsers: SVR12: 87% Partial responders: SVR12: 70% Null responders: SVR12: 57%

Treatment experienced

Simeprevir + peg-IFN-riba in prior relapsers, partial responders, null responders. Compared simeprevir dose (100mg vs150mg) and duration (12 vs24 vs48 weeks). The best results were seen in the 150mg dosing groups: prior relapsers (SVR=85%), prior partial responders (SVR=75%), and null responders achieved (SVR=51%). Simeprevir + sofosbuvir +/- ribavirin: COSMOS study: see Sofobuvir.

Genotype 4

PROMISE study simeprevir peg IFN ribavirin 24 to 48 weeks: SVR12 = 79% (206/260). Results according to fibrosis level: F0-2= 82% (137/167), F3-4: 73% ( 61/83), F4= 74% ( 29/39) See also ASPIRE results.

RESTORE study: ongoing. N=107. Preliminary results: SVR12= 7/9 (among 3 na誰ve and 6 failures to prior treatment)

Advanced liver disease

ASPIRE: Simeprevir+ peg-IFN-riba: 31% of prior null responders with cirrhosis were cured.65 ASPIRE enrolled about 462 treatment-experienced GT1 HCV patients - prior relapsers, partial responders, and null responders including people with advanced fibrosis or cirrhosis (METAVIR stage F4). They were randomly assigned to receive 100 or 150mg once-daily simeprevir or placebo with peg-IFN-riba for 12, 24 or 48 weeks; the 12 week and 24 week groups then continued on peg-IFN alone to week 48.66 SVR 24 in partial prior responders: 65% (15723), in nul prior responders: SVR24 = 53% ( 9/17).

PILLAR trial: 386 treatment-naive GT1 chronic HCV patients including people with advanced fibrosis (METAVIR stage F3). Participants were randomly assigned to receive 75mg or 150mg once-daily simeprevir or placebo in combination with peg-IFNalpha-2a and 1000-1200 mg/day weight-adjusted ribavirin for 12 weeks or 24 weeks.

In case of failure to previous treatment

Simeprevir: Interest is limited for resource limited settings: efficacy is on GT1a or b mainly, still need peg

!simeprevir 150mg in HCV GT1 treatment-experienced patients:33% response rate for prior null responders with advanced fibrosis/cirrhosis (very small number of patients)

Interest

IFN+RBN, photosensitivity reactions( need sun cream) , need to test NS3 Q 80 K polymorphism (presence of Q80k decreases efficacy in GT1 from quasi 50%), more drug interactions are expected, lack of dosing guidance in case of cirrhosis. High price. Sofosbuvir+ simeprevir: potential for a robust oral combination for GT 1 and 4, no FDA approval for this indication. Gilead does not want to pursue the cooperation. Simeprevir is excreted in bile, no data on dose and safety in Child B/C cirrhosis Product

FALDAPREVIR Protease Inhibitor- second generation HCV NS3/4a protease inhibitor BoehringerIngelheim

Drug characteristics

Class Company

Once daily, 120mg (treatment na誰ve), 240mg (treatment experienced)

BI 201335

Daily dose Phase III Yes 1 Adults Yes

Development Potent Genotype Universal Simple to administer Safety/Tolerable /adverse events

With peg-IFN-riba: Severe adverse events were reported in 11.8% of people in the 120mg BI 201335 group, 12.8 to 15.9% in the 240mg group, and 4.2% in the placebo group. Discontinuation rates: 4.4% in the 120mg group, 5.4% to 11.6% in the 240mg group, 1.4% in the placebo group. One death was reported in the placebo group. Discontinuations for rash, jaundice, and photosensitivity occurred only in the 240mg dosing groups. SOUND 2:

No serious adverse events Moderate adverse events lead to 9 treatment discontinuations (2 jaundice, 3 vomiting, 4 diarrhoea) in the 28 weeks treatment group. Laboratory abnormalities in the 28weekgroup: elevated bilirubin; 26% grade 3 ALT elevation and 10% grade 4; ALT elevation: 3% grade 3, and 2% anaemia. Peg-IFN-riba+ BI 201335 120mg or 240mg or placebo once daily.67 BI 201335 OD + BI 207127 (non-nucleoside polymerase inhibitor)+/- ribavirin

Low genetic barrier (class effect)

Combinations SVR

Peg-IFN-riba+ BI 201335 120mg or 240mg or placebo once daily. SVR in the Bi 201335 groups ranged from 71% to 83%.

SOUND-C2: 5 group trial to identify a DAA regimen that is effective for treatment na誰ve people with HCV GT1b and GT1a who have IL28B CC genotype.

Components: BI 201335 OD + twice vs thrice daily BI 207127 (non-nucleoside polymerase inhibitor) +/- ribavirin, 16 to 40 weeks treatment. - Non ribavirin group: SVR12=39% - BI 201335 + QD BI 207127 + ribavirin: SVR12=68% . in GT1a: SVR12=43% . in GT1b: SVR 12=83% . in CC GT: SVR12=79% . in non-CC GT: SVR12=64%

Resistances

Faldaprevir+ pegIFN+RBV in either tt na誰ve or HCV relapsers with Gt1 infection and stable HIV coinfection.69 Note: pegIFN+RBV was given for a total of 48 weeks.

Overall : SVR12 among individuals with GT1a, non=CC=32% SVR12 among GT1a, CC=75% SVR12 among GT1b, non CC=82% SVR12 among GT1b, CC=84%.68

HCV/HIV coinfection

2 doses of faldaprevir were compared: 240mg QD vs 120mg QD. FDV 120mg 24 weeks: SVR12: 71% FDV 240 mg 24 weeks: SVR 12: 72% Overall SVR12: 72%

Treatment experienced

Under study GT1 partial or null responders: SILEN-C2: -240mg BI 201335 OD +/-3 days peg-IFN-ribalead-in, or -BI 201335 QD+ 3 dayspeg-IFN-riba lead-in.

PK studies: FDV increasd raltegravir exposure by 2.5 fold and had no substantial effect on the PK of darunavir/ritonavir, efavirenz, or tenofovir.

Advanced liver disease

Medium Photosensitivity is an issue.

It is not yet sure whether or notthis drug will be further studied for treatment- experienced individuals.

SILEN-C3: treatment with 12 or 24 weeks of once daily 120mg BI 201335 and Peg/IFN,followed by response guided therapy peg-IFN-riba for 24 weeks). Was equally effective with SVR=65%vsSVR=73%.70

People with compensated cirrhosis: SOUND-C2: n=32. 25 of them had HCV GT1b.Overall the SVR12 with thrice-daily BI 207127 was 57%, versus 54% for twice daily Bi 207127 (and 33% for the no ribavirin group). In the 28week group: - Cirrhosis HCV GT1a twice daily dosing BI207127, SVR28:=71% - Cirrhosis GT1b SVR28=33%. SVR ranged from 27% (once-daily, with lead-in) to 31% (twice daily, with lead-in), up to 41% (once-daily, no leadin group). The highest SVR in partial responders was 50%; among null responders it was 35%.

Interest

Product

MK-5172: NS3/4A protease inhibitor MK-8742; NS5A inhibitor

Drug characteristics

Class Merck MK-5172: 100mg QD MK-8742: 50mg QD

MK-5172 MK-8742

Company Daily dose II Yes 1? Adults Yes Good, no discontinuation due to AE.

Development Potent Genotype Universal Simple to administer Safety/Tolerable /adverse events Combinations SVR

Resistances

C-WORTHY study7172 Part A: 12 week MK-5172+ MK-8742 +- RBV among 65 GT1 HCV monoinfected, tt na誰ve, non- cirrhotic patients. SVR12: 96-100%. Only one virologic failure was documented as a relapse at follow-up week 4. Part B: 12 weeks

HCV/HIV coinfection

C-WORTHY study: Part B: 12 weeks MK-5172+ MK-8742 +- RBVamong 403 GT1 infected patients, including 59 HIV/HCV GT1 co-infected, tt na誰ve, non- cirrhotic patients. Note: patients had to be stable on ART containing raltegravir + 2 NRTIs for at least 8 weeks prior to enrollment. Treatment week 12 results: HIV/HCV +RBV (n= 29) SVR 100% (20/20)

Treatment experienced Advanced liver disease Interest 1

HIV/HCV without RBV (n= 30), SVR: 93% (15/17) HCV mono + RBV (n= 52) SVR 100% (48/48) HCV mono without RBV (n= 13) SVR 100% (12/12) na na High?

Sovaldi package insert, available a t: www.gilead.com/~/media/.../sovaldi/sovaldi_pi.pdf. Accessed December 20, 2013 2 American Association for the Study of Liver Diseases (AASLD)/ Infectious Diseases Society of America ( IDSA). Recommendations for Testing, Managing, and Treating Hepatitis C: American Association for the Study of Liver Diseases (AASLD)/ Infectious Diseases Society of America ( IDSA). January 2014. nd Available at: http://www.hcvguidelines.org/full-report-view. Accessed April 2 2014. 3 US Food and Drug Administration. Approval of sofosbuvir tablets for the treatment of chronic hepatitis C infection. Available at: http://www.fda.goc/forconsumers/byaudience/forpatientsadvocates/ucm377920.htm. Accessed December 6, 2013. 4 Kowdley K, Lawitz E, Crespo I, et al. GS 7977+Peg/RBV in HCV genotype1: The ATOMICTrial. An end to response-guided therapy? 47th Annual Meeting of the European Association for the Study of the Liver.April 18-22 2012; Barcelona, Spain. Available from: http://mobile.ilcapp.eu/EASL_161/poster_23748/program.aspx (accessed November 12 2012). 5 Gilead. Presse Relase. Gilead Announces Sustained Virologic Response Rates from Two Phase 3 Studies of Sofosbuvir for Hepatitis C . www.gilead.com/pr_1786260. Published Feruary 19, 2013. Accessed February 19,2013. 6 Press Release Gilead. Gilead Announces 100 Percent Sustained Virologic Response Rate (SVR4) for an Interferon-Free Regimen of Sofosbuvir (GS-7977), GS-5885 and Ribavirin in Treatment-Na 誰ve Genotype 1 Hepatitis C Infected Patients. Phase 3 study with a fixed dose combination tablet of sofosbuvir and GS-5885 now underway. November 10,2012. Available at: http:// www.gilead.com/pr _1757156 7 Sulkowski M, Gardiner D, Lawitz E, et al. Potent viral suppression with all-oral combination of daclastavir (NS5A inhibitor) and GS-7977 (NS5B inhibitor) , +/ribavirin, in treatment-na誰ve patients with chronic HCV GT1,2 and 3 ( Abstract 1422). 47th Annual Meeting of the European Association for the Study of the Liver. April 18-22, 2012: Barcelona, Spain. Available from: http://mobile.ilcapp.eu/EASL_161/poster _24858/program.aspx.(Accessed November12, 2012). 8 Lawitz E, Rodriguez-Torres M, Cornpropst J, et al. The effect of hepatic impairment on the safety, pharmacokinetics and antiviral activity of GS- 7977 in hepatitis C infected subjects treated for seven days ( Abstract 1130). Paepr presented at: 47th Annual Meeting of the European Association for the Study of the Liver; 2012 April 18-22; Barcelona, Spain. Available from: http://mobile.ilcapp.eu/EASL_161/poster_24497/program.aspx.( Accessed on 2012 November 12).

Gilead Sciences (Press release). Gilead announces early sustained virologic response rates for GS-7977 plus ribavirin in genotype 1 treatment naïve hepatitis C patients. Interim results reported from ELECTRON and QUANTUM studies. 2012 April 18. Available from: http://www.gilead.com/pr_1684792. ) Accessed on 2012 November 12). 10 th Osinusi A et al. High efficacy of sofosbuvir with weight-based ribavirin for 24 weeks in difficult-to-treat patients. 20 Conference on Retroviruses and Opportunistic Infections, Atlanta, abstract 157LB, 2013. 11 Osinusi A, et al. 2High efficacy of sofosbuvir in combination with weight based ribavirin for 24 weeks in difficult to treat HCV infected Genotype 1 patients. th Abstract 157LB. 20 Conference on Retroviruses and Opportunistic Infection Atlanta, GA March 3-6 2013.http://www.natap.org/2013 12 th TAG 2012 pipeline report. Available at : www.pipeline report. Accessed December 10 ,2012. 13 Gilead press release. Data from phase 3 studies of Gilead’s Sofosbuvir for hepatitis C to be presented at 48th annual EASL meeting: findings published online today in the new England Journal of medicine. Available at: http://investors.gilead.com/phoenix.zhtml?c=69964&p=itol-news 14 Lawitz E, Mangia E, Wyles D, et al. Sofosbuvir for previously untreated chronic hepatitis C infection. NEJM. April 23,2013. Available at: http://www.nejm.org/doi/full/10.1056/NEJMoa1214853?viewType= 15 Sulkowski M, et al. All-oral therapy with sofosbuvir plus ribavirin for the treatment of HCV genotype 1,2,and3 infection in patients co-infected with HIV th (PHOTON-1). 64 Annual Meeting of the American Associatioj for the Study of Liver Diseases. Washington, CD Nov 1-4 2013. Http://www.natap.org/2013/AASLD/AASLD_34.htm 16 Gilead Sciences (Press release). Gilead announces early sustained virologic response rates for GS-7977 plus ribavirin in genotype 1 treatment naïve hepatitis C patients. Interim results reported from ELECTRON and QUANTUM studies. 2012 April 18. Available from: http://www.gilead.com/pr_1684792. (Accessed on 2012 November 12). 17 Gane EJ, Stedman CA, Hyland RH, et al. All-oral sofosbuvir-based 12-week regimens for the treatment of chronic HCV infection: the ELECTRON study. Program and abstracts of the 48th Annual Meeting of the European Association for the Study of the Liver; April 24-28, 2013; Amsterdam, the Netherlands. Abstract 14 18 Gane EJ, Stedman CA, Hyland RH, et al. Nucleotide polymerase inhibitor sofosbuvir plus ribavirin for hepatitis C. N Engl J Med. 2013;368:34-44. 19 Gane E. Once Daily Sofosbuvir/Ledipasvir Fixed-Dose Combination With or Without Ribavirin: Data From the ELECTRON Trials. 64rd Annual Meeting of the American Association for the Study of Liver DiseasesWashington, DC Nov 1-5 2013. 20 Gane EJ, Stedman CJ, Hyland RH, et al. Once daily sofosbuvir (GS-7977) regimens in HCV genotype 1–3: The ELECTRON trial (Abstract 229). Paper presented at: 63rd Annual Meeting of the American Association for the Study of Liver Diseases (AASLD); 2012 November 9–13; Boston, MA. 21 Lawitz E, Ghalib R, Rodriguez-Torres M, et al. Suppression of viral load through 4 weeks post treatment: results of a once-daily regimen of simeprevir +sofosbuvir with or without ribavirin in hepatitis C virus GT1 null responders. Abstract 155 LB. 20th Conference on Retroviruses and Opportunistic infections: 2013 March 3-6; Atlanta, Georgia. Available from: http://www.retroconference.org/2013b/Abstracts/47930.htm 22 http://www.finanzen.net/nachricht/Medivir_Results-from-the-COSMOS 23 Jacobson I, et al. SVR results of a once-daily regimen of simeprevir (SMV, TMC435) plus sofosbuvir (SOF, GS-7977) with or without ribavirin in cirrhotic and non-cirrhotic HCV genotype 1 treatment-naïve and prior null responder patients: The COSMOS study. 64rd Annual Meeting of theAmerican Association for the Study of Liver Diseases Washington, DC Nov 1-5 2013.

Gilead press release. Data from phase 3 studies of Gilead’s Sofosbuvir for hepatitis C to be presented at 48th annual EASL meeting: findings published online today in the new England Journal of medicine. Available at: http://investors.gilead.com/phoenix.zhtml?c=69964&p=itol-news 25 10: Lawitz E, Mangia E, Wyles D, et al. Sofosbuvir for previously untreated chronic hepatitis C infection. NEJM. April 23,2013. Available at: http://www.nejm.org/doi/full/10.1056/NEJMoa1214853?viewType= 26 Sulkowski MS, Gardiner DF, Rodriguez-Torres M, et al.; AI444040 Study Group. High rate of sustained virologic response with the all-oral combination of daclatasvir (NS5a inhibitor) plus sofosbuvir (nucleotide NS5b inhibitor) with or without ribavirin, in treatment-naive patients chronically infected with HCV GT 1, 2, or 3 (Abstract LB-2). Paper presented at: 63rd Annual Meeting of the American Association for the Study of Liver Diseases (AASLD); 2012 November 9– 13; Boston, MA 27 Sulkowski MS, Gardiner D, Rodriguez-Torres M, et al. Daclatasvir plus sofosbuvir for previously treated or untreated chronic HCV infection. N Engl J Med 2014; 370:211-221. January 16,2014. 28 Lawitz E, et al. Sofosbuvir and Ledipasvir Fixed-Dose Combination with and without Ribavirin in Treatment-Naïve and Previously Treated Patients with Genotype 1 Hepatitis C: The LONESTAR Study. 64rd Annual Meeting of the American Association for the Study of Liver Diseases Washington, DC Nov 1-5 2013. 29 Sofosbuvir + ribavirin in patients with genotypes 2 or 3: the VALENCE trial. AASLD November 2013. 30 Gilead press release: http://www.gilead.com/news/press-releases/2013/12/gilead-announces-svr12-rates-from-three-phase-3-studies-evaluating-ath oncedaily-fixeddose-combination-of-sofosbuvir-and-ledipasvir-for-genotype-1-hepatitis-c-patients. Accessed December 20 2013. 31 Kholi A, et al. Combination Oral, Ribavirin Free, Antiviral Therapy to Optimize Treatment Outcomes for Hepatitis C Treatment Naïve Patients: Interim Results from the NIAID SYNERGY Trial (6 & 12 weeks therapy) AASLD Nov 2013 32 Ruane PJ, et al. Sofosbuvir Plus Ribavirin in the Treatment of Chronic HCV Genotype 4 Infection in Patients of Egyptian Ancestry. 64rd Annual Meeting of the American Association for the Study of Liver Diseases Washington, DC Nov 1-5 2013. 33 Rodriguez-Torres.M, Gonzales.M, Rodriguez.J, Mathias .A, Symonds.B HIV/HCV coinfected and HCV monoinfected patients have similar early HCV viral kinetics with the potent HCV nucleotide polymerase inhibitor Sofosbuvir( SOF). Pres H-1921a.52nd Interscience Conference on Antimicrobial Agents and Chemotherapy, San Francisco, Abstract H-1921a, 2012. Available at : http://www.abstractsonline.com/Plan/Abstract/Print/View.aspx?mID= 34 Liz Highleyman. Sofosbuvir appears safe and effective for HIV/HCV co-infected people. Aidsmap. 13 September 2012. Available at: http://www.aidsmap.com/page/2514717/ 35 Press release Gilead. Gilead ’s Sofosbuvir for Hepatitis C Meets Primary Endpoint in Fourth Pivotal Phase 3 Study . February 19,2013, available at :w th ww.gilead.com/pr_1786260S. Accessed March 5 2013. 36 Gilead. Press release. Gilead Announces Sustained Virologic Response Rate of 78% From Phase 3 Study of Sofosbuvir for Genotype 2/3 Hepatitis C th Infected Patients . www.gilead.com/pr_1761988 . Published Nov 27,2012. Accessed November 29 , 2012. 37 st Naggie S et al. Sofosbuvir plus ribavirin for HCV genotype 1-3 infection in HIV coinfected patients (PHOTON-1). 21 Conference on Retroviruses and Opportunistic Infections (CROI 2014), Boston, abstract 26, 2014 38 Gilead press release. Gilead Announces Sustained Virologic Response Rates from Two Phase 3 Studies of Sofosbuvir for Hepatitis C fission and neutrino studies both meet primary endpoints and will support regulatory filing for sofosbuvir- February 4,2013.www.gilead.com/pr_17800873. Accessed February 4,2014.

Pawlotsky JM. Interferon alfa-free treatment of HCV. Session HCV and beyond. Conference on retroviruses and opportunistic infections 2014, March 3-6, Boston MA. 40 Sulkowski MS, Gardiner DF, Rodriguez-Torres M, et al.; AI444040 Study Group. High rate of sustained virologic response with the all-oral combination of daclatasvir (NS5a inhibitor) plus sofosbuvir (nucleotide NS5b inhibitor) with or without ribavirin, in treatment-naive patients chronically infected with HCV GT 1, 2, or 3 (Abstract LB-2). Paper presented at: 63rd Annual Meeting of the American Association for the Study of Liver Diseases (AASLD); 2012 November 9– 13; Boston, MA 41 Everson GT, Sims KD, Rodriguez-Torres M, et al. Aninterferon-free, ribavirin-free 12-week regimen of daclatasvir (DCV), asunaprevir (ASV), and BMS791325 yielded SVR4 of 94% in treatment-naive patients with genotype (GT) 1 chronic hepatitis C virus (HCV) infection (Abstract LB-3). Paper presented at: 63rd Annual Meeting of the American Association for the Study of Liver Diseases (AASLD); 2012 November 9–13; Boston, MA 42 Everson GT. Phase 2b Study of the Interferon-Free and Ribavirin-Free Combination of Daclatasvir, Asunaprevir, and BMS-791325 for 12 Weeks in Treatment-Naive Patients With Chronic HCV Genotype 1 Infection. AASLD 2013. 43 st Everson GT, Thuluvath PJ, Lawitz E. et al. All-oral combination of daclatasvir, asunaprevir and BMS -791325 for HCV genotype 1 infection. 21 Conference on Retroviruses and Opportunistic Infections, March 3-6, 2014; abstract 25. 44 Izumi N, Lataillade M, Chayama K, et al.; D-LITE Study Team. First report of peginterferon lambda/ribavirin in combination with either daclatasvir or asunaprevir in HCV genotype 1 Japanese patients: early sustained virologic response (SVR4) results from the D-LITE Japanese substudy (Abstract 284). Paper presented at: 63rd Annual Meeting of the American Association for the Study of Liver Diseases (AASLD); 2012 November 9–13; Boston, MA 45 st Zeuzem S, Hezode C, Bronowicki JPP, et al. Daclatasvir in combination with simeprevir+- ribavirin for hepatitis C viris genotype 1 infection. 21 conference on retroviruses and Opportunistic infections, March 3-6,2014; abstract 28LB. 46 Sulkowski MS, Gardiner DF, Rodriguez-Torres M, et al.; AI444040 Study Group. High rate of sustained virologic response with the all-oral combination of daclatasvir (NS5a inhibitor) plus sofosbuvir (nucleotide NS5b inhibitor) with or without ribavirin, in treatment-naive patients chronically infected with HCV GT 1, 2, or 3 (Abstract LB-2). Paper presented at: 63rd Annual Meeting of the American Association for the Study of Liver Diseases (AASLD); 2012 November 9– 13; Boston, MA 47 C Hezode, GM Hirschfield, W Ghesquiere, et al. BMS-790052, A NS5A Replication Complex Inhibitor, Combined with Peginterferon Alfa-2a and Ribavirin in Treatment-Naive HCV- Genotype 1 or 4 Patients: Phase 2b AI444010 Study Interim Week 12 Results. 62nd Annual Meeting of the American Association for the Study of Liver Disease (AASLD 2011). San Francisco, November 4-8, 2011. Abstract 227. 48 Bifano M. Assessment of HIV ARV Drug Interactions with the HCV NS5A Replication Complex Inhibitor BMS-790052 Demonstrates a Pharmacokinetic Profile which Supports Co-administration with TenofovirDisoproxilFumarate, Efavirenz, and Atazanavir/ritonavir. Paper 618. CROI 2012. 49 Chayama K, Takahashi S, Kawakami Y, et al. Dual oral combination therapy with the NS5A inhibitor BMS-790052 and NS3 protease inhibitor BMS-650032 nd achieved 90% sustained virologic response ( SVR12) in HCV genotype 1b-infected null responders. Abstract LB-4. Paper presented at: 62 Annual Meeting of the American Association for the Study of Liver Disease; 2011 November 4-8; San Francisco, SA. 50 Suzuki F, Ikeda K, Toyota J, et al. Dual oral therapy with the NS5a inhibitor daclastavir( BMS 790052) and NS3 protease inhibitor asunaprevir ( BMSth 650032) in HCV genotype 1b-infected null responders or patients ineligible/intolerant to pegylated interferon ribavirin. Abstract 2344. Paper presented at : 47 annual Meeting of the European Association for the study of the Liver; 2012 April 18-22; Barcelona, Spain. Available from :http://mobile.ilcapp.eu/EASL 161/poster_23762/program.aspx

Chayama k, et al. All-Oral Combination of Daclatasvir Plus Asunaprevir in Interferon-Ineligible Naïve/Intolerant and Nonresponder Japanese Patients Chronically Infected With HCV Genotype 1b: Results From a Phase 3 Trial –AASLD November 2013. 52 Lok AS, Gardiner DF, Hézode C, et al. Sustained virologic response in chronic HCV genotype (GT) 1-infected null responders with combination of daclatasvir (DCV; NS5a inhibitor) and asunaprevir (ASV; NS3 inhibitor) with or without peginterferon alfa-2a/ribavirin (PEG/RBV) (Abstract 79). Paper presented at: 63rd Annual Meeting of the American Association for the Study of Liver Diseases (AASLD); 2012 November 9–13; Boston, MA 53 Kris Kowdley, et al"A 12-Week Interferon-free Treatment Regimen with ABT-450/r, ABT-267, ABT-333 and Ribavirin Achieves SVR12 Rates (Observed Data) of 99% in Treatment-Naïve Patients and 93% in Prior Null Responders with HCV Genotype1 Infection". 63 rd Annual Meeting of the American Association for the Study of Liver Diseases, Boston, abstract LB-01, 2012 54 Poordad F et al. 12-week interferon-free regimen of ABT-450r+ ABT-333+ribavirin achieved SVR 12 in more than 90% of treatment –naïve HCV genotype1 infected subjects and 47% of previous non-responders. International Liver Congress, 2012. 55 Lawitz E et al. A 12-week interferon-free regimen of ABT-450r, ABT-072 and ribavirin was well tolerated and achieved sustained virological response in 91% of treatment-naïve HCV IL28B-CC genotype -1 infected patients. International Liver Congress, 2012. http://www.aidsmap.com/ Abbott-interferon-freeth HCV-combinations, International Liver Congre Barcelona, April 2012.published 23 April 2012. accessed November 27 2012. 56 Lawitz E, et al. Interferon- and Ribavirin-free Regimen of ABT-450/r + ABT-267 in HCV Genotype 1b-infected Treatment-naïve Patients and Prior Null Responders. AASLD Nov 2013. 57 st Ferenci P, et al. PEARL III: SVR > or = 99% after 12 weeks of ABT 450/r /267 +ABT 333+- RBV in treatment naïve HCV GT1b infection. 21 Conference on Retroviruses and Opportunistic Infections, March 3-6, 2014; abstract 29LB. 58 Abbvie press release: http://www.prnewswire.com/news-releases/abbvie-releases-first-of-six-phase-iii-results-from-investigational-all-oral-interferon-free12-week-regimen-showing-96-percent-svr12-in-genotype-1-hepatitis-c-patients-new-to-therapy-232329301.html. November 18, 2013. 59 US Food and Drug Administration. FDA approves new treatment for hepatitis C (simeprevir Olysio) , available at: http:// www.fda.gov/newsevents/newsrooom/pressannouncements/UCM376449.htm.Accessed November 22, 2013. 60 American Association for the Study of Liver Diseases (AASLD) / Infectious Diseases Society of America (IDSA). Recommendations for Testing, Managing, and Treating Hepatitis C: American Association for the Study of Liver Diseases (AASLD) / Infectious Diseases Society of America (IDSA). January 2014. nd Available at: http://www.hcvguidelines.org/full-report-view. Accessed April 2 2014. 61 ANSM. Janssen Therapeutics EMEA. ATU cohort simeprevir. November 2013. Available at: th http://ansm.sant.fr/var/ansm_site/storage/original/application/ff090a672c103cde88be13d9cc0.pdf. Accessed March 28 , 2013. 62 Jacobson.IM. Simeprevir (TMC435) with peginterferon/ribavirin for treatment of chronic HCV genotype 1 infection in treatment-naïve patients: efficacy in difficult-to-treat patient sub-populations in the QUEST-1 and 2 Phase III trials. AASLD 2013. 63 Ouwerkkerk-Mahadevan S et al. No clinically significant interaction between the investigational HCV protease inhibitor TMC 435 and the rd immunosuppressive cyclosporine and tacrolimus. 63 Annual meeting of the American Association for the Study of Liver disease. Boston, abstract 769,2012 64 st Dietrich D, Rockstroh J, Orkin C, e tal. Simeprevir plus peg IFN alfa 2a ribavirin in HIV/HCV co.infection (Study C212). 21 Conference on Retroviruses and Opportunistic infections, March 3-6, 2014; abstract 24.

Zeuzem S, Berg T, Gane E, et al. TMC 435 in HCV Genotype 1 patients. Who have failed previous pegylated interferon / ribavirin treatment: final SVR24 th results of the ASPIRE trial. 47 annual meeting of the European Association for the study of the Liver; 2012 April 18-22 Barcelona, Spain. Abstract 2. Available from: http://mobile.ilcapp.eu/EASL_161/poster_23749/programs.aspx 66 Poordad F et al. Efficacy and tolerability of TMC 435 150mg once daily with peginterferon alpha 2a and ribavirin for treatment of HCV genotype 1 infection rd in patients with Metavir score F3 and F4 ( PILLAR and ASPIRE trials). 63 Annual meeting of the American Association for the Study of Liver disease, Boston, abstract 769,2012. 67 Sulkowski M, Emanoil C, Asselah T, et al. Sustained virologic response and safety of BI 201335 combined with pegylated interferon alfa 2 a and ribavirin in th treatment naive patients with chronic genotype 1 HCV infection. 46 International Liver Congress; 2011 March 30-April 3; Berlin, Germany. Abstract 60/324 68 Zeuzem S, Soriano V, Asselah T, et al. SVR4 and SVR 12 with an interferon â&#x20AC;&#x201C;free regimen of BI 201335 and BI2007127 +/- ribavirin, in treatmentâ&#x20AC;&#x201C;naive th patients with chronic genotype-1 HCV infection: interim results of SOUND-C2 (Abstract 101). 47 A Annual meeting of the European Association for the Study of Liver disease; 2012 April 18-22; Barcelona, Spain. Available from: http://mobile.ilcapp.eu/EASL_161/poster_24354/program.aspx 69 st Haubitz S, Schaerer V, Ambrosini J, et al. Protease inhibitors to treat hepatitis X viruses in the Swiss HIV Cohort Study: high efficacy but low uptake. 21 Conference on Retroviruses and Opportunistic infections, March 3-6, 2014; abstract 658. 70 Dieterich D, Asselah T, GuyaderD, et al. SILEN-C3: treatment for 12 or 24 weeks with BI201335 combined with peg interferon alfa 2a and ribavirin in nd treatment naive patients with chronic genotype 1 HCV infection. Abstract 36.62 Annual meeting of the American Association for the Study of Liver disease.,2011 November 4-8; San Francisco, CA. 71 st Sulkowski M, Mallolas J, Bourliere M, et al. On-treatment viral response to MK-5172 /MK-8742+- RBV for 12 weeks in HIV/HCV co-infected patients. 21 Conference on Retroviruses and Opportunistic infections, March 3-6, 2014; abstract 6LB. 72 Rockstroh JK. Summary from CROI 2014 for hepatitis HCV direct acting antivirals (DAAs) in HCV and HIV/HCV coinfection: same outcome? Which DAA regime will allow for the shortest treatment duration? Conference reports for NATAP. Available at: http:// www.natap.org/2014/CROI_110.htm. Accessed rd April 3 , 2014.

Storage temperature (°C)

Point-of-care

Point-of-care; lateral flow casette

Shelf life (months) Test type

TABLE 4: SEROLOGICAL POINT-OF-CARE AND RAPID DIAGNOSTIC TESTS (RDTs) FOR HCV Volume required for testing

2-30

Point-of-care

Antigen used

1 drop

Point-of-care

Time to result (minute)

2-30

Manufacturer

1 drop

2-30

Point-of-care Point-of-care; immunofiltration

Test

10-20µL

15-30

Core, NS3, NS4

2-30

20-40

Specimen required for testing Oral fluid, whole blood, serum, plasma Oral fluid, whole blood, serum, plasma

10-20µL

OraSure Technologies Core, NS3, NS4, NS5 Whole blood, serum, plasma Whole blood, serum, plasma Whole blood, serum, plasma Whole blood, serum, plasma

OraQuick HCV Antibody Test*

Core, NS3 Core, NS3, NS4, NS5 Core, NS3, NS4, NS5 Core, NS3, NS4, NS5

SD Bioline HCV 5-20

5-20

Dual Path Platform Chembio Diagnostic test Systems 15-30 Multiplo Rapid HIV/HCV Antibody Test 3

20-30

MedMira Standard Diagnostics Human Diagnostics Worldwide Green Cross Medical Sciene

Point-of-care

Hexagon HCV Genedia HCV Rapid LF

1 drop

Point-of-care

Whole blood

Point-of-care

RDT

2-30

RDT

NA 2-8; after opening: <30

Whole blood, serum 30-40µL Whole blood, serum, plasma 10µL

2-30

4µL

2-8

RDT

Anti-HCV Antibody rapid test Tema Ricerca SERO-MED Labor SM-HCV rapid test Spezialitaten

80µL

Core, NS3, NS4 Core, NS3, NS4, NS5

Bioeasy HCV Test Bioeasy Diagnostica 10

Serum, plasma Whole blood, serum, plasma

2-8

Advanced Quality One Step HCV Test Bionike Serocard HCV Diagnos HCV BiDot

RDT RDT

Trinity Biotech

Serum, plasma

12 6-8

2-8 2-25

Lateral flow, casette

J. Mitra

45µL 45µL

Unknown

NA Core, NS3, NS4, NS5 Core, NS3, NS4, NS5 NA

2-30

5 10

10µL

Lateral flow, casette

J. Mitra MP Biomedicals

Serum, plasma Serum, plasma Whole blood, serum, plasma

Unknown

4-30

Unknown

Whole blood, serum, plasma

80-100µL

InTec Products 15 Guangzhou Wondfo Biotech 15

Core, NS3, NS4, NS5

Serum, plasma

Whole blood, serum, plasma

Lateral flow, casette

Lumiquick

structural & nonstructural antigens

HCV-Tri-Dot HCV Spot Rapid Anti-HCV Test One Step Hepatitis C Virus Quickview HCV ANTIBODY TEST CARD

10-20

Lateral flow, casette

Dialab

Whole blood, serum, plasma

HCV Ab

Core, NS3, NS4, NS5A

Lateral flow, casette

10-15

Bioland Ltd

10µL 4-30 4 drops serum, plasma; 1 drop whole blood 2-30 10µL serum, plasma; 20µL whole blood 4-30

NanoSign HCV

Compiled from the internal MSF laboratory working group review and from data from Shivkumar S, Peeling R, Jafari Y, et al. Accuracy of Rapid and Point-of-Care Screening Tests for Hepatitis C. Ann Intern Med 2012;157:558–566. *Eur 14 per test = ˜10x more expensive than other tests. Best test in terms of performance and good manufacturing practice. RDT=Rapid diagnostic test; NA=Not available

TABLE 5: SEROLOGICAL PIPELINE POINT-OF-CARE TEST FOR HCV Mbio Assay type Technological set-up Extraction method / sample preparation Target region Genotypes, subtypes Linear range Sensitivity / limit of detection Specificity Standardisation Time to result Throughput Sample type Sample volume

Controls Transport requirements Equipment required Indicative cost of equipment ($) Indicative cost per test (for reagents/cartridge) ($) Technical skill Laboratory set-up Storage conditions Applicable settings

Regulatory approval Reference

Prototype Hepatitis C Virus Antibody System HCV antibody reactivity; point-of-care immunoassay Single-use, disposable cartridges, simple, robust, low-cost reader No extraction required; direct addition of whole blood (finger stick or venous), plasma or serum Can be configured to detect antibodies against multiple HCV antigens (eg, core, NS3, NS4, etc) Not applicable Not applicable; dynamic range ~3.5 logs Limit of detection for analogous immunoassay (HIV p24 antigen) is ~20pg/mL For preliminary performance assessement see Lochhead, et al. J Clin Micro 2011; 49: 3584-3590. Multiple internal quality controls, and compatibility with external quality assurance standards < 20 minutes 80 - 100 tests per day (10 - 15 / hour) Whole blood (finger stick or venous), plasma, serum ~10 µL Multiple in-cartridge controls (sample addition, nonspecific binding); compatible with external quality assessment No cold chain required MBio Reader is portable, robust, and can be run on an internal rechargeable battery for up to 8 hours ~$5000 (USD) Volume dependent; competitive with visual read rapid diagnostic tests Minimally trained healthcare worker Access to power for battery recharge; battery provides 8 hours of operation target is 12 months at ≤40°C in original packaging Point-of-care, health post, district hospital, small and medium volume laboratories MBio Diagnostics expects ISO 13485 certification in the second quarter of 2013; HCV product still in development Manufacturer

TABLE 6: COMMERCIALLY AVAILABLE QUALITATIVE AMPLIFICATION TESTS FOR HCV

Technological set-up

Assay type

Uses the AMPLICOR® HCV Specimen Preparation Kit, version 2.0 Conserved 5´UTR and core region

Manual extraction, automated amplification and detection

Qualitative PCR with colourimetric detection

COBAS® AmpliPrep/COBAS® AMPLICOR HCV Test v2.0 (being discontinued)

WHO International Standard for HCV RNA 5 hours 10 - 94 samples / day (flexible)

Manual Conserved 5´UTR and core region

Semi-automated, open system

Qualitative target amplification-based nucleic acid probe test using Transcription-Mediated Amplification and chemiluminiscent detection

VERSANT® HCV RNA Qualitative Assay

Siemens

Extraction method / sample preparation Target region

1, 2, 3, 4, 5 and 6 50 IU/mL for EDTA plasma; 60 IU/mL for serum 99,99% WHO International Standard for HCV RNA, NIBSC code 96/790 Approx 8 hours Approx 3 hours; 24 samples / day

Plasma, serum 0.5 mL

Roche

Standardisation Time to result Throughput

Plasma, serum 200µL

Internal; external (optional): positive, negative

Hologic (Gen-Probe)

Not provided Not provided DTS 400: 400 results in 8hrs (kit is 100 tests) Fresh or frozen plasma (EDTA, sodium citrate, and ACD) or serum 0.5 mL Assay performance is monitored using an internal nucleic acid control added to each specimen with the Target Capture reagent; Internal Control: RNA transcripts in HEPES Buffer with detergent to monitor whole procedure from sample preparation to detection; Negative Calibrator and HCV Positive Calibrator to determine run validity and analyte and Internal Control cutt-offs Whole blood may be held and transported at room temperature for 24 hours prior to processing serum or plasma; Serum or plasma may be stored/transported at 28°C for 48 hours or frozen below -20°C for longer periods

APTIMA HCV RNA Qualitative Assay In-vitro nucleic acid amplification assay for the detection of HCV RNA; Validated on DTS 400 System; The assay utilizes Transcription-Mediated Amplification (TMA) to amplify conserved regions within the HCV genome (TMA utilizes Moloney Murine Leukemia Virus (MMLV) reverse transcriptase (RT) and T7 RNA polymerase to generate multiple RNA copies from viral nucleic acid template) Automated, closed system (the assay has 3 main steps performed in a single tube: sample preparation, target amplification and detection) Sample preparation involves detergent lysis of virus, followed by hybridization of free virus nucleic acid with capture oligonucleotides complementary to a conserved region of HCV genome (5'UTR); Hybridization steps take place in solution; Internal control or viral RNA hybridized targets are subsequently captured by magnetic microparticles and separated from remaining specimen components using a magnet; After wash steps to remove inhibitory substances, the target is ready for amplification Conserved 5´UTR region 1, 2, 3, 4, 5 and 6; and subtypes 2a, 2b, 3a, 4a, 5a, and 6a have all been tested using clinical specimens and transcripts of the 5'UTR region 5.3IU/mL (95% probability) 0,996

Requires refrigeration

DTS 400: 63,000

Hologic DTS 400 system (or DTS 800 or DTS 1600)

Luminometer (Siemens or any brand) Please contact manufacturer to discuss project specific pricing

1, 2, 3, 4, 5 and 6 5.3 IU/mL 99,60%

Sample type Sample volume

AMPLICOR® HCV (–) Control and the AMPLICOR® HCV (+) Control

Refrigerated item (4-8°C) COBAS® AMPLICOR Analyzer & 3rd party equipment as described on package insert

Genotypes, subtypes Sensitivity / limit of detection Specificity

Controls

Equipment required

Cobas®Amplicor® 30,000

Transport

Indicative cost of equipment (USD $)

Indicative cost per test (for reagents) (USD $) Technical skill Laboratory set-up Storage conditions Applicable settings Regulatory approval Advantages Disadvantages

Reference

49-56 Medium-highly trained, precision pipetting required at low volumes Specialised; 2-3 dedicated areas are required Not provided

Highly trained, precision pipetting required at low volumes

Please contact manufacturer to discuss project specific pricing

Highly trained, precision pipetting required at low volumes

80 (US Price Catalogue: $8000 for 100 test Kit)

http://www.gen-probe.com/products-services/aptima-hcvqualitative-kit; Manufacturer

Not for monitoring of patients

Not provided -15°C to -35°C: box 1; 2°C to 8°C upon receipt: box 2; 15°C to 30°C upon receipt: box 3 Developed / highly resourced settings CE-IVD; US-FDA-IVD

2-8°C -15°C to -35°C: box 1; 2-8°C: box 2; 15-30°C: box 3 Developed / highly resourced settings Developing, low-medium resourced settings CE-IVD CE-IVD; US-FDA-IVD Extremely high sensitivity, superior to RT-PCR-based qualitative HCV RNA detection assays Not for monitoring of patients; phasing out plan fourth quarter of 2013 Not for monitoring of patients http://www.medical.siemens.com/webapp/wcs/stores/servle t/ProductDisplay~q_catalogId~e_101~a_catTree~e_100001,1023815,1023070,1015865~a_l http://molecular.roche.com/assays/Pages/COBASAmpliPre angId~e_pCOBASAMPLICORHCVTestv20.aspx; package insert; 101~a_productId~e_172984~a_storeId~e_10001.html; manufacturer package insert; manufacturer

Disclaimer: price is subject to region and can differ from one market to another; in addition, final pricing within a region is also subject to training, installation, technical support and other requirements.

TABLE 7: PIPELINE QUALITATIVE AMPLIFICATION TESTS FOR HCV WAVE80 Assay type Technological set-up Extraction method / sample preparation

Target region Genotypes, subtypes Sensitivity / limit of detection Specificity Standardisation Time to result

Throughput Sample type

Sample volume Controls Transport Equipment required Indicative cost of equipment ($) Indicative cost per test (for reagents) ($) Technical skill Laboratory set-up Storage conditions Applicable settings Regulatory approval Advantages Disadvantages Reference

EOSCAPE-HCV-D Isothermal target amplification with bipartite photonic signaling Disposable cartridge, processing unit and analyzer Integrated sample preparation Genotype: NS5b and E1 regions; detection: 3â&#x20AC;&#x2122;-X-tail (highly conserved >99%) 1, 2, 3, 4, 5 and 6 <10-15 IU/mL >98% External calibration for linear range (>100,000 IU/mL) <1 hour Parallel processing with multiple processing units (up to 10 processing units per analyzer) Whole blood (capiliary), plasma 100ÂľL, acquired through fingerstick using standard lancets through protocol developed by Wave 80 IAC on-board No cold chain requirement EOSCAPE analyzer <10,000 20 CLIA moderate complexity Not specialised, laboratory or point-ofcare Refrigeration may be required for external calibrants Resource-poor, low-medium resourced settings CE-IVD; US-FDA-IVD to be sought Low cost, point-of-care, easy to use, same device for all their tests Manufacturer

TABLE 8: COMMERCIALLY AVAILABLE GENOTYPING TESTS FOR HCV Abbott

Roche

CLIP Sequencing; produces bi-directional sequences using two fluorescentlyReal time PCR with 2-channel fluorescent labeled DNA primers detection

Sacace

VERSANT® HCV Genotype 2.0 Products (LiPA) Line probe assay (LiPA) uses reverse hybridization. Biotinylated DNA PCR product, generated by RTPCR amplification of the 5'UTR and core region of HCV RNA, is hybridized to immobilized oligonucleotide probes.

Semi-automated, closed system Automated or manual, open system Manual (any nucleic acid extraction kit; Previously amplified product used with Sacace recommend their own one) or TRUGENE HCV 5’NC Genotyping Kit and automated (e.g. NucliSens® easyMAG™ OpenGene® DNA Sequencing System (bioMérieux))

Siemens

Automated, closed system Automated (using the strip processors Auto LiPA 48 or AutoBlot 3000H); PCR product is produced using the VERSANT HCV Amplification 2.0 Kit (LiPA) after extraction of viral RNA

Siemens

Conserved 5´UTR, core regions and NS5b

5'UTR 5'UTR 6 major hepatitis C genotypes and 41 subtypes 1a, 1b, 2, 3, 4, 5a, 6

HCV Genotype Plus Real-TM

Qualitative real-time PCR using fluorescently-labelled probes; 3 separate reactions required: A (GT 1a, C), B (GT 1, 1b, 2), and C (GT 4, 5, 6) Linear array Fully automated or manual, closed system Manual, closed system

1a, 1b, 2, 3, 4, 5 and 6 (subtypes c-l)

NA NA

4µL of amplicon

16 samples / day plasma, serum

2-8°C (max 3-4 days)

internal; external: positive, negative

0.1-1.0 mL

50 samples / day Plasma

Dependent on the extraction method used (~40 min using Ribo-Virus Sacace kit)

Dependent on the extraction method used (~120 min)

external: positive, negative

OpenGene DNA sequencing system Please contact manufacturer to discuss project specific pricing Please contact manufacturer to discuss project specific pricing Medium-highly trained, precision pipetting required at low volumes Specialised; 2-3 dedicated areas are required

2-8°C: Part N°1; -20°C: Part N°2 and N°3

Specialised; 2-3 dedicated are required

20 (without extraction) Medium-highly trained, precision pipetting required at low volumes

-20°C

Sacace (or any) real time PCR instrument with 2 fluorescent channels; optional automated sample prep instrument SaCycler real time PCR instrument, 20,000

requires refrigeration

TRUGENE® HCV Genotyping Assay

Technological set-up

Conserved 5´UTR, core region and NS5b Conserved 5'-UTR and core region

Manual or automated (m24sp or m2000sp)

1, 2, 3, 4, 5 and 6

96% 99.4%

LINEAR ARRAY HCV Genotyping Test (being discontinued)

Extraction method / sample preparation

≤500IU/mL 99.99%

RealTime HCV Genotype II

Target region

unknown

NA NA Approx 8 hours for 48 samples: ~2.7 hours for amplification and ~3.3 hours for strip processing with AutoLiPA 48 (both fully hands-off processes) 30 minutes

Assay type

Genotypes, subtypes

1a, 1b (NS5b), 1, 2, 3, 4, 5, 6 (5'UTR) ≥500 IU/mL, 0.5 mL prep; ≥1250 IU/mL, 0.2 ml prep ≥ 97.0% Second WHO international standard for HCV RNA (NIBSC 96/798)

Approx 3 hours

Manual using the AMPLICOR® HCV Specimen Preparation Kit, version 2.0

Standardisation

Manual 10.5 hr; m2000 6 hours

Sensitivity / limit of detection Specificity

Time to result

1000 IU/mL; 100% 100% 4th WHO International Standard for HCV RNA

Hands-on time per patient sample

Throughput Sample type Sample volume

Controls Transport

Equipment required Indicative cost of equipment (USD $) Indicative cost per test (for reagents) (USD $) Technical skill

m24sp or m2000sp (sample preparation) plus m2000rt (amplification + detection) Please contact manufacturer to discuss project specific pricing Please contact manufacturer to discuss project specific pricing Medium-highly trained, precision pipetting required at low volumes Specialised; 1 dedicated area is required -10°C: reagens kits A, B and C; internal control; + and -B3 controls

Manual 13 min; m2000 4 min Approx 10 hours 30 minutes 96 samples / day with VERSANT kPCR SP module and 2x Auto-LiPA 48. Scalable strip processing automation: up to 48 tests with the AutoLiPA 48; up 48 samples / day 24 samples / day to 20 tests with the AutoBlot 3000H Plasma, serum plasma, serum plasma, serum 100µL of denatured amplicon (using Depends on extraction method used; 10µL of 0.2 mL or 0.5 mL COBAS AMPLICOR detection material) amplicon Internal; external: positive (5000 IU/mL of VERSANT HCV Control 2.0 Kit (LiPA): 3 control GT1 and GT4 of RNAs diluted in HCV AMPLICOR® HCV (–) Control and the lines: conjugate control, 2 amplification controls negative plasma) and negative AMPLICOR® HCV (+) Control (5'UTR and core), negative control Requires refrigeration and freezing (amplification kit Requires refrigeration (ship on dry ice) Requires refrigeration (4-8°C) only) Auto LiPA 48 or AutoBlot 3000H; VERSANT® HCV COBAS® AMPLICOR Analyzer & Genotype 2.0 Assay (LiPA); Amplification 2.0 Kit; 3rd party equipment (as described on Control 2.0 Kit; LiPA Scan HCV Interpretation package insert) Software Please contact manufacturer to discuss project COBAS® AMPLICOR® 30,000 specific pricing Including extraction, detection and Please contact manufacturer to discuss project genotyping 94-111 specific pricing Highly trained, precision pipetting required Medium-highly trained, precision pipetting required at low volumes at low volumes Specialised; 3 dedicated areas Specialised; 2-3 dedicated areas are required are required 2-8ºC for Genotype kit; -25ºC to -15ºC for 2-8°C Amplification kit

Laboratory set-up Storage conditions

Applicable settings Regulatory approval

Advantages Disadvantages

Reference

Developed / highly resourced settings CE-IVD

HCV viral load and HCV genotyping on one automated platform; results obtained more rapidly compared to sequencingbased assays (1.5 days) Does not bind to unusual subtypes http://www.abbottmolecular.com/products/ infectious-diseases/realtime-pcr/hepatitishcv-genotype-II-assay.html; Abbott broshure (package insert not found online); manufacturer

NA=Not available; RUO=research use only

http://healthcare.siemens.com/moleculardiagnostics/molecular-diagnostics-systems/versanthcv-genotype-2-products; package insert; manufacturer

Both developed and developing settings, highly Developed / highly resourced settings resourced CE-IVD CE-IVD; RUO in the USA It is the only commercially available assay able to detect 6 (c-l). Only 4% of clinical specimens are mistyped with the VERSANT genotype assay relative to the reference method (direct sequence Fast turn around time with minimal hands analysis of the NS5B region), which makes it the on time most accurate method for use in clinical practice. phasing out plan fourth quarter of 2013 http://molecular.roche.com/ASSAYS/Page s/LINEARARRAYHepatitisCVirusGenotypi ngTestv2.aspx (package insert not found on line); manufacturer

Both developed and developing settings, Resource-poor, low-medium resourced highly resourced settings no, RUO None Compared to other methodologies that require hybridization of the HCV virus, the TRUGENE速 HCV Genotyping Assay directly amplifies and sequences the virus allowing direct examination of the viral RNA. Low cost, flexible Not regulatory approved http://healthcare.siemens.com/moleculardiagnostics/molecular-diagnosticsresearch-use-only/trugene-hcvgenotyping-assay; package insert; http://www.sacycler.com; package insert; manufacturer manufacturer

TABLE 9: PIPELINE GENOTYPING TEST FOR HCV WAVE80 EOSCAPE-HCV-G

Assay type Technological set-up Extraction method / sample preparation

Target region Genotypes, subtypes Sensitivity / limit of detection Specificity Standardisation Time to result Hands-on time per patient sample

Throughput Sample type

Sample volume Controls Transport Equipment required Indicative cost of equipment (USD $) Indicative cost per test (for reagents) (USD $) Technical skill Laboratory set-up Storage conditions Applicable settings Regulatory approval Advantages Disadvantages Reference

Epistem HCV genotype, VL and IL-28B (multiplex)

Isothermal target amplification with bipartite photonic signaling See info under viral load pipeline tests Disposable cartridge, processing unit and analyzer Integrated sample preparation Genotype: NS5b and E1 regions; detection: 3â&#x20AC;&#x2122;-X-tail (highly conserved >99%) 1, 2, 3, 4, 5 and 6 <10-15 IU/mL >98% External calibration for linear range (>100,000 IU/mL) <1 hour Blood draw Parallel processing with multiple processing units (up to 10 processing units per analyzer) Whole blood (capiliary), plasma 100ÂľL, acquired through fingerstick using standard lancets through protocol developed by Wave 80 IAC on-board No cold chain requirement EOSCAPE analyzer <10,000 50 CLIA moderate complexity Not specialised, laboratory, or point-ofcare Refrigeration may be required for external calibrants Resource-poor, low-medium resourced settings CE-IVD; US-FDA-IVD to be sought low cost, point-of-care, easy to use, same device for all their tests Manufacturer

COBAS® Ampliprep®/COBAS® TaqMan® HCV Test, v2.0

TABLE 10: COMMERCIALLY AVAILABLE VIRAL LOAD TESTS FOR HCV Abbott COBAS® TaqMan® HCV Test, v2.0 with VERSANT® HCV RNA 3.0 Assay the use of Highpure (bDNA)

Roche

quantitative real time PCR using fluorescently-labeled probes automated, closed system

bDNA signal amplification using ELISA with chemiluminescent detection automated, closed system

Reverse transcription (RT) kinetic polymerase chain reaction (kPCR) procedure for quantifying HCV RNA in human serum and plasma

VERSANT® HCV RNA 1.0 Assay (kPCR)

Siemens

fully automated or manual, closed system fully automated, closed system

RealTime HCV assay

Assay type

quantitative real time PCR using fluorescently-labeled probes; automated specimen preparation on the COBAS® AmpliPrep Instrument by a generic silicabased capture technique with magnetic quantitative real time PCR using glass particles (MGP) fluorescently-labeled probes manual extraction automated amplification and detection

Technological set-up

Sacace

automated or manual, open system manual (any nucleic acid extraction kit; Sacace recommend their own one) or automated (e.g. NucliSens® easyMAG™ (bioMérieux)) 5'UTR 1, 2, 3 ,4, 5, 6

quantitative real time PCR assay incorporating QIAGEN magnetic particle technology for sample preparation and one-step RT-PCR enzyme which enables quantitative real time PCR using reverse transcription and real-time PCR fluorescently-labeled probes and dualreactions in a single tube colour detection automated (QIAsymphony SP/AS instrument), open system

HCV Real-TM Quant

20 -108 IU/ml

artus HCV QS-RGQ PCR Kit

sample prep and assay set-up can be run on QIAsymphony SP/AS instrument conserved 5´UTR and core region 1, 2, 3, 4, 5, 6

QIAGEN careHCV RT-PCR Kit V2 (from the Shenzhen subsidiary) quantitative real time PCR assay incorporating QIAGEN silica membrane column purification technology for sample preparation and one-step RT-PCR enzyme which enables reverse transcription and real-time PCR reactions in a single tube automated (QIAcube) or manual, open system manual (Qiagen viral RNA mini kit) or automated (on QIACube); sample preparation reagents are included in the kit conserved 5´UTR and core region 1, 2, 3, 4, 5, 6

10 IU/ml; 100% (new kit)

automated using VERSANT kPCR Molecular System conserved 5’ UTR 1, 2, 3, 4, 5 and 6 15 IU/mL (64.5 copies/mL) to 1 x 108 IU/mL (4.3 x 108 copies/mL) 15 IU/mL (64.5 copies/mL) to 1 x 108 IU/mL (4.3 x 108 copies/mL)

manual extraction (High Pure System Viral Nucleic Acid Kit) conserved 5´UTR and core region 1a, 1b, 2a,2b, 3, 4, 5 and 6

35.0 to 1.77 x 107 IU/ml

615 IU/mL

no sample extraction required conserved 5´UTR and core region 1, 2, 3, 4, 5 and 6 615 to 7,690,000 IU/mL (2.79 to 6.89 log IU/mL)

1 KIT CAP/CTM HCV QUANT 72T v2.0 conserved 5´UTR and core region 1a, 1b, 2a,2b, 3, 4, 5 and 6

21 IU/ml

25 to 390,000,000 IU/mL

unknown

Extraction method / sample preparation Target region Genotypes, subtypes

1x103 - 5x107 IU/ml

15 IU/ml

500 IU/ml 100% (tested against the national standard panel (China) for common infectious disease, which includes HAV, HBV, HIV, HDV, CT, NG, CMV, HPV, TB, and showed no cross reactivity) 2nd WHO International Standard for HCV RNA (NIBSC code 02/202)

15 to 100,000,000 IU/mL

3 hr

15 IU/ml

100% WHO 3rd Hepatitis C Virus (HCV) RNA International Standard (06/100)

manual or automated (m24sp or m2000sp) conserved 5´UTR and core region 1, 2, 3, 4, 5 and 6 12 IU/mL (1.08 log IU/mL) to 100 million IU/mL (log 8.0 IU/mL) 12 IU/mL, 0.5 ml sample; 30 IU/mL, 0.2 ml sample

Linear range Sensitivity / limit of detection

Specificity

≤6 hrs

VERSANT kPCR Molecular System

Please contact manufacturer to discuss project specific pricing Please contact manufacturer to discuss project specific pricing Highly trained, precision pipetting required at low volumes

dry ice or blue ice Rotor-Gene Q real time PCR cycler plus QIAcube (optional); other real-time PCR instruments such as ABI7300/7500, LC480, and i-Cycler are also compatible and have been validated for use

Specialised; 2 dedicated areas are required

Please contact manufacturer to discuss project specific pricing Please contact manufacturer to discuss project specific pricing Highly trained, precision pipetting required at low volumes

Rotor-Gene Q real time PCR cycler plus QIAsymphony SP/AS instrument

Specialised; 2-3 dedicated areas are required

17 (without extraction) Highly trained, precision pipetting required at low volumes

Sacace (or any) real time PCR instrument with 2 fluorescent channels; optional automated sample prep instrument

unknown plasma 1000 µl

100% 100% 2nd WHO International Standard for HCV 4th WHO International Standard for HCV RNA (NIBSC code 02/202) RNA (NIBSC code 96/798) it depends on the used extraction method (~120 min)

22 hr

≥ 99.5% second WHO international standard for HCV RNA (NIBSC 96/798)

98.8% WHO International Standard for HCV RNA

manual: 10.5 hr; m2000: 6 hr

5.5 hr

Standardisation

100% First WHO International Standard HCV RNA (NIBSC code 96/790)

Time to result

100 samples plasma 0.1-1,0 ml internal; external: low positive, high positive, negative

Throughput Sample type Sample volume

refrigeration required (4-8°C)

2.15 hr; ≤48 samples / d plasma, serum 500 µl internal (quantitation std); external: low positive, high positive, negative

2-8°C (max 3-4 days)

refrigeration required (4-8°C)

100% First WHO International StandardHCV RNA (NIBSC code 96/790) ~ 5.5 hours (including setting-up the COBAS® AmpliPrep Instrument) ~30 minutes per 48 tests (0.6 minutes/patient sample); 72 samples/day up to 168 samples/day plasma, serum 650 µl internal (quantitation std); external: low positive, high positive, negative

internal; external: positive, negative

96 samples / d plasma, serum 0.5 ml or 0.2 ml internal; external: low positive, high positive, negative

dry ice or blue ice

refrigeration required (ship on dry ice)

89 samples / batch = 178 samples / d 72 samples / d plasma, serum plasma, serum 500 µl 200 µl external: low positive, high positive, negative internal; external: positive, negative Box 1 refrigerated; Box 2 deep frozen @ 60 to -80ºC

Controls

12 – 168 samples / run plasma, serum 50 µl external: low positive, high positive, negative refrigeration required (Box 1) and deepfreezing @ -60 to -80ºC (Box 2)

Transport

m24sp or m2000sp (sample prep) plus m2000rt (amplification + detection)

Specialised; 2-3 dedicated areas are required

www.qiagen.com/Products/.../artus-HCVRT-PCR-Kits-CE; package insert; http://www.sacycler.com; package insert; manufacturer manufacturer yes yes

not yet regulatory approved

CE certification on-going

SaCycler real time PCR instrument, 20,000

Please contact manufacturer to discuss project specific pricing Please contact manufacturer to discuss project specific pricing Highly trained, precision pipetting required at low volumes Specialised; can be set up in one-room; deep-freezing (-20ºC) required for kit storage

2-8°C: Part N°1; -20°C: Part N°2 developing, low-medium resourced settings

Specialised; 2-3 dedicated areas Not specialised; single work area; are required deep-freezing required 2-8°C: COBAS TaqMan HCV v2.0 48 Tests 2-30°C Highpure Viral Nucleic Acid kit 48 tests

-20oC

Specialised; 1 dedicated area only 2-8°C: COBAS AmpliPrep/COBAS TaqMan HCV v2.0 Test; 2-30°C: COBAS AmpliPrep/COBAS TaqMan Wash Reagent

CE-IVD, US-FDA-IVD

2-8°C: box 1; -60°C to -80°C: box 2 -20ºC for Boxes 1 & 2 Both developed and developing settings, highly resourced Developed / highly resourced settings

Developed / highly resourced settings

-20oC developing, low-medium resourced settings CE-IVD, US-FDA-IVD, Canada-IVD

CE-IVD; not available in the US

Developed / highly resourced settings CE-IVD, US-FDA-IVD, Canada-IVD, Japan-IVD

COBAS® AmpliPrep (sample prep) plus COBAS® TaqMan® 48 Analyzer COBAS® TaqMan® Analyzer or (amplification and detection) & 3rd party COBAS® TaqMan® 48 Analyzer equipment such a centrifuge with a plate (amplification and detection) rotor as described on package insert VERSANT 440 Molecular System Cobas®Ampliprep® 80-100,000; Cobas® TaqMan96 Analyzer with docking station 110,000 or Cobas®TaqMan® 48 Please contact manufacturer to discuss Analyzer 40-50,000 Cobas®TaqMan® 48 Analyzer 40-50,000 project specific pricing Please contact manufacturer to discuss 42-52 52-64 project specific pricing Medium-highly trained, precision pipetting Medium-highly trained, precision pipetting Medium trained, basic precision pipetting required at low volumes required at low volumes

Equipment required

Indicative cost of equipment ($) Indicative cost per test (for reagents) ($)

Specialised; 1-2 dedicated areas are required

-10°C: amplification reagent pack and internal control, control kit, calibrator kit

Please contact manufacturer to discuss project specific pricing Please contact manufacturer to discuss project specific pricing Medium-highly trained, precision pipetting required at low volumes

Developed / highly resourced settings

Technical skill

Storage conditions

CE-IVD; US-FDA-IVD

Laboratory set-up

Applicable settings

low cost, flexible

http://www.qiagen.com/about/pressreleas es/pressreleaseview.aspx?PressReleaseI D=337 (package insert not found online) no

China (SFDA) CE-IVD careHCV test designed for use in areas with limited resources or infrastructure; first locally-manufactured PCR test in the domestic market that can be used in conjunction with automated sample technology solutions, such as QIAGEN's QIAcube, which limits hands-on time

ELISA-like format; single-room technology Due to the potential for false-positive results, this assay should NOT be used for initial detection of hepatitis C virus (HCV) RNA in patients with suspected acute or chronic HCV infection. It should be used to quantify HCV RNA in patients who have been found to be positive by a more sensitive HCV RNA detection or quantification assay. http://healthcare.siemens.com/molecular- http://www.medical.siemens.com/webapp http://molecular.roche.com/assays/Pages/ http://molecular.roche.com/assays/Pages/ diagnostics/molecular-diagnostics-in-vitro- /wcs/stores/servlet/PressReleaseView~q COBASAmpliPrepCOBASTaqManHCVTe COBASAmpliPrepCOBASTaqManHCVTe diagnostics/versant-hcv-rna-3_catalogId~e_http://www.abbottmolecular.com/products/ st.aspx; st.aspx; assay/features; 1~a_catTree~e_100005~a_langId~e_infectious-diseases/realtime-pcr/hepatitis- http://molecular.roche.com/assays/Pages/ http://molecular.roche.com/assays/Pages/ http://www.mayomedicallaboratories.com/ 1~a_pageId~e_144756~a_storeId~e_100 hcv-assay.html; Abbott broshure; COBASTaqManHCVTestv20HPS.aspx; COBASTaqManHCVTestv20HPS.aspx; test-catalog/print/81130; package insert; 01.htm (package insert not found or package insert; manufacturer package insert; manufacturer package insert; manufacturer manufacturer provided); manufacturer yes yes yes yes yes

Regulatory approval

Advantages

Disadvantages

Reference HBV test

IU = 2-5 viruses (3 is generally used but no standard has been fixed); ≥ 800 000 - 1 million IU/mL is considered a high viral load EASL recommends lower limit of detection for quantitative VL at 10-20 IU/ml Disclaimer: price is subject to region and can differ from one market to another; in addition, final pricing within a region is also subject to training, installation, technical support and other requirements.

TABLE 11: PIPELINE VIRAL LOAD TESTS FOR HEPATITIS C* HCV

Daktari

EOSCAPE-HCV-Q Isothermal target amplification with bipartite photonic signaling

Wave80 Assay type

disposable cartridge, processing unit and analyzer disposable cartridge, analyzer

Epistem HCV genotype, VL and IL-28B (multiplex) Truenat HCV

Molbio

100µl

12-24 results/instrument/day whole blood

TBD 30 min

core antigen not provided <10,000 - 10 million copies/mL <10,000 TBD

integrated sample preparation

no cold chain requirement

Internal inhibition control

20µl

1 sample/hour/unit whole blood

not provided < 60 min

proprietary 1, 2, 3, 4, 5 and 6 10 to 10^6 copies/mL TBD TBD

proprietary activated filter paper-based extraction

full process Internal Positive Control 2 - 30°C with transportation stress up to 35°C Truelab micro PCR work station (no additional equipment required) 8,000

100µl

12 samples/day whole blood, plasma, serum

WHO standard <60 min

core gene 1, 2, 3, 4, 5 and 6 2 to 9 log (under evaluation) 2 log range (being evaluated) 100% (based on preliminary evaluation)

microfluidics

Technological set-up

integrated sample preparation genotype: NS5b and E1 regions; detection: 3’-X-tail (highly conserved >99%) 1, 2, 3, 4, 5 and 6 50-1e6 IU/mL (LLOQ 50 IU/mL) <10-15 IU/mL >98% external calibration for linear range (>100,000 IU/mL) <1 hr parallel processing with multiple processing units (up to 10 processing units per analyzer) whole blood (capiliary), plasma 100µL, acquired through fingerstick using standard lancets through protocol developed by Wave 80

On board positive/negative controls

Genedrive 4,000

PCR real-time quantitative PCR Truenat HCV: Ready to use, disposable disposable cartridge, analyzer; 3 capillaries micro chips; Truelab: Portable, therefore 3 different tests can be run in automated, battery operated real-time parallel (i.e. genotype, VL and IL-28B) micro PCR analyzer Trueprep Mag: Magnetic nano particlesbased reagents using portable semiautomated battery-operated sample prep device

Sample volume

IAC on-board

no cold chain requirement

TBD

Extraction method / sample preparation

Controls no cold chain requirement

Daktari analyzer TBD

Throughput Sample type

Standardisation Time to result

Target region Genotypes, subtypes Linear range Sensitivity / limit of detection Specificity

Transport

TBD

Equipment required Indicative cost of equipment ($) Indicative cost per test (for reagents) ($)

Cepheid

Xpert HCV Fully automated real time amplification and detection

fully automated, closed system

automated within system; no off‐line sample prep steps

conserved region of HCV genome 1, 2, 3, 4, 5 and 6 10 – 1x108 IU/ml ≤ 10 IU/ml 99.5% (in seronegative blood donor) WHO 3rd Hepatitis C Virus (HCV) RNA International Standard (06/100) ~90 min comparable to Xpert MTB/RIF, system dependent (device sizes: single, 2, 4, 16 modules) plasma, serum

≤ 1ml two Internal Quantification Standards (IQS) - high and low - used in quantification

comparable to Xpert MTB/RIF

low; comparable to Xpert MTB/RIF

to be decided

GeneXpert comparable to Xpert MTB/RIF

EOSCAPE analyzer <10,000

very low

minimal; comparable to Xpert MTB/RIF

Community health worker and above

15 Minimally skilled operator with pipetting knowledge not specialised but precision pipetting required, laboratory or near patient

40 CLIA moderate complexity; calibration required

Technical skill

not specialised, laboratory or point-of-care not specialised, laboratory or point-of-care not specialised, laboratory or point-of-care refrigeration may be required for external calibrants 4 to 40°C Ambient

Laboratory set-up Storage conditions

Stable at 2-30°C for 1 year to be decided developing, low-medium resourced setting; all levels of health care chain up to peripheral laboratories with minimal or no infrastructure support to be decided developing, low-medium resourced settings

developing, low-medium resourced setting; remote settings

Applicable settings

CE-IVD to be sought

CE-IVD; US-FDA-IVD to be sought

TBD

CE-IVD; US-FDA-IVD to be sought

developing, low-medium resourced settings; health posts and above CE-IVD, ISO 13485 certification, WHO PQ, local country approval to be sought

Regulatory approval

Advantages Disadvantages Reference HBV test in the pipeline Manufacturer no, but possibly in the future

Manufacturer no

Multiplex for genotype, viral load and IL-28B low cost, point-of-care, easy to use, same low cost, point-of-care, easy to use, same (but pan-genotypic treatment with DAAs automated device, relatively easy to use, device for all their tests device for all their tests may not need genotyping or IL-28B testing) same device for all their tests not true POC (multiple steps and precision pipetting required) Manufacturer yes Manufacturer yes

*Alere and Iquum also have pipeline HCV, and Alere HBV, viral load tests, but were not able to provide information at this time.

automated, modular device, easy to use, same device for all their tests not under preferential pricing, not true POC Manufacturer yes