11/7/2016

State-of-the-Art Prevention and Management of Hepatitis B Virus Infection Kenneth E. Sherman, MD, PhD Gould Professor of Medicine University of Cincinnati Cincinnati, Ohio

FORMATTED: 10/11/16 New York, New York: November 4, 2016

Financial Relationships With Commercial Entities  Dr Sherman has received research grants or contracts

awarded to his institution from AbbVie, Bristol-Myers Squibb, Gilead Sciences, Inc, Inovio Pharmaceuticals, Intercept Pharmaceuticals, Inc, MedImmune, and Merck & Co, Inc. He has served as an advisory board member or a consultant to Merck & Co, Inc, MedImmune, and ViiV Healthcare. He has also served on data safety monitoring boards for SynteractHCR and Medpace. (Updated 11/1/16)

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Learning Objectives After attending this presentation, learners will be able to:  Describe the principles of hepatitis B virus (HBV) prevention through vaccination  Describe current and emerging therapies for HBV infection  Describe the known risk factors of hepatocellular carcinoma (HCC) and summarize the available approaches for screening and surveillance for early detection and management Slide 3 of 40

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ARS Case A 46 yo man with HCV infection is undergoing evaluation for HCV treatment. Initial evaluation reveals the following labs. • ALT 56 AST 54 Bili 1.1 Hgb 13.7 • HIV Ab negative HCV 5.6 million IU/ml Genotype 1a • Anti-HAV negative, anti-HBs negative, HBsAg negative, anti-HBc negative (total)

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• Which of the following is most correct? 4% 1. Hepatitis A vaccination is indicated before treatment initiation 2. Hepatitis B vaccination is indicated before treatment initiation 12% 3. Both hepatitis A and B vaccination is indicated after completion of HCV treatment 9% 4. Both hepatitis A and B vaccination is indicated before completion 65% of HCV treatment 5. During and after HCV therapy, the patient should be treated with 11% tenofovir or entecavir

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CASE • A 47 yo MSM with history of HIV for 11 years develops acute onset of jaundice, abdominal pain, nausea and anorexia. He reports having one partner in stable relationship – HIV regimen changed 6 months ago due to rising creatinine attributed to TDF. cART efavirenz/tenofovir/emtricitibine changed to efavirenz/abacavir/lamivudine – ALT 847 AST 755 Bilirubin 11.7 Creatinine 1.47 mg/dl HIV< 50 copies/ml HLA-B*5701 negative Slide 6 of 40

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Which of the following is the most likely explanation? 1% 1. Drug toxicity is the most likely cause for liver injury 94% 2. Chronic HBV flare is common after discontinuation of HBV

active agents 5%

3. Acute HCV should be suspected

0% 4. Acute HAV should be suspected

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TOPICS • • • • •

EPIDEMIOLOGY VIROLOGY PREVENTION TREATMENT OTHER MANAGEMENT

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Prevalence of Hepatitis B Virus • Globally 2 billion people have been exposed • 350 million people with chronic HBV infection

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HBV/HIV Disease Burden Worldwide Prevalence of Chronic Hepatitis B and HIV

HBV 350 million

HIV 50 million

4-8 million HBV/HIV coinfected Slide 10 of 40

Increased Liver Mortality in HIV/HBV Coinfected Men: MACS 16

14.2

14 Liver MR/1000 PYs

• 5293 men (326 HBsAg+ baseline) followed 10.5 years

12 10 8 6 4 2

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VB /H VHI

Thio C et al. Lancet. 2002;360:1921-26.

1.7

0.8

0.0

0

+ BV /H VHI

BV /H V+ HI

+ BV /H V+ HI

D:A:D Study: Independent Predictors of Liver-Related Death in HIV Latest CD4 Cell Count (cells/µL)

16.06

500

2.01

HIV Acquisition via IDU Hepatitis C Status Negative

6.66

Positive

Hepatitis B Status Negative

3.73

Positive D:A:D: Data Collection on Adverse Events of Anti-HIV Drugs.

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0.2

1.0

10

100

Relative Risk of Death

Weber R, et al. Arch Intern Med. 2006;166:1632-1641.

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ESLD NA-ACCORD

Marina B. Klein et al. Clin Infect Dis. 2016

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HCC RISK REVEAL COHORT Baseline HBV DNA ≥106 copies/mL

RR 6.6

105– 2.0 indicates cirrhosis

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Sarin et al., HEPATOL INT, 2016

HBV MANAGEMENT APASL

Liver stiffness > 8 kPa (by transient elastography) or APRI > 1.5 indicates significant fibrosis; Liver stiffness > 11 kPa (by transient elastography) or APRI > 2.0 indicates cirrhosis

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Sarin et al., HEPATOL INT, 2016

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HBV MANAGEMENT APASL

Consider LT if no stabilization

* Cirrhosis by non-invasive markers means Liver stiffness > 11 kPa (by transient elastography) or APRI > 2.0

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Sarin et al., HEPATOL INT, 2016

HBV/HIV COINFECTION TREATMENT GUIDELINES •

•

•

Prior to initiation of antiretroviral therapy (ART), all patients who test positive for hepatitis B surface antigen (HBsAg) should be tested for hepatitis B virus (HBV) DNA using a quantitative assay to determine the level of HBV replication (AIII). Because emtricitabine (FTC), lamivudine (3TC), and tenofovir (TDF) have activity against both HIV and HBV, if HBV or HIV treatment is needed, ART should be initiated with the combination of TDF + FTC or TDF + 3TC as the nucleoside reverse transcriptase inhibitor (NRTI) backbone of a fully suppressive antiretroviral (ARV) regimen (AI). If HBV treatment is needed and TDF cannot safely be used, the alternative recommended HBV therapy is entecavir in addition to a fully suppressive ARV regimen (BI). (BII).

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DHHS Guidelines for Use of Antiretroviral Agents in HIV-1 Infected Adults And Adolescents. Accessed 2/9/2016 at www.aidsinfo.nih.gov

TDF TO TAF REGIMEN SWITCH • Two Study Reports Available – Assess HIV Suppression Efficacy • N= 663 – Assess HBV Suppression Efficacy • N= 72

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100 90 80 70 60 50 % 40 30 20 10 0

Switch No Switch

Gallant JE, et al. CROI 2016 Gallant JE, et al. IAS 2015

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HBV Mutation • Arises due to the relatively low fidelity of the HBV polymerase • Mutation rate of approximately 3x10-4 (Park et al., Eur J Biochem, 2004)

• 10-fold higher than most DNA viruses

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HBV Polymerase Key Mutations

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Koziel and Peters, NEJM, 2007

HBV/HIV Coinfection Lamivudine Breakthrough 1200

LAMIVUDINE Anti-HBc IgM

+

+

-

ALT (U/L)

1000 800 600 400 200 0 0

4

8

12

16

20

ALT Slide 36 of 40

Bessesen et al., CID, 1999

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RISK OF RESISTANCE

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Sarin et al., HEPATOL INT, 2016

HBV Targets HBV HBeAg

Core particle plus strand synthesis

Recycling

HBsAg

Entry of HBV into cell Core particle minus strand synthesis Core assembly and RNA packaging

Vesicular transport to cell membrane Translation

Transcription

Repair

cccDNA Slide 38 of 40

THERAPEUTIC APPROACHES

VIROLOGIC

IMMUNOLOGIC VIRION ASSEMBLY INHIBITION THERAPEUTIC VACCINE

ENTRY/UNCOATING INHIBITION

DNA PROCESSING INHIBITION Slide 39 of 40

REVERSE TRANSCRIPTION INHIBITION IMMUNE STIMULATION cccDNA INHIBITION OR CLEAVAGE

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BIOMARKERS OF RESPONSE Beyond HBV DNA and Serology • • • •

Quantitative HBsAg HBV RNA in SERUM cccDNA Elimination of Integrated HBV DNA

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HCC SURVEILLANCE • Who? – Asian male over 40 – Asian Female over 50 – Any with family history of HCC – African/North American Blacks – ALL Patients with Cirrhosis – HIV???

• How?

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– US every 6 months but some might need CT/MRI – ?AFP

Conclusions • Vaccination is a critical element of prevention but current methods are imperfect, particularly in those with HIV infection • Treatment goal is complete suppression of HBV viral replication • Long term suppression will rarely lead to functional cure (HBsAg negative state) • Other modalities are needed to clear cccDNA reservoir or to achieve functional cure • Don’t forget HCC screening/surveillance Slide 42 of 40

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ARS Case A 46 yo man with HCV infection is undergoing evaluation for HCV treatment. Initial evaluation reveals the following labs. • ALT 56 AST 54 Bili 1.1 Hgb 13.7 • HIV Ab negative HCV 5.6 million IU/ml Genotype 1a • Anti-HAV negative, anti-HBs negative, HBsAg negative, anti-HBc negative (total)

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• Which of the following is most correct? Hepatitis A vaccination is indicated before treatment initiation Hepatitis B vaccination is indicated before treatment initiation 3. Both hepatitis A and B vaccination is indicated after completion of HCV treatment 3% 4. Both hepatitis A and B vaccination is indicated before completion of HCV 94% treatment 3% 5. During and after HCV therapy, the patient should be treated with tenofovir or entecavir

0% 0%

1. 2.

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Which of the following is most correct? 4%

Hepatitis A vaccination is indicated before treatment initiation

0%

Hepatitis B vaccination is indicated before treatment initiation

0%

Both hepatitis A and B vaccination is indicated after completion of HCV treatment

12%

9% 3%

Both hepatitis A and B vaccination is indicated before completion of HCV treatment During and after HCV therapy, the patient should be treated with tenofovir      or entecavir

65% 94%

11% 3% First Slide

Second Slide

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11/7/2016

State-of-the-Art Prevention and Management of Hepatitis B Virus Infection Kenneth E. Sherman, MD, PhD Gould Professor of Medicine University of Cincinnati Cincinnati, Ohio

FORMATTED: 10/11/16 New York, New York: November 4, 2016

New York, New York: November 4, 2016

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