hcv aasld guidelines 2016

1. HCV is just a matter of time
Last guidelines updates
July2016
By
Mohammed Aboelmagd (MD)
Endemic & Infectious diseases Department

2. HCV Timeline
• 5000 years ago Jaundice at the dawn of
medicine .
• For centuries, hepatitis was a mystery and
understanding came in waves until its origin
was finally unraveled.

3. At 4th millennium BC
• The word icterus was first found in the
Hippocratic corpus as early as 460 BC.
• Hippocrates described the first clinical
features of epidemic jaundice.
• A fulminant course in patients who died
within 11 days. The recommended treatment
was a diet of honey and water.

4. At 3th millennium BC
• early description of jaundice was found in Sumeria
clay tablets(The first handbook of medicine )
Description of the etiology of jaundice was a devil
name “Ahhazu” who attacked the liver which in those
days was the home of the soul.

5. At 6th century
• As early as 752, Pope Zacharias wrote about “jaundice of a
contagious nature” where those affected would have to be
segregated.
• Pope Zackary clearly recommended isolation as the best
approach in dealing with an epidemic of jaundice.
• Patients were considered ‘impure’ and were therefore to be
‘avoided’ and isolated.

6. Outbreaks of epidemic jaundice
have been recorded in military
during the war time
Napoleon-time

7. • Lurman (1883):
reported outbreaks of serum hepatitis
following vaccination
• McDonald (1908):
postulated that the infectious jaundice is
caused by virus.

8. 1947, Mac Callum
suggested the first historical distinction between two forms of
hepatitis in :
1- epidemic hepatitis .
2- serum hepatitis .
1988 ,Harvey & Alter discover non A non B virus

9. Identification of non-A non-B hepatitis
1973 HAV
1977 HDV
1983 HEV
1988 HCV
Life cycle fully understood in 2005

11. Road map

12. Specific Targets for HCV Treatment:
Protease and Polymerase Inhibition
C E1 E2 p7 NS2 NS3 NS4A NS4B NS5A NS5B
PolymeraseProtease
Kwong A, et al. Beyond interferon and ribavirin: Antiviral therapies for hepatitis C virus.
Drug Discovery Today: Therapeutic Strategies. 2006;3:211-220.
NS5A
Inhibitors
M.Mekky March.2016

13. buvirAsvirPrevir
sofosbuvirDaclatasvir
Ombitasiver
ledipasvir
-Simprevir
- Asunaprevir
- Faldaprevir

15. AASLD-IDSA JULY 2016
Recommendations for Testing,
Managing, and Treating Hepatitis C

16. Rating System Used to Rate the Level of the Evidence
and Strength of the Recommendation for Each
Recommendation

17. Summary of Recommendations for HCV Testing and
Linkage to Care

18. Recommendations for HCV Testing and Linkage to Care
3. Other considerations
• HIV infection
• Sexually active persons about to start pre-exposure
prophylaxis (PreP) for HIV
• Unexplained chronic liver disease and/or chronic hepatitis
including elevated alanine aminotransferase levels
• Solid organ donors (deceased and living)
Rating: Class I, Level B
*Regardless of country of birth

19. Recommendation for HCV Testing Those with Ongoing
Risk Factors
• Annual HCV testing is recommended for
persons who inject drugs and for HIV-
seropositive men who have unprotected sex
with men. Periodic testing should be offered
to other persons with ongoing risk factors for
exposure to HCV.
Rating: Class IIA, Level C

20. Recommendations for Follow-up of Initial
Testing

21. Recommendations for Counseling Those with
Current (Active) HCV Infection
1. Abstinence from alcohol and, when appropriate, interventions
to facilitate cessation of alcohol consumption should be advised
for all persons with HCV infection.Rating: Class IIa, Level B
2. Evaluation for other conditions that may accelerate liver
fibrosis, including HBV and HIV infections, is recommended for all
persons with HCV infection. Rating: Class IIb, Level B
3. Evaluation for advanced fibrosis using liver biopsy, imaging,
and/or noninvasive markers is recommended for all persons with
HCV infection, to facilitate an appropriate decision regarding
HCV treatment strategy and to determine the need for initiating
additional measures for the management of cirrhosis (eg,
hepatocellular carcinoma screening). Rating: Class I, Level A

22. Recommendations for Counseling Those with
Current (Active) HCV Infection
4. Vaccination against hepatitis A and hepatitis B is
recommended for all susceptible persons with HCV
infection. Rating: Class IIa, Level C
5. Vaccination against pneumococcal infection is
recommended to all patients with cirrhosis. : Class
IIa, Level C
6. All persons with HCV infection should be provided
education on how to avoid HCV transmission to
others. Rating: Class I, Level C

23. CDC Recommended Testing Sequence for Identifying
Current HCV Infection

24. Summary of Recommendations for When and in
Whom to Initiate HCV Therapy

25. Recommendations for When and in Whom to
Initiate Treatment
• Treatment is recommended for all patients with
chronic HCV infection, except those with short
life expectancies that cannot be remediated by
treating HCV, by transplantation, or by other
directed therapy.
• Patients with short life expectancies owing to
liver disease should be managed in consultation
with an expert.
Rating: Class I, Level A

26. Recommendations for Pretreatment
Assessment
• Evaluation for advanced fibrosis using liver
biopsy, imaging, and/or noninvasive markers is
recommended for all persons with HCV
infection, to facilitate an appropriate decision
regarding HCV treatment strategy and to
determine the need for initiating additional
measures for the management of cirrhosis (eg
, hepatocellular carcinoma screening).
Rating: Class I, Level A

27. INITIAL TREATMENT OF HCV INFECTION
• A. Genotype 1a

32. B. Genotype 1b

36. II. Genotype 2

38. III. Genotype 3

40. IV. Genotype 4

42. V. Genotype 5 or 6

43. Recommended Assessments Prior to Starting
Antiviral Therapy