CROI 2018 Abstract eBook

Abstract eBook

Oral Abstracts

increase in acute hepatitis B, a vaccine preventable disease, from 2014 to 2015. The toll of opioid related death and morbidity is even greater if one considers the impact of bacterial endocarditis, septic arthritis, and other infectious complications of intravenous drug use. Opioid-associated infectious disease epidemics are emerging in areas of the United States that have historically not been infectious disease hotspots. Acute hepatitis C amongst persons < 30 years of age who inject drugs has been demonstrated to be greater in nonurban compared with urban areas and is occurring in predominantly white persons. The incendiary nature of injection drug use, viral hepatitis, and HIV, the emergence of these synergistic epidemics in rural America, and implications for stemming the tide will be discussed. Jordan Feld , Toronto General Hospital, Toronto, ON, Canada With the remarkable advances in therapy for hepatitis C virus (HCV) infection, almost all infected individuals can now be cured with short-course, well- tolerated therapy. The success of current treatment has raised the prospect that perhaps this chronic infection could actually be eliminated as a public health threat on a global scale. With this in mind, the World Health Organization (WHO) set out ambitious elimination goals, aiming to reduce new HCV infections by 90% and HCV-related mortality by 65% by the year 2030. As countries strive to meet these targets, it has become abundantly clear that elimination will take a lot more than effective medications. Although some challenges are common to all environments, the local epidemiology and health care systemmust be considered when developing HCV control strategies. Major improvements in the left side of the continuum of care including improved diagnostics, active case-finding and novel models of care will be required to allow the therapeutic advances to deliver a public health benefit. In addition, major innovations in prevention strategies will be required, which differ significantly across regions. In middle and high-income countries, harm reduction strategies to reduce drug- use-related transmission will be critical whereas in many low and some middle- income countries, needle safety will be paramount. Challenges and successes at every step in the continuumwill be discussed with a focus on countries that are on target to meet the WHO elimination goals, particularly those that have used HCV as a tool to strengthen their health sector infrastructure. Remaining research challenges will also be highlighted, particularly the need for a protective vaccine if HCV is truly to be not just regionally eliminated, but actually globally eradicated. In 2015 there have been 854,000 incident cases of liver cancer and 810,000 related deaths globally contributing to > 20 million disability-adjusted life- years (DALYs).Incident liver cancer increased by 75% between 1990-2015 : 47% explained by changing population age structures, 35% by population growth and 8% to changing age-specific incidence rates. Infection with the hepatitis B virus accounted for 33% liver cancer deaths, alcohol for 30%, hepatitis C (HCV) for 21%, and other causes for 16%,the latter including metabolic syndrome . HCC is on the raise in northern and central Europe, N America and English speaking Asia, mainly due to epidemics of viral hepatitis, alcohol abuse and metabolic syndrome. HCC is declining in several traditionally high risk countries of the Mediterranean Europe, Japan and Hong Kong following effective measures of

sanitation, including vaccination. In HIV population HCC stands as a growing cause of end stage HCV infection and related mortality. Surveillance of patients with chronic liver disease allows for increased detection of small, potentially curable tumors via such radical therapies as liver transplantation, hepatic resection and local ablative therapies that in accurately selected populations result in survival rates up to 75% at 5 year. Survival benefits, were further extended following successful control/cure of viral hepatitis. Since the Milan criteria(MC) for liver transplantation(up to one 5 cm tumor or 3 nodules each 3 cm) are too restrictive and the prognosis is dismal for patients beyond MC treated with local ablative techniques, loosed criteria of listing are increasingly being adopted in patients beyond MC who are successfully downstaged with local ablative techniques. Patients with an intermediate burden of HCC not bridged to transplantation, can still have limited survival benefits from local tumor ablation through repeat courses of chemo embolization (TACE) whereas both patients failing TACE and those with advanced HCC may respond to first and second lines of systemic therapy with targeted agents sorafenib, regorafenib, lenvantinib and cabozantinib. In these patients, 2 RCT failed to show superiority of radio embolization with yttrium versus sorafenib immune therapy with PD1 check point inhibitors has been registered in the USA to treat experienced patients with advanced HCC. 166 EXPANDING HOPE: ORGAN TRANSPLANTS FROM DONORS WITH HIV OR HCV INFECTION Christine Durand , Johns Hopkins Hospital, Baltimore, MD, USA For those living with end-stage organ disease, transplantation provides a clear survival benefit. However, due to a critical shortage of donated organs, many individuals awaiting organ transplantation will die before every receiving an organ offer. As such, innovative strategies to expand the organ donor pool are needed. One such strategy is the use of organs from donors with chronic viral infections. More specifically, the use of organs from HIV-infected (HIV+) donors for HIV+ transplant candidates and the use of organs from hepatitis C virus- infected (HCV+) donors for HCV-uninfected transplant candidates is currently under investigation. HIV-to-HIV kidney transplantation was pioneered in South Africa in 2010 with good results in a small cohort. Inspired by this experience, in the United States the HIV Organ Policy Equity (HOPE) Act was enacted in 2013 and reverses the federal ban on HIV-to-HIV transplantation. Pursuant to the HOPE Act, HIV-to-HIV transplants have been allowed within research protocols since 2015. The first HIV-to-HIV kidney and liver transplants were performed at Johns Hopkins in March of 2016 and a national multicenter study of HIV-to- HIV kidney and liver transplantation is ongoing. This session will discuss the potential risks and benefits of HIV-to-HIV transplantation and transplant outcomes to date. Since HIV remain an incurable illness even with effective antiretroviral therapy, the use of HIV+ donors for those without HIV is not being considered. However, for chronic HCV infection, direct acting antivirals (DAAs) provide a definitive cure for HCV including for transplant recipients. Moreover, in the United States high-quality organs from HCV+ donors are currently underutilized and represent a neglected public health resource. Pilot studies have investigated the use of DAAs as pre-emptive or prophylactic treatment in combination with kidney transplantation from HCV+ donors for HCV- recipients. This session will also review the results of these trials and discuss the potential that HCV+ to HCV- transplantation has to expand organ options more broadly.

164 GLOBAL ELIMINATION OF HEPATITIS C

Oral Abstracts

165 THE RISING CHALLENGE OF LIVER CANCER Massimo Colombo , University of Milan, Milan, Italy

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CROI 2018