Diagnosis and Point of Care Testing of Hepatitis C Heidar Sharafi, PhD Baqiyatallah Research Center for Gastroenterology and Liver Disease (BRCGL)

Where are we going with the current strategies? Number of individuals with HCV-related decompensated cirrhosis and hepatocellular carcinoma Number of individuals living with HCV infection Assuming the diagnosis (6000) and treatment uptake (4500) and utilising interferon-based treatment in 2015 Hajarizadeh et al. Hepat Mon. 2016.

What is the Solution? Stepwise Increase in diagnosis 6,000 (2016 - 2017) 12,000 (2018 - 2019) 24,000 (2020 - 2030) Stepwise treatment increase 9,000 (2016 -2017) 18,000 (2018 - 2030) Hajarizadeh et al. Hepat Mon. 2016.

Strategies for Screening and Diagnosis 1 Treatment & Monitoring Response Assessment 3 months Traditional Strategy with PegIFN+RBV Therapy Time- and resource-consuming procedure HCV Ab HCV RIBA HCV RNA (VL) & genotyping HCV RNA X 3 HCV RNA No plan for finding the patients ELISA ECLIA … .. . PCR TMA … .. . PCR TMA … .. . PCR TMA … .. .

Approved HCV Direct-acting Antiviral (DAA) Agents >95% efficacy, short 12-week treatment duration, low side-effects (Feasible therapy) Core E1 E2 P7 NS2 NS3 4A NS4B NS5A NS5B 5’UTR 3’UTR Protease Inhibitors Simeprevir (SMV) Paritaprevir (PTV) Grazoprevir (GZR) NS5B NUC Inhibitors Sofosbuvir (SOF) NS5B non-NUC Inhibitors Dasabuvir (DSV) NS5A Inhibitors Ledipasvir (LDV) Daclatasvir (DCV) Ombitasvir (OMV) Elbasvir (EBR) Velpatasvir (VEL) Bertino G. World Journal of Hepatology. 2016;8(2):92-106.

Strategies for Screening and Diagnosis 2 Treatment & Monitoring Response Assessment 1 months Current Strategy in Clinical Setting with DAAs HCV Ab HCV RNA (VL) & genotyping HCV RNA No plan for finding the patients Pangenotypic HCV Therapies: SOF/VEL ELISA ECLIA … .. . PCR TMA … .. . PCR TMA … .. .

HCV RNA Assessment HCV RNA detection/quantification should be tested before initiation of treatment, at the end of treatment and 12 or 24 weeks after treatment completion. HCV RNA detection/quantification should be made by a reliable sensitive assay (LLD <15 IU/ml) and HCV RNA levels should be expressed in IU/ml.

DAAs and Virologic Responses Sustained virologic response (SVR) Undetectable HCV RNA 12 w (SVR12) or 24 w (SVR24) after the end of therapy by a sensitive molecular method with a LLD <15 IU/ml Both SVR12 and SVR24 have been accepted as endpoints of therapy given that their concordance is 99%.

HCV Core Ag (cAg) Evaluation Attractive alternative to molecular methods Advantages over molecular methods Cheap (50% to 70% less expensive) Stability of the marker at RT for 96 hours Easy to perform through various methods even ELISA New HCV treatment monitoring tool, well suited to IFN- free regimens

HCV cAg and HCV RNA Lamoury et al. J Clin Virol. 2017.

Strategies for Screening and Diagnosis 3 Treatment & Monitoring Response Assessment Upcoming Strategy in Community Settings POCT (RDT) for HCV Ab

Rapid Diagnostic Test (RDT) HCV or HBV Ags or Abs

Rapid Diagnostic Test (RDT) Can be used at the site of patient care Prison DIC, MMT, VCT Rural areas Can use original specimen matrices in addition to serum and plasma Oral fluid Fingerstick whole blood

Performance of RDTs: Meta-Analysis More than 13,000 individuals included in 28 studies between 1994 and 2011 Specimen Specificity Sensitivity Whole blood 99.5% 98.9% Saliva 98.2% 97.1% Shivkumar et al. Ann Intern Med. 2012.

Strategies for Screening and Diagnosis 3 Treatment & Monitoring Response Assessment Upcoming Strategy in Community Settings HCV RNA Or HCV cAg HCV RNA Or HCV cAg POCT (RDT) for HCV RNA or cAg PCR TMA ELISA .. . POCT (RDT) for HCV Ab PCR TMA ELISA .. . POCT (RDT) for HCV RNA or cAg

Point of Care Diagnosis Dried Blood Spots (DBS) Feasible and reliable alternative to point-of-care assays for viral hepatitis HCV RNA HCV Genotyping Solves the problem of storage and shipment of samples Can be stored for weeks at ambient temperature without clinically significant degradation of nucleic acids Use of DBS is limited by the small amount of plasma per blood spot and less efficient nucleic acid extraction, which gives a reduced sensitivity in samples with low-level viremia. With regard to hepatitis C, this rarely has any practical consequences, as most untreated patients have viral loads (far) above 1000 IU/ml.

HCV RNA POCT Xpert HCV Viral Load quantifies HCV genotypes 1–6 over the range of 10 to 100,000,000 IU/mL 1 minute hands-on time No requirements for PCR room settings 105 minutes run time with a viral load report Run daily or on-demand

Point-of-care Tests in the Pipeline HCV Core Ag

Strategies for Screening and Diagnosis 4 Treatment & Monitoring Response Assessment Future Strategy in Community Settings CURE POCT (RDT) for HCV cAg

Thank You Very Much