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

2. 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

3. What is the Solution? Stepwise Increase in diagnosis
6,000 ( )
12,000 ( )
24,000 ( )
Stepwise treatment increase
9,000 ( )
18,000 ( )
Hajarizadeh et al. Hepat Mon

4. 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 … .. .

5. 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):

6. 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 … .. .

7. 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.

8. 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%.

9. 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

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

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

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

13. 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

14. 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

15. 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

16. 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.

17. 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

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

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

20. Thank You
Very Much