1. CASE 3 48 yo man HIV positive/HEP C positive 12 yrs ago Tenofovir/FTC/RTV/Lopinavir x 7 yrs CD4 310/40% HIV Viral Load <40

2. CASE 3 Genotype 1a Hepatitis C Liver biopsy in 2009 reveals 4/4 scarring with ongoing active inflammation Compensated Cirrhosis and clinically stable OGD negative for varices and U/S negative for hepatoma/Ascites

3. CASE 3 2010 HIV meds switched form TDF/FTC/RTV/LPV to TDF/FTC/RGV Therapy for Hepatitis C initiated with PEG INF 180mcg/RBV 1200 mg/Boceprevir 2400 mg

4. CASE 3 Week 0 HCVRNA 1.67 x 10e7 Week 4 HCVRNA 4.22 x 10 e4 Week 8 HCVRNA 1.90 x 10 e1 Week 10 HCVRNA Not detected

5. CASE 3 WeekWBCPmns 04.32.3 42.81.0 81.30.3 101.00.1

6. CASE 3 Pegasys dose decreased to 135 mcg Ended up with a fever and was hospitalized with febrile neutropenia…hypotensive…no source of infection found G-csf initiated and titrated up to daily dosing

7. CASE 3 WeekWBCPmns 04.32.3 42.81.0 81.30.3 121.00.1 140.90.1 160.90.1

8. CASE 3 Pegasys dose decreased to 90 mcg Ended up with a fever and was hospitalized once again with febrile neutropenia…

9. CASE 3 Therapy abandoned Over the ensuing 3 years…Pmns remained below 0.5 despite G-csf daily…antibodies to GCSF not detected Bone marrow done and PMN progenitors seen…spleen not huge on U/S Trial of IVIG given without benefit in regards to increasing PMNs

10. CASE 3 Early 2014 Baseline pmns are 0.4-0.5 Would you retreat with Sofosbuvir/PEGINF/RBV?

11. CASE 3 Early 2014 Fighting with private insurance to get Sofosbuvir/Simeprevir Denied

12. CASE 3 Late 2014 Pmns 0.4-0.5 What should we do?

13. CASE 3 Late 2014 Sofosbuvir/RBV now vs wait for Sofosbuvir/Ledipasvir ABBVIE quad Other?