Interview with Professor Jean Michel Pawlotsky about the new EASL hepatitis C guidelines
Professor Jean Michel Pawlotsky is Professor at the University of Paris-Est and director of the French national reference centre for viral hepatitis B, C and Delta. He is a leading researcher in the field of viral hepatitis and recently coordinated the new European hepatitis C clinical practice guidelines that were presented at the EASL International Liver congress in London earlier this year. We spoke with Professor Pawlotsky about the latest developments in the treatment of hepatitis C (HCV) and the implications of the new HCV treatment guidelines for patients with HIV/HCV co-infection.
Could you briefly outline your background and how you came to be involved in hepatitis research?
My training was initially as a resident in hepatology. When, in 1990, I arrived as a resident in the hospital where I still am today, my boss told me a new virus had been discovered the year before (hepatitis C virus), and that I should probably become a virologist. So I trained in virology in addition to my training in liver disease and became a virologist. I set up a translational research setting with clinical research, clinical virology lab and basic research. It’s a big centre - we are now the national reference centre for hepatitis in France.
Rapid advances are currently being made in HCV treatment. How do you, as a medical professional, view these changes?
Well, for the patients it’s fantastic. For us it means a different type of work. We focused initially on describing the disease, and then there was all the clinical work that has to be done when you discover a new disease. After that we worked a lot on therapy. Now, with the new treatment there are very high cure rates, but there remain some issues. I think the two main issues will be how to deal with the small number of patients who fail on therapy, and access to care. This is a major problem, not only in Europe where access to care is guaranteed in most cases, but also outside of Europe in low-to-middle income countries. But overall it’s an outstanding achievement. I mean we discovered the virus in 1990 and 25 years later we have good treatment. It’s expensive, but very good.
So you see the cost and access to care as the biggest challenge?
Once you have good treatment, the real question is who will benefit from it. Of the 180 million people who are infected worldwide, the real question is what proportion of these people will benefit from these new therapies. So far, based on what we know, it will be a very small proportion. This is a big challenge, but it’s more a public health issue than the kind of research we’ve been doing up to now.
Do you have any thoughts on how this challenge can be tackled?
The three key factors are first, active screening to find the patients; second, having a decent setting for care (in many countries the medical systems are not effective) and, third, having affordable drugs.
HIV care is well-structured in many countries. Could you use this infrastructure to reach hepatitis patients?
The problem is that, in developing countries, the HIV infrastructure will essentially only benefit co-infected patients. If you are mono-infected with hepatitis B or C in Africa or Asia, nobody will take care of you. This is a serious problem and poses the biggest challenge.
What will change in the guidelines for HCV treatment as a result of the new developments?
Well, everything. The new guidelines presented in London at EASL and published in July in the Journal of Hepatology are guidelines for the new drugs that are on the European market. The guidelines give options for all the different genotypes with these drugs. This includes options with interferon and ribavirin, one of the drugs in combination with interferon & ribavirin, or an interferon-free regimen, such as sofosbuvir/ribavirin, sofosbuvir/daclatasvir, sofosbuvir/simeprevir. For each genotype we indicate which options are correct and acceptable, and give all the information to support these claims. We also provide recommendations for special groups of patients. So these are actually very novel guidelines. But they will have to be updated before the end of this year with the arrival of other treatments.
Do you foresee the upcoming HCV drugs offering any particular benefits to HIV/HCV co-infected patients?
The main point that we made in the EASL clinical practice guidelines is that there is no longer any difference between HIV co-infected and HCV mono-infected patients in terms of indications and therapy, treatment regimens, and results. The only difference that may remain is potential drug-drug interactions with antiretroviral drugs. However, the main point is that the HIV-infected patients are no longer a special population within the HCV-infected group. I think this is very important.
Do you anticipate such drug-drug interactions occurring in HIV/HCV co-infected patients?
It depends on the drugs. There’s not much drug-drug interaction with sofosbuvir, but there may be drug-drug interactions with the protease inhibitors, such as simeprevir and ABT-450, and maybe a little for some of the NS5A inhibitors, although it’s not clear yet. This is the only area where people will have to pay attention. Everything else is the same as for HIV-negative HCV-infected patients. It’s really a very strong message.
You mentioned that HIV-infected patients will no longer be considered a special population within the HCV-infected group. Does this mean that they will not be included in the guidelines for special populations?
The message we are sending out is that there is no need for different guidelines; our guidelines are for both HIV-negative and HIV-positive patients. Again the only issue that may make a difference and might need an additional chapter is interactions with antiretroviral drugs. But as I said, there do not seem to be any problems with sofosbuvir-based regimens. We might have to wait and see with the other drugs, but it’s not a big issue.