What is the recommended treatment for Hepatitis C Virus (HCV) genotype 1a in a patient with Human Immunodeficiency Virus (HIV) on darunavir (Prezista), ritonavir (Norvir), and Descovy (emtricitabine/tenofovir alafenamide)?

Treatment Recommendation for HCV Genotype 1a in HIV-Coinfected Patient

Treat this patient with glecaprevir/pibrentasvir for 8 weeks without ribavirin, as this regimen achieves 99% SVR12 rates in treatment-naïve HCV genotype 1a patients without cirrhosis, regardless of HIV coinfection status, and has no significant drug-drug interactions with the current antiretroviral regimen. 1, 2

First-Line Treatment Selection

• Glecaprevir/pibrentasvir for 8 weeks is the optimal choice for this treatment-naïve patient with genotype 1a infection without cirrhosis, achieving SVR12 rates of 99.1% in clinical trials 3, 4
• The American Association for the Study of Liver Diseases and European Association for the Study of the Liver both recommend glecaprevir/pibrentasvir as first-line therapy for genotype 1a infection 1, 2
• This regimen offers the shortest treatment duration (8 weeks vs 12 weeks for alternative options) with equivalent efficacy 1, 2

HIV Coinfection Considerations

• HIV coinfection does not alter the treatment recommendation or require dose adjustments for glecaprevir/pibrentasvir 1, 5
• The same HCV treatment regimens are used in HIV-coinfected patients as in HIV-negative patients 2, 5
• Glecaprevir/pibrentasvir has no clinically significant drug-drug interactions with darunavir, ritonavir, or Descovy (emtricitabine/tenofovir alafenamide) 1

High Viral Load Impact

• The baseline HCV RNA of 7 million IU/mL does not require treatment modification with glecaprevir/pibrentasvir 3, 4
• Clinical trials demonstrate that virologic failure with glecaprevir/pibrentasvir is not associated with baseline viral load 4
• The 8-week duration remains appropriate regardless of HCV RNA level in treatment-naïve patients without cirrhosis 1, 3

Alternative Regimens (If Glecaprevir/Pibrentasvir Unavailable)

• Sofosbuvir/velpatasvir for 12 weeks achieves 98% SVR12 in genotype 1a patients and 95% in HIV-coinfected patients 6, 2
• Ledipasvir/sofosbuvir for 12 weeks is another acceptable alternative with 98% SVR12 rates in genotype 1a infection 6, 7
• Both alternatives require longer treatment duration (12 weeks) compared to glecaprevir/pibrentasvir (8 weeks) 1, 2

Regimens to Avoid in This Patient

• Do not use ombitasvir/paritaprevir/ritonavir plus dasabuvir due to significant drug-drug interactions with the patient's current ritonavir-containing antiretroviral regimen 6
• This regimen contains ritonavir as a pharmacokinetic booster, creating potential for complex interactions with darunavir/ritonavir 6
• Additionally, genotype 1a requires 12 weeks with ribavirin (or 24 weeks with ribavirin if cirrhosis present), making it less favorable 6

Treatment Monitoring

• Assess SVR12 (HCV RNA <15 IU/mL at 12 weeks post-treatment) to confirm cure 1
• No on-treatment HCV RNA monitoring is required during the 8-week treatment course 3, 4
• Continue HIV viral load and CD4 monitoring per standard HIV care guidelines 5

Important Clinical Considerations

• Ribavirin is not needed with glecaprevir/pibrentasvir in this treatment-naïve patient without cirrhosis 1, 3
• The patient's treatment-naïve status and absence of cirrhosis (based on the clinical scenario) make this the ideal candidate for shortened 8-week therapy 1, 4
• Glecaprevir/pibrentasvir was well tolerated in clinical trials with adverse event-related discontinuation rates <1% 3, 4
• Most common adverse events are headache (12%) and fatigue (12%), which are generally mild 4

Post-Treatment Surveillance

• No hepatocellular carcinoma surveillance is required after achieving SVR in this non-cirrhotic patient 1
• If cirrhosis were present, ultrasound surveillance every 6 months would be necessary even after SVR 2, 5