Impact of Hepatitis C Therapy and Bone Health

Both HCV and HIV are associated with an increased risk of osteoporosis and osteoporotic
fractures among HIV-infected patients and the general population. While HIV significantly
increases cardiovascular risk, the contribution of HCV to cardiovascular disease (CVD) is
less certain. Increased inflammation could potentially underlie the effect of HCV on CVD,
bone health, and other extra-hepatic complications. HCV appears to remain an independent
predictor of osteoporotic fractures even after controlling for severity of liver disease. The
impact of HCV therapy on inflammation, CVD and bone health is unclear. Our previous studies
suggest a beneficial impact of interferon therapy on bone turnover and some CVD markers,
while others studies have found on-treatment increases in bone mineral density with
interferon-based therapy. Whether these are related to the interferon itself or the virologic
response, and whether changes in biomarkers lead to improved fracture risk or CVD morbidity
is uncertain. Investigator propose to conduct a prospective analysis of markers of
inflammation, immune activation, and bone turnover as well as bone mineral density (BMD)
among both HIV/HCV co-infected and HCV mono-infected patients undergoing treatment with the
novel direct-acting antiviral elbasvir/grazoprevir (EBR/GZR). Should EBR/GZR therapy
significantly improve CV risk and bone health, it would be an additional benefit and
indication for its use in HCV therapy.

Inclusion Criteria:

1. HCV antibody and HCV RNA positive

2. HCV Genotype 1a, 1b, or 4

3. Liver staging assessment:

a. Cirrhosis will be defined by any of the following: i. A liver biopsy prior to day 1
of this study showing cirrhosis (F4) ii. Fibroscan within 12 calendar months of day 1
of this study showing cirrhosis with result > 12.5 kPa iii. FibroSURE performed during
screening with a score > 0.75 and APRI > 2 b. Absence of cirrhosis will be defined by
any of the following: i. Liver biopsy performed within 24 months of day 1 of this
study showing absence of cirrhosis ii. Fibroscan performed within 12 months of day 1
of this study with a result of ≤ 12.5 kPa iii. FibroSURE score ≤ 0.48 and APRI ≤ 1
during screening

4. If HIV co-infected, HAART regimen will consist of two NRTIs (abacavir, tenofovir
disoproxil fumarate or tenofovir alafenamide, each in combination with lamivudine or
emtricitabine) with one of the following 3rd agents:

1. raltegravir

2. dolutegravir

3. rilpivirine HIV co-infected patients must be on their stable HAART regimen for at
least 6 months, with HIV viral load < 50 c/mL at screening

Exclusion Criteria:

1. Hepatitis B surface antigen positivity

2. Decompensated cirrhosis (Child Pugh B or C)

3. Any prior hepatitis C treatment

4. Pregnant or nursing

5. Treatment with any medication specifically contraindicated with EBR/GZR or not
recommended for concomitant use as per the prescribing label (Table 2)

6. Age less than 18

7. Prisoners or subjects otherwise involuntarily incarcerated

8. Absence of signed informed consent by patient or appropriate surrogate

9. Known hypersensitivity to elbasvir or grazoprevir

10. For patients with genotype 1a, one more of the following mutations on baseline NS5A
genotype: M28, Q30, L31, or Y93