Immunologic Effects of HCV Therapy With HARVONI in HCV Genotype 1 Chronically Mono-infected Active and Former IDUs

Study Overview
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Brief Summary
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The investigator's hypothesis is that active injectors will show a partial reduction in markers of immune activation with HCV therapy whereas non-injectors will show a more significant reduction in these markers, and will exhibit levels of immune activation that approach that seen in similarly studied healthy volunteers.This is based on observations that this group of investigators have made. They have shown that individuals who inject drugs have high level of immune activation in blood and tissue. Immune activation or chronic inflammation has been associated with accelerated aging, cardiovascular, renal and liver disease as well as CNS dysfunction. It remains unclear whether increased levels of immune activation are due to non-sterile injection of drugs, chronic infection with Hepatitis C, chronic opiate use, or perhaps combinations of all 3. To understand the potential contribution of infection with Hepatitis C the investigators will compare levels of immune activation pre- and post treatment with an all oral, one pill once daily, interferon sparing treatment of HCV in 2 groups of chronically HCV infected patients- one actively injecting with drugs and the other free of injection for at least 4 months. Immune activation comparisons will also include non-injecting healthy volunteers.

Detailed Description
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This group of multidisciplinary investigators has discovered increased levels of immune activation among HIV-1-uninfected active injection drug users (IDUs) when compared to non-IDU controls . The vast majority (80%) are also infected with HCV. Active injectors have high levels of immune activation as measured by sCD14, CD8 co-expression of CD38 and HLA-DR, as well as Type 1 cytokines. Within months of ceasing injecting, there are observable decreases in some parameters however in general they remain elevated when compared to non-injecting healthy volunteers. As approximately 80% of these subjects are HCV infected and viremic, these results are confounded as to the cause of the observed increased levels of markers of immune activation- active injection or chronic Hepatitis C. Until recently HCV treatment required the use of IFN which has immunomodulatory activity which would cause perturbations in the markers of immune activation. However the development of direct acting agents (DAA) to treat HCV has revolutionized therapy. In this trial the investigators will employ the once daily FDC formulation of sofosbuvir and ledipasvir to assess changes in markers of immune activation during therapy. There have been multiple clinical trials of FDC LDV-SOF in patients with Genotype 1 HCV. When taken once daily for 12 weeks, sustained virologic response rates have been very high with response rates nearing 99% in most studies with a 12-week course of therapy. Common adverse events associated with FDC LDV-SOF in ION-1 include fatigue (21%), headache (25%), nausea (11%), insomnia (8%), asthenia (7%), diarrhea (11%), rash (7%), irritibility (7%), cough (3%), and pruritis (5%). Ledipasvir undergoes minimal metabolism and expectations are that this medication will have few clinically significant drug-drug interactions. In general, sofosbuvir is considered to have relatively few clinically significant drug-drug interactions, but coadministration of sofosbuvir with the following medications is not recommended because these medications may significantly lower sofosbuvir levels: Anticonvulsants: carbamazepine, oxycarbazepine, phenobarbital, and phenytoin Antimycobacterials: rifabutin, rifampin, rifapentine Herbal Supplements: St. John's wort HIV Protease Inhibitors: tipranavir-ritonavir Antiarrhythmic Drugs : amiodarone (Cordarone®, Nexterone®, Pacerone®) Participants will be provided with a 12-week course of FDC LDV-SOF which will provide a near 99% likelihood of a SVR in participants who are adherent to therapy with low likelihood of significant adverse events and drug-drug interactions. In treating HCV effectively the investigators will measure changes in immune activation and gene expression that accompany HCV treatment.

Official Title
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The Immunologic Effects of HCV Therapy With Fixed Dose Combination Ledipasvir/Sofosbuvir (HARVONI) in HCV Genotype 1 Chronically Mono-infected Active and Former IDUs.

Conditions
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Hepatitis C

Intervention / Treatment
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* Drug: Harvoni (Fixed dose combination ledipasvir/sofosbuvir)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Ability to give written informed consent in English Age≥18 and ≤55 HCV antibody positive HCV RNA >1,000 copies/mL plasma HCV treatment naive HCV genotype 1a or 1b or mixed type 1 AST, ALT <10x ULN Direct bilirubin <3.0 Platelet count >50,000 Creatinine clearance >30mL/min as estimated by Cockroft Gault Hemoglobin >10 if female, >11 if male Albumin > 2.8 INR<2.0 If Group A: urine dip for opiates + and active injection drug use of heroin defined as injecting at least 3 times per week. If Group B then no IDU for at least 4 months and a negative urine for opiates at screening. Venous access for phlebotomy Willingness to agree to effective contraception during the course of the study. If Group C: - negative urine for opiates at screening no recreational drug use for at least 2 years (excluding marijuana) HIV, HCV and HBV uninfected Exclusion Criteria: HIV infection Chronic infection with Hepatitis B Uncompensated cirrhosis Required use of: Anticonvulsants: carbamazepine, oxycarbazepine, phenobarbital, and phenytoin Antimycobacterials: rifabutin, rifampin, rifapentine Herbal Supplements: St. John's wort HIV Protease Inhibitors: tipranavir-ritonavir Antiarrhythmic Drugs: amiodarone (Cordarone, Nexterone, Pacerone) Any medical condition that in the opinion of the investigator would interfere with study participation and medical adherence Pregnancy/breast feeding -

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 55 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Active injection drug use (IDU)<br>In active IDU, Harvoni (Fixed dose combination ledipasvir/sofosbuvir), one pill orally daily x 12 weeks | Drug: Harvoni (Fixed dose combination ledipasvir/sofosbuvir)<br>* Harvoni (Fixed dose combination ledipasvir/sofosbuvir), one pill daily x 12 weeks<br>* Other names: Fixed dose combination ledipasvir/sofosbuvir;|
| Active Comparator: Former injection drug use (former IDU)<br>In former IDU, Harvoni (Fixed dose combination ledipasvir/sofosbuvir), one pill orally daily x 12 weeks | Drug: Harvoni (Fixed dose combination ledipasvir/sofosbuvir)<br>* Harvoni (Fixed dose combination ledipasvir/sofosbuvir), one pill daily x 12 weeks<br>* Other names: Fixed dose combination ledipasvir/sofosbuvir;|
| No Intervention: Healthy volunteers<br>HIV, HCV and HBV negative, never injected drugs, no recreational drugs for at least 2 years (does not include marijuana) and negative urine screen for opiates at the screening visit. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| sCD14 (ng/mL) | Marker of immune activation as measured by levels of soluble CD14. Note that the levels of sCD14 were only measured at baseline in the Healthy Volunteers group and therefore there are no data for weeks 4, 12, or 24 entered. | 24 weeks | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Virologic Response to Therapy as Measured by HCV RNA | HCV RNA levels in plasma (IU/mL) | 24 weeks | 
| Gene Expression Profiles | Gene expression profiles in PBMC will be determined using RNA Seq | 24 weeks | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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HCV, injection drug use