Hello Tatty,

We do suspect that your immune system still plays a role but it’s small. The evidence suggestive of this includes past treatment failures (Peg/Riba) being harder to treat and VL > 6 million treatment naive GT1 needing 12 rather than 8 weeks.

That said the cure rates for HIV positive people don’t seem to be reduced.

So in short nobody really knows what the impact of cyclosporin might be. Optimists would say none, pessimists would say a lot.

What is useful is an observation from both Egypt (unpublished) and the USA (published) that notes in the Egyptian case that a 4 log drop by the end of week 1 indicates 12 weeks will work, and in the US case that being detectable at week 4 reduces a 92% SVR in GT1 patients on Harvoni by 8-10%.

So if you are undetectable I would suggest being happy and leaving things as planned with 12 weeks treatment. In NOT undetectable then consider extending the duration by 4 or more weeks.

You really already know enough – genotype and fibrosis to select the correct treatment. Your discussion of the options is also correct. With Sof/Dac and GT3 F3 I would suggest >12 weeks if finances permit.

With Sof/Vel only approved in late June there is nobody outside trials at SVR12 so while it may/should be slightly better for GT3 Sof/Dac is a good option, and well proven

The downward trend relates mostly to missing projected targets.

From memory they had 150,000 script this time last year for the quarter, but only 110,000 in the most recent quarter.

I am on day 26 of my course, going for my 4 weeky blood test on Friday. Can I really expect to see an improvement on this test. I must say I am not very good at interpreting blood tests. I just hope its not too long before the doctor has the results back.

Unless you are cirrhotic your ALT and AST will be in the normal range and it’s likely your viral load will be <15 or undetected.

The liver functions take 24 hours to come back. The viral load takes a week or so.

What does get reported in fmol/L is HCV CORE ANTIGEN. This is a test like PCR (in that it is looking for and counting how much virus it can see).

Here is a paper: http://www.ejmm.edu.eg/beta/images/articles/April_2014/67-74.pdf

In the paper it says:

Based on this equation, it was possible to calculate that 3 fmol/L of total HCV core Ag is equivalent to 263 IU/mL HCV RNA

So that would be 1 fmol/L to 90 IU/ml of HCV RNA – call it 100

So your 673 represent a viral load of about 60,000

Vox is not available as a generic yet, but your SVR rate with either Sofosbuvir + Daclatasvir or Sofosbuvir + Velpatasvir will be >95%

Loceryl is a topical agent used once a week.

The application time depends on speed of nail growth.

What you expect to see is new health nail growing outwards. Once all the infected nail is gone (ie trimmed off) treat for a bit longer to be sure, but you can see it progressively growing out.

I would be happy with your ALT and AST. The reason we need a normal range is that normal people vary. Some are normally in the middle, some at the upper end, some at the lower end. The drop from pretreatment levels is the significant thing.

GT1b is the easiest GT to cure. This is in your favour. Low fibrosis and low viral load are both good but past treatment failure means your predicted SVR is 94% with 12 weeks and 99% at 24 weeks. This is from Gilead’s trials and in the real world this is a little optimistic ie treatment naive GT1 patients got 97% in the trials (about 300 patients) but the VA in the US found it to be 91.3% (in 4200+ veterans)

So good odds with 12 weeks, 5% (ish) better with 24 but at double the price. I would be happy with you doing 12, 16, 20 or 24 weeks. The extra bit from 12->16 has more value than the 20->24 block.