Moving Towards More Individualized Therapies in HIV/HCV Co-infected Patients

描述（由申请人提供）：在美国，估计有270 - 390万人患有慢性HCV感染，约占人口的1.3-1.9%。由于有共同的传播途径，15-40%的人类免疫缺陷病毒（HIV）慢性感染者会同时感染丙型肝炎病毒。现在，在有效的抗逆转录病毒联合治疗（ART）的背景下，肝病已成为艾滋病毒感染者死亡和医疗资源利用的主要原因。最近发现的宿主IL28B基因上游单核苷酸多态性（rs12989760）被报道为HCV治疗反应、自发病毒清除、脂蛋白水平和脂肪变性的预测因子。HCV病毒粒子与脂蛋白的相互作用已被很好地描述。本研究计划的长期目标是确定art诱导的脂蛋白增加在HIV/HCV合并感染个体中肝病中的作用。该研究将通过以下几个具体目标来实现：(1)探索抗逆转录病毒诱导的脂蛋白升高与HIV/HCV合并感染患者HCV发病机制的关系；(2)确定降脂药物治疗对HIV/HCV合并感染患者HCV发病机制的影响；(3)在候选基因方法中，研究IL28B基因型作为HIV/HCV合并感染患者在ART开始后6个月和12个月ART相关脂蛋白增加和HCV病毒载量增加风险的宿主基线预测因子；(4)确定宿主遗传学对基线时HIV/HCV合并感染患者ISG差异表达和脂蛋白生物合成的影响以及对pegIFN/RBV治疗的影响。具体目标1将通过一个大型的描述良好的队列库来确定HIV/HCV合并感染患者开始抗逆转录病毒治疗后脂蛋白参数和HCV RNA增加的相关性。具体目标2和3将通过HIV/HCV合并感染患者启动利托那韦增强蛋白酶抑制剂为基础的抗逆转录病毒治疗的前瞻性研究设计来实现。患者将随机分为降脂治疗组和单独的蛋白酶抑制剂治疗组。将在基线时收集患者DNA用于宿主基因分型。特定目标4将通过使用基于干扰素的HCV治疗方案治疗的HIV/HCV合并感染患者的良好描述的临床队列来实现；这将与NIAID的调查人员合作完成。pbmc将用于基因表达微阵列，基线DNA将用于宿主基因分型。这些具体目标将有助于证明在HIV/HCV合并感染患者中进行更个体化治疗的可行性。该结果将阐明进一步研究在评估降脂剂和IL28B多态性在治疗HIV/HCV合并感染患者中的作用方面的效用，特别是在新的联合治疗时代，包括直接作用抗病毒药物治疗HCV。随着SVR率的提高，但更昂贵的联合治疗方案，针对HCV治疗的效用和益处做出个性化治疗决策的能力将变得至关重要。

DESCRIPTION (provided by applicant): In the United States it is estimated that 2.7-3.9 million persons are living with chronic HCV infection, which accounts for approximately 1.3-1.9% of the population. Due to shared routes of transmission, co-infection with HCV occurs in 15-40% of persons chronically infected with human immunodeficiency virus (HIV). Now, in the context of effective combination antiretroviral therapy (ART), liver disease has emerged as a predominant cause of death and of healthcare resource utilization in HIV-infected persons. A recently discovered host single nucleotide polymorphism upstream of the IL28B gene (rs12989760) has been reported as a predictor of HCV treatment response, spontaneous viral clearance, lipoprotein levels, and steatosis. The interaction of HCV virions and lipoproteins is well described. The long-term objective of this research proposal is to determine the role of ART-induced lipoprotein increases on liver disease in HIV/HCV co-infected individuals. The objective will be achieved through several specific aims: (1) Explore the association of antiretroviral-induced lipoprotein increases on HCV pathogenesis in HIV/HCV co-infected patients; (2) Determine the effect of treatment with lipid lowering compounds on HCV pathogenesis in HIV/HCV co-infected patients; (3) In a candidate gene approach investigate the IL28B genotype as a host baseline predictor for risk of ART-related lipoprotein increases and increased HCV viral load in HIV/HCV co-infected patients at months 6 and 12 following ART initiation; (4) Determine the impact of the host genetics on differential ISG expression and lipoprotein biosynthesis in HIV/HCV co-infected patients at baseline and on pegIFN/RBV therapy. Specific Aim 1 will be achieved using a large well-described cohort repository to determine the correlation of increases in lipoprotein parameters and HCV RNA after the initiation of ART in HIV/HCV co-infected patients. Specific Aims 2 and 3 will be achieved using a prospective study design of HIV/HCV co-infected patients initiating ritonavir-boosted-protease inhibitor-based ART. Patients will be randomization into a lipid lowering therapy arm versus protease inhibitor therapy alone. Patient DNA will be collected at baseline for host genotyping. Specific Aim 4 will be achieved using a well-described clinical cohort of HIV/HCV co-infected patients treated with interferon based regimens for HCV; this will be done in collaboration with investigators at the NIAID. PBMCs will be used for gene expression microarray and baseline DNA will be used for host genotyping. These Specific Aims will help demonstrate the feasibility of more individualized therapy in HIV/HCV co-infected patients. The results will clarify the utility of further study in assessing the role of lipid lowering agents and the IL28B polymorphism in the treatment of HIV/HCV co-infected patients, especially in the era of new combination therapies that will include directly acting antivirals for the treatment of HCV. With improved SVR rates, but more expensive combination regimens, the ability to individualize treatment decisions regarding the utility and benefit of HCV therapy will be critical.