Hepatitis C Virus Elimination is Not Attained in a Certain of Immunocompetent Patients Who Achieved Sustained Viral Response to Direct-Acting Antiviral Agents

Abstract

Background: Direct-acting antiviral agents (DAAs) have opened a new era for treating chronic hepatitis C virus (HCV) infection. However, whether DAA induced SVR attains real cure and complete eradication of HCV RNA is unknown, because occult HCV infection (OCI), as defined the detection of HCV RNA in hepatocytes or peripheral blood mononuclear cells (PBMC) in absence of serum of HCV RNA, may occur despite SVR and the clinical significance is yet to be established. We thus investigated the prevalence and provisional outcome of OCI in patients who achieved spontaneous or therapy-induced resolution of hepatitis C. Methods: Chronic HCV subjects from three tertiary hospitals who had achieved serum viral clearance, including 60 of DAAs treatment, 50 of pegylated interferon plus ribavirin (PR) treatment, and 30 of spontaneous recovery, were subjected to detect HCV RNA in hepatocytes by in suit hybridization as well as in PBMC by PCR. Liver function testes, HCV genotypes, and paired liver biopsies of pre- and post-treatment for each patient were acquired for comparison analysis. Findings: 16 of 140 subjects (11·4%) were found to have OCI, with the highest (15·0%) rate in DAA-based treated subjects, 10·0% in PR treated subjects and 6·7% in spontaneously resolved cases. Rates of OCI were 16·7% and 11·1% among patients with PR-free regimen and PR-based regimen, respectively. The existence of intermediate negative strand of HCV genome in all PBMCs of OCI patients suggested ongoing viral replication. The occurrence of OCI is more frequent in patients with genotype 3 HCV but less in patients with genotype 1. No correlation between baseline HCV viral load, interleukin-28B genotype, baseline transaminases, post transaminases and occurrence of OCI was found. While notably, OCI patients had more advanced liver fibrosis and active inflammation at both baseline and post- treatment. In addition, fibrosis scores were significantly decreased after SVR only in patients without OCI (P <0·001), but not in OCI subjects (P = 0·385). Patients with OCI have less incidence of fibrosis regression than in those without OCI after SVR. Importantly, we found two cases of HCV reactivation in OCI patients during 48 weeks to three-year follow up. Interpretation: HCV RNA can persist as ongoing replicative virus after treatment-induced or spontaneous serum resolution of hepatitis C, with highest incidence in patients with PR-free regimen induced SVR. The existence of OCI is associated with persistent pathological abnormality and likely to result in HCV relapse. Funding Statement:This study is supported by grants from National Natural Science Foundation of China (NNSFC) (No. 81673654) (to J.Zhao); NNSFC (No. 31770186) (to Y. Wang); the National S&T Major Project for Infectious Diseases (No. 2017ZX10302201001007). Declaration of Interests: The authors have declared that no competing interests exist. Ethics Approval Statement: This study was done in accordance with the ethical principles of the Declaration of Helsinki as revised in 2013 and was approved by the Ethics Committee by each institution’s human research committee. Informed consent was obtained from all participants prior to enrollment. All patients were recruited from three tertiary hospitals, Peking University People’s Hospital, the first Hospitalof Jilin University and Beijing 302 hospital.