INTRODUCTION: Mortality associated with hepatitis C virus (HCV) infection is increasing, yet only a small percentage of HCV-infected individuals are aware of their infections, complete treatment, and achieve a cure, defined as a sustained virologic response. In March 2015, the Section of General Internal Medicine at Boston Medical Center (BMC), New England’s largest safety-net hospital, implemented the Adult Primary Care HCV Treatment and Triage Program to increase access to treatment. We are unaware of prior studies that have explored a pharmacist-centered primary care-based HCV treatment model in the era of newer direct-acting antiviral (DAA) medications. OBJECTIVES: To gain a deeper understanding of the roles of each program staff member, as well as an understanding of how primary care providers (PCPs) who refer patients to the program perceive and interact with the program. Such an understanding will help promote implementation and dissemination of the program. METHODS: We conducted in-depth semi-structured interviews with six staff members and with five PCPs in the Section of General Internal Medicine at BMC who refer patients to the program. We asked staff members about their roles and their perception of the program’s impact on patient linkage to HCV treatment. We probed PCPs about their experiences with HCV screening, referral, and follow-up processes, and differences in accessing HCV treatment for their patients prior to and following the implementation of the program. We audiotaped and transcribed interviews, and identified major themes through qualitative analysis. RESULTS: We identified five major themes that characterize how the HCV treatment program delivers care: 1) efficiency (“So here I feel like…they get evaluated…they get treated. Boom, it’s done”); 2) clear and open communication (“…one of the strengths of our program is that we have…a lot of direct contact with patients…”); 3) personalized medicine (“…I've set up the pill box for them [patients]…we tailor it to whatever they need”); 4) high patient engagement (“So if I get a referral for a patient…I call the patient three times. If I haven’t heard from the patient…I send them a letter and I tell the PCP”); 5) patient empowerment through education (“I think patient education is the best thing…if the patient is involved then… they’ll do what they need to do”). Additionally, the public health social worker and the pharmacist play key roles in the program. The social worker supports patients throughout treatment and addresses psychosocial barriers to treatment engagement (“I had a patient…who stopped taking his medication because his apartment was infested with bed bugs…[Social worker] got the patient furniture for free and got an exterminator…”). The pharmacist provides medication management during face-to-face patient visits (“…I go over everything imaginable...proper adherence…adverse effects, interactions…”). CONCLUSIONS: The HCV treatment program at BMC is a promising model to deliver HCV treatment to urban, underserved patient populations. Our findings suggest that public health social workers and pharmacists may be one approach to increasing access to HCV treatment in primary care settings in the era of DAA medications. Further study of the program’s efficacy in improving HCV outcomes is warranted.

Hepatitis C Virus (HCV) is a small RNA virus that progresses to chronicity in 50-80% of infected individuals. Direct-acting antivirals (DAAs) are revolutionary treatments for HCV with 90-98% cure rates. However, over time, chronic HCV infections can result in advanced liver disease, including cirrhosis. Patients with advanced fibrosis experience a poor response to vaccination, recurrent infections and increased risk for hepatocellular carcinoma (HCC). These outcomes are, in part, a consequence of immune dysfunction. Increased inhibitory receptor and Galectin-9 (GAL-9) expression is a possible mechanism promoting lymphocyte dysfunction. In this study, blood samples were collected from chronic HCV patients with different degrees of liver fibrosis. I conducted a 13-parameter flow stain on the peripheral blood mononuclear cells (PBMC) of these patients. Next, I measured the expression of inhibitory receptors (PD-1, CTLA-4, LAG-3, TIGIT and TIM-3) and GAL-9 on bulk T cell and NK cells of 15 chronic HCV patients with no to moderate fibrosis (F0-F2) and 15 with advanced fibrosis (F3-F4). To analyze receptor co-expression, I employed t-distributed stochastic neighbor embedding (t-SNE) analysis to dimensionally reduce the multi-parametric data. Notably, I found that F3-F4 patients had higher frequencies of >3 inhibitory receptor co-expression on NK cells. Moreover, t-SNE analysis of bulk T cells revealed that F3-F4 patients manifest a higher frequency of cells in the clusters with CD25+TIGITmed-hi CD4+ T cells and PD-1medLAG-3med-hiGAL-9med-hi CD4+ T cells. t-SNE analysis of NK cells also showed that F3-F4 patients manifest a higher frequency of cells in the cluster with CD25+TIGITmed-hiTIM-3med-hi CD56Dim NK cells and CCR7+ PD-1medLAG-3med-hiGAL-9med-hi CD56Dim NK cells. Lastly, the frequency of cells in these clusters was found to positively correlate with patient’s extent of liver damage. In conclusion, I identified phenotypes of immune dysregulation that could explain the increased susceptibility to infection and HCC in chronic HCV patients with advanced fibrosis. These phenotypes could identify targets for combinatorial checkpoint blockade therapy to potentially improve immune function in these patients.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第20989号 / 医博第4335号 / 新制||医||1027(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 朝長 啓造, 教授 松田 文彦, 教授 小柳 義夫 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Until recently, the standard therapy for hepatitis C treatment has been interferon and ribavirin. Such treatment has only 50% efficacy and is not well tolerated. The emergence of new drugs has increased the treatment efficacy to 90%. Despite such an achievement, the success is limited since the virus mutates rapidly, causing the emergence of drug resistant forms. In addition, most new drugs were developed to treat genotype 1 infections. Thus, development of new potent antivirals is needed and drug discovery against hepatitis C is continued. In this thesis, a FRET-based protease assay was used to evaluate new pyrazinone based NS3 protease inhibitors that are structurally different to the newly approved and currently developing drugs. Several compounds in this series showed good potencies in the nanomolar range against NS3 proteases from genotype 1, 3, and the drug resistance variant R155K. We assume that these compounds can be further developed into drug candidates that possess activity against above mentioned enzyme variants. By using SPR technology, we analyzed interaction mechanisms and characteristics of allosteric inhibitors targeting NS5B polymerases from genotypes 1 and 3. The compounds exhibited different binding mechanisms and displayed a low affinity against NS5B from genotype 3. In order to evaluate the activity and inhibitors of the NS5B polymerase, we established an SPR based assay, which enables the monitoring of polymerization and its inhibition in real time. This assay can readily be implemented for the discovery of inhibitors targeting HCV. An SPR based fragment screening approach has also been established. A screen of a fragment library has been performed in order to identify novel scaffolds that can be used as a starting point for development of new allosteric inhibitors against NS5B polymerase. Selected fragments will be further elaborated to generate a new potent allosteric drug candidate. Alternative approaches have successfully been developed and implemented to the discovery of potential lead compounds targeting two important HCV drug targets.

Hepatitis C virus (HCV) infection globally affects 130-150 million people. It causes both acute and chronic infections. Due to the severe side effects and low success rates of interferon based treatments, which formed the standard treatment for HCV, the treatment paradigm shifted to direct acting antivirals (DAAs). DAAs have revolutionized the treatment of hepatitis C virus infection. Clinical trials with combinations of DAAs have recorded >90% response with shorter treatment durations and fewer side effects than earlier treatments involving IFN. Outside the controlled setting of a clinical trial, however, response rates with DAA combinations are much lower (<70%). DAAs can fail if HCV accumulates mutations that confer drug resistance. Interestingly, the pre-existence of mutant frequency in the virus appears not to influence treatment outcome. A better predictor for DAA treatment outcome is yet to be unravelled. Surprisingly, individuals who respond poorly to IFN appear to be more likely to fail DAA treatment. IFN is a generic antiviral that improves immune responses and is expected not to have any bearing on DAA treatment outcomes. Why individuals with poor IFN sensitivity fail DAA treatment remains a mystery. In a recent study of the IFN signalling network, HCV has been shown to compromise IFN activity. It induces bistability in the network leading to distinct phenotypic responses of cells to IFN exposure. In particular, individuals who respond poorly to IFN tend to have a higher percentage of cells that are refractory to IFN; these cells allow viral persistence despite IFN exposure. We hypothesized here that in such individuals, greater ongoing replication would allow increased development of resistance and thus lead to the failure of DAAs. We constructed a model of viral dynamics that accounts for the distinct phenotypic responses of cells to IFN, viral replication and mutation, and the development of resistance to DAAs. Our model predicted that although the relative prevalence of pre- existing mutants is unaffected by IFN sensitivity, in agreement with observations, the growth of drug resistant mutants is accelerated in individuals with poor IFN sensitivity. Based on a distribution of IFN sensitivity across individuals, our model accurately described clinical observations of the response rates to different current treatment protocols. With this model, we predict that the common strategy of increasing the genetic barrier by adding more drugs to the combination was not necessary to avert the development of drug resistance. Instead, an optimised increase in DAA dosage alone or DAA+PR or PR dosage depending on the patient’s IFN sensitivity could help achieve success.

Les vascularites cryoglobulinémiques associées au virus de l'hépatite C (VC-VHC) sont caractérisées par une expansion clonale de lymphocytes B mémoires anergiques CD27+IgM+CD21-/low (Bm21-), un défaut quantitatif en lymphocytes T régulateurs (Tregs) et une polarisation Th1. Les antiviraux d'action directe sans interferon (DAAs) sont très efficaces chez les patients VC-VHC mais leur mécanisme d'action sur l'immunité cellulaire reste inconnu. Nous montrons que les DAAs normalisent la plupart des perturbations de l'homéostasie lymphocytaire B et T, en diminuant l'expansion des Bm21- et T folliculaires, et en augmentant les T régulateurs (Tregs). Nous avons étudié l'effet des Bm21- sur les sous-populations lymphocytaires T, et les réactivités de leur récepteur B. Nous montrons que les Bm21- stimulés par le CpG favorisent la sécrétion d'IFNγ par les T effecteurs et induisent leur prolifération. Inversement, les Bm21- stimulés par CpG diminuent la capacité proliférative des Tregs. Nous montrons la diversité intraclonale des IgM mutés des Bm21-, conduite par maturation d'affinité antigène dépendante. Les anticorps (Ac) des Bm21- ont une activité facteur rhumatoïde (FR) mais ne sont ni polyréactifs, ni autoréactifs contre les autoantigènes ubiquitaires. Les Ac des Bm21- ne présentent pas de réactivité croisée contre des antigènes viraux du VHC. Les Bm21- stimulés par CpG ont une signature transcriptomique révélant un phénotype non tolérogène. Ainsi, ces résultats suggèrent le rôle majeur des Bm21- dans le défaut tolérance des patients CV-VHC, à la fois par la stimulation CpG conduisant à une réactivation des Bm21- anergiques, et par l'expression clonale des IgM à activité FR. / Hepatitis C virus-associated cryoglobulinemia vasculitis (HCV-CV) is characterized by an abnormal clonal expansion of anergic CD27+IgM+CD21-/low memory B cell (Bm21-), a quantitative defect in regulatory T cells (Tregs) and Th1 profile. Interferon-free direct-acting antivirals (DAAs) proved to be very effective in patients with HCV-CV but their mechanisms of action and their effects on cellular immunity remain poorly defined. Our results indicate that DAAs effectively normalizes many of the disturbances in peripheral B- and T-lymphocyte homeostasis of HCV-CV patients, by reducting Bm21- and T follicular helper expansion and promoting Tregs. Then, we investigated the effects of Bm21- on T-cell subpopulations and study the reactivities of their B-cell receptors. We show that CpG-stimulated Bm21- promote the secretion of IFNγ by effector T cells and induce their proliferation. Conversely, stimulated Bm21- reduce the proliferative capacity of regulatory T cells. Bm21- B-cell expansions show intraclonal diversity of highly mutated IgM antibodies that were shape by an antigen-driven maturation process. Bm21- antibodies possess rheumatoid factor activity but are neither polyreactive nor recognize ubiquitous autoantigens. No crossreactivity of Bm21- antibodies against several HCV antigens was observed. We also identify a transcriptional signature in CpG-stimulated Bm21- revealing a phenotype sufficient to break the immune tolerance. Thus, these results strongly suggest a major role for Bm21- in defective tolerance of HCV-CV patients, both through CpG stimulation leading to reactivation of anergic Bm21-, and through the clonal expression of IgM antibodies with RF activity.

Le traitement du virus de l'hépatite C (VHC) a connu une révolution récente, rapide et exemplaire grâce à l'arrivée des agents antiviraux directs (AAD) en plusieurs vagues depuis 2011, détrônant ainsi la bithérapie interféron-pégylé/ribavirine. Ces nouveaux traitements ont été rapidement confrontés à des limites concernant leur efficacité et leur tolérance notamment à leurs débuts avec les inhibiteurs de la protéase NS3/4A de première génération. L'arrivée de nouveaux AAD sur le marché lors d'une 2ème vague en 2014 a permis toutefois de surpasser celles-ci et de devenir le traitement de référence du VHC.Leur efficacité remarquable a laissé naître l'idée d'une potentielle élimination du VHC grâce à l'utilisation universelle de ces traitements. Cependant, leur coût élevé et les comportements à risque observés dans des sous-groupes de population (utilisateurs de drogues intraveineuses et homosexuels) restent encore des problématiques cruciales à surmonter pour espérer atteindre les objectifs fixés par l'Organisation Mondiale de la Santé en 2030 concernant l'élimination du VHC. De plus ces traitements, permettant l'élimination virale quasi-systématique et donc consécutivement une diminution du risque de complications hépatiques, ont été récemment confrontés à une polémique concernant un potentiel risque de récidive précoce de carcinome hépatocellulaire (CHC) suite à une exposition à ces derniers.Le travail présenté dans cette thèse s'articule autour de trois problématiques ayant toutes pour objectif principal d'optimiser l'utilisation de ces traitements dans l'optique de contrôler l'histoire naturelle de la maladie à l'échelle individuelle et à l'échelle populationnelle par l'intermédiaire de diverses méthodes statistiques.Nos résultats ont permis de montrer au sein d’une première problématique ayant exploré l'efficacité et la tolérance de ces traitements antiviraux à l’échelle individuelle: (i) une efficacité antivirale moindre que celle annoncée dans les essais de phase III des inhibiteurs de protéase de première génération(télaprévir et bocéprévir), (ii) un effet indésirable significatif des inhibiteurs de protéase de première génération sur la fonction rénale, (iii) une tolérance moins bonne de ces premières molécules que lors du traitement par bithérapie avec une incidence accrue d'anémie probablement liée à un surdosage en ribavirine induit par les inhibiteurs de protéase et (iv) une efficacité antivirale remarquable des AAD arrivés depuis 2014 sans impact des caractéristiques du patient ni des dosages pharmacologiques sur la réponse virologique. Dans un second temps, la problématique d'un risque de récidive de CHC accru après un traitement par AAD a également été explorée par l'analyse d'une cohorte locale, celle-ci ayant conclu à l'absence de risque accru comparé à un groupe de patients non exposés. Enfin, nos travaux basés sur la modélisation de la transmission du VHC en France dans la population coinfectée VIH-VHCont montré qu'un taux annuel de traitement par AAD de 50% était nécessaire dans la population homosexuelle ayant des pratiques à haut-risque de transmission pour contrer l'épidémie actuellement observée.Nos travaux ont donc permis d'apporter des données pour optimiser l'utilisation des nouveaux traitements anti-VHC par l'intermédiaire de diverses approches statistiques et ont apporté des éléments de réponse aux grandes problématiques actuelles. L'efficacité exemplaire et la tolérance quasi-parfaite des dernières molécules antivirales permettent une utilisation universelle de ces traitements dans toutes les populations de patients. Des études complémentaires robustes sont cependant nécessaires pour apporter des arguments à la question de la récidive du CHC. Des efforts sont également attendus concernant l'accès au traitement, la diminution des coûts associés et un dépistage renforcé du VHC pour espérer pouvoir éradiquer un jour cette maladie. / The arrival of direct-acting antivirals agents (DAAs) has spurred a rapid revolution in the treatment of hepatitis C virus (HCV), supplanting the previous standard of care, i.e. pegylated interferon and ribavirin. These new treatments are associated with an increased rate of virological response however they rapidly faced some limits more particularly at the beginning with the first generation NS3/4A protease inhibitors. From 2014 on the second wave of DAA was available for treatment of chronic HCV infection and surpassed previous encountered limits. These treatments are nowadays the gold standard for HCV treatment in high-income countries.The idea of HCV eradication recently emerged since DAA treatment are highly effective. However, their associated high cost and recent high-risk behaviors associated with an increased risk of HCV transmission (among intravenous drug users and homosexuals) have been reported. These issues need therefore to be addressed in order to achieve the objectives of the World Health Organization for 2030 of an HCV eradication. Moreover, these treatments allow a sustained virological response in almost all patients and consequently reduce the risk of liver-related complications, but a recent controversy regarding a potential increased risk of hepatocellular carcinoma after DAA treatment has been raised.Three issues will be extensively discussed in this manuscript regarding how these treatments can be used to optimize their effect on HCV natural history at the individual and population level through different statistical approaches.As regards the first issue, this project allowed us to demonstrate regarding the tolerance and efficacy of DAA treatment: (i) a lower antiviral efficacy than previously reported in the phase III trials for first generationprotease inhibitor regimen (telaprevir and boceprevir), (ii) impairment of renal function during first generation protease inhibitor treatment, (iii) an increased rate of reported side effects during first-generation protease inhibitor treatment and more particularly anemia, potentially related to an increased ribavirin biodisponibility induced by protease inhibitor intake and (iv) a remarkable antiviral efficacy of second generation DAAs without impact of patients' characteristics norpharmacology on virological response rate. The recent issue regarding a higher risk of HCC recurrence after DAA treatment was also explored through a local cohort study and no impact of DAA treatment was observed when comparing DAA-exposed vs non DAA-exposed patients. Finally, we conducted amodelling study on HCV transmission in the coinfected HIV-HCV French population and our results suggested that an annual DAA treatment coverage rate of 50% was required in the homosexual population with high-risk behaviors to counter the recent observed epidemic in this population.Our different works provide new insights on how to optimize the use of DAA treatment through several statistical approaches and bring new elements for discussion on the recent controversy. The new DAA have an excellent efficacy and tolerance profile and should be universally used in all populations without restriction. However, further studies are required to explore on a deeper level the question regarding HCC recurrence after DAA treatment. Efforts are also still needed regarding DAA treatment access, associated costs and HCV screening to reach the objective of HCV eradication

Le virus de l’hépatite C (VHC) est un agent causateur de maladies du foie important responsable d’une pandémie affectant près de 180 millions d’individus mondialement. L’absence de symptômes dans les premières années d’infection entraîne des diagnostics tardifs qui empêchent la prise en charge rapide des patients avant l’apparition d’une fibrose et, dans près de 16 % des cas d’infection, d’une cirrhose. En exploitant les interactions protéine-protéine membranaires, des essais utilisant la technologie BRET, dans les cellules vivantes, ont été précédemment optimisés afin d’établir le réseau complet des interactions du VHC. En utilisant les fondements de cette étude, un essai à haut débit dans les cellules vivantes a été réalisé pour identifier de nouveaux composés anti-VHC ciblant une nouvelle interaction NS3/4A-NS3/4A. Approximativement 110,000 petites molécules ont été criblées pour leurs effets sur l’homodimérization de NS3/4A et ont été classées par rapport à leur spécificité et à leur puissance contre le VHC. Au terme de cette étude, UM42811 a été identifié comme un activateur potentiel de l’interaction NS3/4A-NS3/4A offrant une activité antivirale prometteuse dotant une excellente fenêtre thérapeutique. Par la suite, un séquençage exhaustif des virus, soumis à un traitement de UM42811, a permis d’établir le profil de résistance du VHC contre ce composé. Grâce à cette fine cartographie, il a été possible d’identifier un nouveau mécanisme d’inhibition de NS3/4A qui est indépendant de son activité protéase. En utilisant les données de notre groupe sur les interactions VHC-hôte, il a été possible de continuer la caractérisation fonctionnelle du composé UM42811 en étudiant son effet sur les interactions potentiellement bénéfiques à la persistance virale. Pour ce faire, les protéines associées au transport nucléaire et mitochondriale qui sont des interactants de choix de NS3/4A ont été priorisées. Parmi ces facteurs de l’hôte, l’étude de karyopherin subunit beta 1 (KPNB1) et de heat shock protein 60 (HSP60) a été priorisée. De façon intéressante, les expériences de co-immunoprécipitation ont démontré que UM42811 était capable de prévenir l’interaction KPNB1-NS3/4A ainsi que l’interaction HSP60-NS3/4A. De plus, les études ii fonctionnelles et les analyses d’immunobuvardage de type western ont démontré que l’interaction KPNB1-NS3/4A avait des effets délétères sur l’induction des gènes stimulés par l’interféron (ISG). Finalement, il a été démontré que KPNB1 est possiblement clivé par NS3/4A suggérant la présence potentielle d’un mécanisme de subversion ou d’échappement. En bref, cette étude démontre la puissance des stratégies impliquant les interactions protéine-protéine dans les cellules vivantes pour l’identification de nouveaux composés inhibiteurs, caractérise un nouveau mécanisme d’inhibition anti-VHC et révèle la possibilité d’un nouveau mécanisme d’évasion du système immunitaire. / Hepatitis C virus (HCV) is an important causative agent for liver diseases and is responsible for a worldwide pandemic affecting roughly 180 million individuals worldwide. Late diagnosis following the progression to fibrosis and to cirrhosis, in nearly 16% of chronic infections, is attributed to the absence of symptoms in the first years of infection. By exploiting membrane protein-protein interactions (PPI), live cell assays using bioluminescence resonance energy transfer (BRET) technology have previously been optimized to complete a comprehensive hepatitis C virus (HCV) protein interaction network. Using the groundwork laid by this network study, a high-throughput assay (HTS) cell-based assay was implemented to identify novel inhibitory compounds targeting an unreported NS3/4A-NS3/4A interaction. Approximately 110,000 compounds from a small-molecule collection were screened to monitor modulation of NS3/4A homodimerization and were discriminated based on specificity and potency. UM42811 was identified as a potential NS3/4A-NS3/4A interaction activator and found to have a promising antiviral activity boasting an excellent therapeutic window. Combined deep sequencing and mutation mapping have yielded a resistance profile based on statistical and functional probability pointing towards a novel inhibitory mechanism targeting the HCV NS3/4A independent from protease activity inhibition. Data from an HCV to host protein interaction network generated by our group was used to analyze alternative effects of UM42811 on interactions which potentially benefit viral persistence. NS3/4A-specific host interactors were heavily associated with nuclear and mitochondrial transport based on Gene Ontology (GO). Among these specific interactors, karyopherin subunit beta 1 (KPNB1) and heat shock protein 60 (HSP60) were selected for further study. Interestingly, co-immunoprecipitation experiments revealed that UM42811 was able to prevent both KPNB1-NS3/4A and HSP60-NS3/4A interactions. Moreover, functional and western analysis revealed the KPNB1-NS3/4A interaction to have deleterious effects on iv interferon stimulated gene (ISG) induction. Unexpectedly, analysis revealed a putative NS3/4A mediated cleavage of KPNB1. Overall, this study demonstrates the strength of cell-based PPI strategies in the identification of novel HCV antiviral compounds, characterizes a novel inhibitory mechanism for HCV and reveals a potentially novel viral immune evasion mechanism.