Research Article JOURNAL

Viral Hepatitis OF HEPATOLOGY

96 weeks treatment of tenofovir alafenamide vs. tenofovir

disoproxil fumarate for hepatitis B virus infection
Kosh Agarwal1,⇑, Maurizia Brunetto2, Wai Kay Seto3, Young-Suk Lim4, Scott Fung5,
Patrick Marcellin6, Sang Hoon Ahn7, Namiki Izumi8, Wan–Long Chuang9, Ho Bae10,
Manoj Sharma11, Harry L.A. Janssen12,13, Calvin Q. Pan14, Mustafa Kemal Çelen15,
Norihiro Furusyo16, Dr. Shalimar17, Ki Tae Yoon18, Huy Trinh19, John F. Flaherty20, Anuj Gaggar20,
Audrey H. Lau20, Andrea L. Cathcart20, Lanjia Lin20, Neeru Bhardwaj20, Vithika Suri20,
G. Mani Subramanian20, Edward J. Gane21, Maria Buti22, Henry L.Y. Chan23,⇑,
and the GS-US-320-0108 Investigators
1
Kings College Hospital, London, United Kingdom; 2University of Pisa, Pisa, Italy; 3University of Hong Kong, Hong Kong; 4Asan Medical Center,
University of Ulsan College of Medicine, Seoul, South Korea; 5Toronto General Hospital, Toronto, ON, Canada; 6Hôpital Beaujon, Clichy, France;
7
Yonsei University, Seoul, South Korea; 8Musashino Red Cross Hospital, Tokyo, Japan; 9Kaohsiung Medical University Hospital, Kaohsiung Medical
University, Kaohsiung, Taiwan; 10Asian Pacific Liver Center, St. Vincent Medical Center, Los Angeles, USA; 11Institute of Liver and Biliary
Sciences, New Delhi, India; 12Toronto Western Hospital, Toronto, ON, Canada; 13Erasmus Medical Center, Rotterdam, The Netherlands;
14
NYU Langone Medical Center, NYU School of Medicine, New York, USA; 15Dicle University Hospital Infectious Diseases, Diyarbakir, Turkey;
16
Kyushu University Hospital, Fukuoka, Japan; 17All India Institute of Medical Sciences, New Delhi, Delhi, India; 18Pusan National University
Yangsan Hospital, Yangsan, South Korea; 19San Jose Gastroenterology, San Jose, USA; 20Gilead Sciences, Foster City, CA, USA; 21Auckland Clinical
Studies, Auckland, New Zealand; 22Hospital Universitario Valle Hebron, Barcelona, Spain; 23The Chinese University of Hong Kong, Hong Kong

Background & Aims: Tenofovir alafenamide (TAF) is a new
prodrug of tenofovir developed to treat patients with chronic
hepatitis B virus (HBV) infection at a lower dose than tenofovir
disoproxil fumarate (TDF) through more efficient delivery of
tenofovir to hepatocytes. In 48-week results from two ongoing,
double-blind, randomized phase III trials, TAF was non-inferior
to TDF in efficacy with improved renal and bone safety. We
report 96-week outcomes for both trials.
Methods: In two international trials, patients with chronic HBV
infection were randomized 2:1 to receive 25 mg TAF or 300 mg
TDF in a double-blinded fashion. One study enrolled HBeAg-
positive patients and the other HBeAg-negative patients. We
assessed efficacy in each study, and safety in the pooled population.
Results: At week 96, the differences in the rates of viral sup-
pression were similar in HBeAg-positive patients receiving TAF
and TDF (73% vs. 75%, respectively, adjusted difference
2.2%
(95% CI
8.3 to 3.9%; p = 0.47), and in HBeAg-negative patients
receiving TAF and TDF (90% vs. 91%, respectively, adjusted dif-
ference
0.6% (95% CI
7.0 to 5.8%; p = 0.84). In both studies
the proportions of patients with alanine aminotransferase above
the upper limit of normal at baseline, who had normal alanine
aminotransferase at week 96 of treatment, were significantly
higher in patients receiving TAF than in those receiving TDF.
In the pooled safety population, patients receiving TAF had sig-
nificantly smaller decreases in bone mineral density than those
receiving TDF in the hip (mean % change
0.33% vs.
2.51%;
Keywords: Chronic hepatitis B virus; Bone safety; Renal safety.
Received 3 August 2017; received in revised form 13 October 2017; accepted 12
November 2017
⇑ Corresponding authors. Addresses: Kings College Hospital, London, United Kingdom
(K. Agarwal), or The Chinese University of Hong Kong, Hong Kong (H.L.Y. Chan).
E-mail addresses: kosh.agarwal@nhs.net (K. Agarwal), hlychan@cuhk.edu.hk
(H.L.Y. Chan).
p <0.001) and lumbar spine (mean % change
0.75% vs.

2.57%; p <0.001), as well as a significantly smaller median
change in estimated glomerular filtration rate by Cockcroft-
Gault method (
1.2 vs.
4.8 mg/dl; p <0.001).
Conclusion: In patients with HBV infection, TAF remained as
effective as TDF, with continued improved renal and bone
safety, two years after the initiation of treatment. Clinicaltrials.-
gov number: NCT01940471 and NCT01940341.
Lay summary: At week 96 of two ongoing studies comparing
the efficacy and safety of tenofovir alafenamide (TAF) to teno-
fovir disoproxil fumarate (TDF) for the treatment of chronic
hepatitis B patients, TAF continues to be as effective as TDF with
continued improved renal and bone safety.
Registration: Clinicaltrials.gov number: NCT01940471 and
NCT01940341.
Ó 2017 European Association for the Study of the Liver. Published by
Elsevier B.V. All rights reserved.
Introduction
The World Health Organization estimates that approximately
240 million people worldwide are chronically infected with
the hepatitis B virus (HBV).1 Without treatment, chronic HBV
infection can cause progressive liver fibrosis, which may lead
to cirrhosis, decompensation, and hepatocellular carcinoma.2–4
Suppressive antiviral treatment has been shown to reduce the
risk of liver-related complications, and can halt or even reverse
disease progression.5–7 However, since few patients achieve
seroclearance of the hepatitis B surface antigen (HBsAg), which
is considered the hallmark of functional cure, treatment is gen-
erally life-long.6–9 In an aging population with comorbidities,
side effects of treatment such as renal and bone complications
can be problematic with long-term treatment.9–13

Journal of Hepatology 2018 vol. xxx j xxx–xxx

Please cite this article in press as: Agarwal K et al. 96 weeks treatment of tenofovir alafenamide vs. tenofovir disoproxil fumarate for hepatitis B virus infection. J Hepatol (2018), https://doi.org/
10.1016/j.jhep.2017.11.039
Research Article
Tenofovir alafenamide (TAF) is an orally bioavailable prodrug
of tenofovir (TFV), a nucleotide analog that inhibits reverse tran-
scription of HIV and HBV.14–16 TAF was designed to have greater
plasma stability than tenofovir disoproxil fumarate (TDF) allow-
ing delivery of the active metabolite, tenofovir diphosphate, to
hepatocytes more efficiently than TDF, which must be dosed
at relatively high levels to achieve a therapeutic concentration
in hepatic cells.17,18 Because of this high systemic exposure of
tenofovir (TFV), the long-term use of TDF has been be associated
with bone and renal toxicity in some patients.10,13,19–21 When
TAF is administered at a dose of 25 mg to patients with HBV
or HIV infection, circulating levels of TFV were approximately
90% lower than levels with the standard 300 mg dose of
TDF.22,23
GS-US-320-0110 and GS-US-320-0108 are large, ongoing,
randomized, double-blind, international phase III trials
designed to compare the efficacy and safety of TAF with that
of TDF in treatment-naïve and treatment-experienced patients
with chronic HBV infection, including those with compensated
cirrhosis. The studies were identical in design except that
GS-US-320-0110 enrolled only patients with HBeAg-positive
HBV infection and GS-US-320-0108 enrolled only patients with
HBeAg-negative HBV infection. After 48 weeks, TAF was shown
in both studies to be statistically non-inferior to TDF in antiviral
efficacy, as measured by rates of suppression of HBV DNA to
<29 IU/ml.24,25 Moreover, patients receiving TAF in both trials
had significantly smaller decreases in bone mineral density
(BMD) in the lumbar spine and hip, smaller increases in serum
creatinine and smaller decreases in estimated creatinine clear-
ance, as well as other biomarkers of bone and renal safety than
TDF. In the current report, we present 96-week results from
both trials.
Patients and methods
Patients and study design
The designs of these two randomized, double-blind, active-
controlled international phase III trials have been described pre-
viously.24,25 Briefly, patients were at least 18 years of age with
chronic HBV infection (with HBV DNA levels of at least 20,000
IU/ml), alanine transaminase (ALT) levels of >60 U/L in men or
>38 U/L in women, and estimated creatinine clearance of at least
50 ml/min (by the Cockcroft-Gault method). We excluded
patients with platelet count ≤50,000 cells/ll, hemoglobin <10
g/dl, albumin <3 g/dl, direct bilirubin of >2.5 times the upper
limit of normal (ULN), and aspartate transaminase or ALT >10
times the ULN. Patients with evidence of decompensation (i.e.
clinical ascites, encephalopathy, or variceal hemorrhage) and
those with hepatocellular carcinoma were not enrolled. Full eligi-
bility criteria are provided in the supplementary information.
Patients in both trials were randomly assigned in a 2:1 ratio
to receive TAF 25 mg orally once daily or TDF 300 mg orally
once daily. All patients received placebo tablets matching the
alternative treatment (i.e. patients assigned to receive TAF also
received a matching TDF placebo tablet, and vice versa). Patients
and investigators were blinded to treatment assignment
throughout the 96 weeks of the double-blind phase. Members
of the clinical research and biometrics departments of the spon-
sor were unblinded at the 48-week timepoint for the assess-
ments related to the primary analysis. Randomization was
stratified by screening HBV DNA levels (≥8 log10 IU/ml vs. 7 to
8 log10 IU/ml vs. <7 log10 IU/ml in Study GS-US-320-0108, and
2 Journal of Hepatology 2018 vol. xxx j xxx–xxx
Please cite this article in press as: Agarwal K et al. 96 weeks treatment of tenofovir alafenamide vs. tenofovir disoproxil fumarate for hepatitis B virus infection. J Hepatol (2018), https://doi.org/
10.1016/j.jhep.2017.11.039
Viral Hepatitis
≥8 log10 IU/ml vs. <8 log10 IU/ml in Study GS-US-320-0110)
and prior oral antiviral treatment (naïve vs. previously treated).
Before enrollment, written informed consent was obtained
from all patients. The study was approved by the institutional
review board or independent ethics committees at all partici-
pating sites and was conducted in accordance with the princi-
ples of the Declaration of Helsinki and Good Clinical Practice.
All authors had access to the study data and had reviewed
and approved the final manuscript.
Procedures
Study visits occurred every four weeks starting at treatment
week four until treatment week 48, after which study visits
occurred every eight weeks. Laboratory assessments included
hematologic analysis, serum chemistry tests, fasting lipid
parameters, and measures of renal function (serum creatinine,
estimated glomerular filtration rate, proteinuria by dipstick),
as well as quantitative markers of proteinuria (protein to crea-
tinine ratio, albumin to creatinine ratio, retinol-binding protein
to creatinine ratio, b2-microglobulin to creatinine ratio; Cov-
ance Laboratories, Indianapolis, IN, USA). Percentage change in
BMD was assessed in all patients by dual energy x-ray absorp-
tiometry scans of the lumbar spine and hip at screening, and
every 24 weeks thereafter. Biomarkers of bone turnover were
also assessed, including C-type collagen sequence, which is
associated with bone resorption, and bone-specific alkaline
phosphatase, osteocalcin, and procollagen type 1 N-terminal
propeptide, which are all associated with bone formation.
Outcomes
Efficacy endpoints for this week 96 analysis were the proportion
of patients with HBV DNA <29 IU/ml, proportions of patients
with HBsAg loss and seroconversion to anti-HBs, and, in the
HBeAg-positive patients, proportions of patients HBeAg loss
and seroconversion to anti-HBe. Other prespecified week 96
efficacy endpoints include proportion of patients with ALT nor-
malization (defined as ALT above the ULN at baseline but within
the normal range at week 96) and the incidence of drug-
resistant mutations. We assessed ALT using normal ranges set
by the central laboratory (Covance), and those set forth in the
American Association for the Study of the Liver Diseases
(AASLD) guidelines.8 Resistance analyses included population
or deep sequencing of the HBV polymerase/reverse transcrip-
tase region in all patients with HBV DNA ≥69 IU/ml at week
96 or those who discontinued the study early with viremia
(HBV DNA ≥69 IU/ml) after a minimum of 24 weeks of treat-
ment. Safety endpoints at week 96 included percentage change
in hip BMD, percentage change in spine BMD, and changes in
renal function, as measured by serum creatinine and estimated
glomerular filtration rate (eGFRCG) determined by the
Cockcroft-Gault method.
Statistical analysis
For the primary efficacy analysis, the difference in proportions
between treatment groups and its 95% CI was calculated based
on the Mantel-Haenszel proportions adjusted by baseline HBV
DNA categories and oral antiviral treatment status (naïve vs.
experienced) strata. P values were from the Cochran-Mantel-
Haenszel tests stratified by baseline HBV DNA categories and
oral antiviral treatment status strata.
For further details regarding the materials used, please refer
to the CTAT table and supplementary information.

Role of the funding source
The study sponsor oversaw trial management, data collection,
and statistical analyses. The first draft of the report was pre-
pared by a medical writer employed by the sponsor. The corre-
sponding authors had full access to all data in the study and had
final responsibility for the decision to submit for publication.
Results
Patient disposition
Of the 873 HBeAg-positive patients originally randomized and
treated in the GS-US-320-0110 study (581 to TAF and 292 to
receive TDF), 792 (91%; 530 TAF and 262 TDF) completed two
years of double-blind treatment. Of the 425 HBeAg-negative
patients originally randomized and treated in the GS-US-320-
0108 trial, 395 (93%; 266 TAF and 129 TDF) completed two
years double-blind treatment at the time of this analysis. Fur-
ther details on patient disposition are provided (Figs. S1 and
S2), as well as details regarding treatment-emergent adverse
events leading to treatment discontinuation (Table S1).
The baseline demographic characteristics of the patients for
the individual studies were described in the 48-week
reports.24,25 The patients characteristics of the pooled popula-
tion are shown (Table 1). The characteristics of patients receiv-
ing TAF and TDF were similar. Most patients were male (63%)
and Asian (79%), with a mean age of 41 years. Mean HBV DNA
and median ALT at baseline were 7.0 log10 IU/ml and 80 U/L,
respectively. Two-thirds of patients were HBeAg-positive and
the most common HBV genotype was C, observed in about half
(48%) of patients, followed by genotype D (25%), genotype B
(19%), and genotype A (7%). Median estimated glomerular filtra-
tion rate estimated by the Cockcroft-Gault method (eGFRCG) for
patients at baseline was 106 ml/min. Comorbidities (hyperten-
sion, diabetes mellitus, cardiovascular disease, and hyperlipi-
demia) were present in a small percentage (<13%) of the
overall study population with a similar distribution between
the TAF and TDF groups.
Efficacy
Antiviral efficacy
The proportion of HBeAg-positive patients receiving TAF who
had HBV DNA <29 IU/ml at week 96 was 73% (423 of 581
patients), compared to 75% (218 of 292 patients) of those
receiving TDF (Fig. 1A and Table 2). The adjusted difference
was
2.2% (95% CI
8.3% to 3.9%; p = 0.47). At week 96, the
lower bound of the two-sided 95% CI of the adjusted difference
(TAF – TDF) in the response rate was greater than the prespec-
ified
10% margin used to determine noninferiority for the pri-
mary efficacy endpoint (proportion of patients with HBV DNA
<29 IU/ml) at week 48. In patients with HBV DNA <29 IU/ml,
the proportion of patients with HBV DNA ‘‘target not detected”
was 14% (81 of 581 patients) in patients receiving TAF compared
to 9% (25 of 292 patients) of patients receiving TDF. Of the 873
patients randomized and treated, 232 did not have HBV DNA
<29 IU/ml at week 96. Of these, 148 had observed treatment
failure (HBV DNA ≥29 IU/ml) at the week-96 visit: 106 patients
(18%) receiving TAF and 42 patients (14%) receiving TDF. Of
those with observed treatment failure there was a higher pro-
portion of patients in the TAF group (n = 28; 5%) compared with
the TDF group (n = 6; 2%) with HBV DNA values ≥29 IU/ml and
<69 IU/ml. There were 84 patients who were considered treat-
ment failures at week 96 for nonvirologic reasons: 52 patients
Journal of Hepatology 2018 vol. xxx j xxx–xxx
Please cite this article in press as: Agarwal K et al. 96 weeks treatment of tenofovir alafenamide vs. tenofovir disoproxil fumarate for hepatitis B virus infection. J Hepatol (2018), https://doi.org/
10.1016/j.jhep.2017.11.039
JOURNAL
OF HEPATOLOGY
(9%) receiving TAF and 32 patients (11%) receiving TDF; the rea-
sons for treatment failure (lack of efficacy, early discontinua-
tions for an adverse event or death, other reasons [e.g.
withdrawal of consent or lost to follow-up], or those having
missing data within the analysis window but remaining on
study) were similar between groups.
The proportion of HBeAg-negative patients receiving TAF
who had HBV DNA <29 IU/ml at week 96 was 90% (257 of 285
patients), compared to 91% (127 of 140 patients) of those receiv-
ing TDF (Fig. 1B and Table 2). The adjusted difference was
0.6%
(95% CI
7.0% to 5.8%; p = 0.84). At week 96, the lower bound of
the two-sided 95% CI of the adjusted difference (TAF – TDF) in
the response rate was greater than the prespecified
10% mar-
gin used to determine noninferiority for the primary efficacy
endpoint (proportion of patients with HBV DNA <29 IU/ml) at
week 48. In patients with HBV DNA <29 IU/ml, the proportion
of patients with HBV DNA ‘‘target not detected” was 33% (93
of 285 patients) in patients receiving TAF compared to 31%
(44 of 140 patients) of patients receiving TDF. Of the 425
patients randomized and treated, 41 were considered treatment
failures at week 96. Of these, eight had observed treatment fail-
ure (HBV DNA ≥29 IU/ml) at the week-96 visit: five patients (2%)
receiving TAF and three patients (2%) receiving TDF. There were
33 patients who failed treatment at week 96 for nonvirologic
reasons: 23 patients (8%) in the TAF group and 10 patients
(7%) in the TDF group; the reasons for nonvirologic failure were
similar between treatment groups.
ALT normalization
The proportion of HBeAg-positive patients receiving TAF with
ALT above the ULN at baseline who had normal ALT at week
96 of treatment by central laboratory criteria was 75%, com-
pared to 68% among patients receiving TDF; the difference of
8.0% was statistically significant (95% CI 1.2% to 14.7%; p =
0.017) (Table 2). The same was true using laboratory criteria
recommended by the AASLD (≤30 U/L for men and ≤19 U/L for
women), a significantly higher proportion of patients receiving
TAF achieved normalized ALT than those receiving TDF (52%
vs. 42%, a difference in proportions of 10.6% (95% CI 3.6% to
17.6%; p = 0.003). Patients receiving TAF had higher rates of
ALT normalization than patients receiving TDF at every study
visit after week 8 (Fig. 2).
The proportion of HBeAg-negative patients receiving TAF,
with ALT above the ULN at baseline, who had normal ALT at
week 96 of treatment by central laboratory criteria was 81%,
compared to 71% among patients receiving TDF; the difference
of 9.8% was statistically significant (95% CI 0.2% to 19.3%;
p = 0.038) (Table 2). When assessed using laboratory criteria
recommended by the AASLD, a significantly higher proportion
of patients receiving TAF than those receiving TDF achieved
normalized ALT (50% vs. 40%, a difference in proportions of
10.9% [95% CI 0.8% to 21.0%]; p = 0.035). Moreover, patients
receiving TAF had higher rates of ALT normalization than
patients receiving TDF at every study visit after week 4 (Fig. 2).
HBeAg and HBsAg loss and seroconversion
The rate of HBeAg loss among HBeAg-positive patients receiving
TAF was 22% (123/565) at week 96, which was not statistically
different from the rate of 18% (51/285) among patients receiv-
ing TDF; the rate of HBeAg seroconversion was also numerically
higher among patients receiving TAF than among those
receiving TDF, but the difference did not achieve statistical
3
Research Article Viral Hepatitis

Table 1. Patient characteristics in the pooled population.

TAF 25 mg TDF 300 mg Total
(n = 866) (n = 432) (N = 1,298)
Mean age, years (range) 40 (18–80) 41 (18–72) 41 (18–80)
Male sex, n (%) 544 (63) 275 (64) 819 (63)
Race
Asian 687 (79) 333 (77) 1,020 (79)
White 167 (19) 87 (20) 254 (20)
Black 7 (1) 6 (1) 13 (1)
Pacific Islander 3 (<1) 3 (1) 6 (<1)
Other 2 (<1) 3 (1) 5 (<1)
Mean HBV DNA, log10 IU/ml (range) 7.0 (1.8–9.9) 7.0 (1.4–9.9) 7.0 (1.4–9.9)
Median ALT (Q1, Q3) 80 (56, 123) 80 (53, 130) 80 (54, 125)
HBeAg status
Positive 569 (66) 290 (67) 859 (66)
Negative 297 (34) 142 (33) 439 (34)
HBV genotype
A 54 (6) 31 (7) 85 (7)
B 160 (18) 88 (20) 248 (19)
C 418 (48) 200 (46) 618 (48)
D 224 (26) 105 (24) 329 (25)
E 7 (1) 3 (1) 10 (1)
F 3 (<1) 2 (<1) 5 (<1)
H 0 2 (<1) 2 (<1)
Unknown 0 1 (<1) 1 (<1)
Patients with known cirrhosis 65/636 (10) 38/326 (12) 103/962 (11)
Mean Fibrotest score (range) 0.37 (0.04–0.98) 0.37 (0.03–0.99) 0.37 (0.03–0.99)
Fibrotest score ≥0.75 76/846 (9) 42/421 (10) 118/1267 (9)
Median eGFR by Cockcroft-Gault (Q1, Q3) 106 (91, 125) 105 (90, 124) 106 (91, 125)
Diabetes mellitus 57 (7) 29 (7) 86 (7)
Cardiovascular disease 28 (3) 14 (3) 42 (3)
Hypertension 98 (11) 61 (14) 159 (12)
Hyperlipidemia 76 (9) 42 (10) 118 (9)
Total hip bone mineral density clinical status
Normal (T-score ≥
1.0) 570 (67) 285 (67) 855 (67)
Osteopenia (
2.5 ≤T-score <
1.0) 256 (30) 131 (31) 387 (30)
Osteoporosis (T-score <
2.5) 12 (1) 2 (<1) 14 (1)
Not determined 13 (2) 8 (2) 21 (2)
Lumbar spine bone mineral density clinical status
Normal (T-score ≥
1.0) 477 (56) 237 (56) 714 (56)
Osteopenia (
2.5 ≤T-score <
1.0) 309 (36) 152 (36) 461 (36)
Osteoporosis (T-score <
2.5) 57 (7) 29 (7) 86 (7)
Not determined 13 (2) 8 (2) 21 (2)
25-hydroxy vitamin D, ng/ml n = 861 n = 429 n = 1,290
Median (Q1, Q3) 17.2 (12.8, 22.4) 17.2 (12.4, 22.4) 17.2 (12.8, 22.4)
<20 ng/ml 546 (63) 276 (64) 822 (64)
ALT, alanine aminotransferase; eGFR, estimated glomerular filtration rate; HBeAg, Hepatitis B e antigen; HBV, hepatitis B virus; TAF, tenofovir alafenamide; TDF, tenofovir
disoproxil fumarate.

significance (18% [99/565] vs. 12% [35/285], respectively,
p = 0.05). In both groups, the rate of HBsAg loss at week 96
was 1%: 7 of 576 of patients receiving TAF, and 4 of 288 patients
receiving TDF. HBsAg seroconversion at week 96 was experi-
enced by 6 of 576 patients (1%) receiving TAF and no patients
receiving TDF. At baseline, mean levels of HBsAg were similar
between treatment groups (4.0 and 4.1 log10 IU/ml, for the
TAF and TDF groups, respectively), and similar mean declines
were observed at week 96 (
0.51 and
0.64 log10 IU/ml for
the TAF and TDF groups, respectively; p = 0.13).
One patient in the study in HBeAg-negative patients experi-
enced loss of HBsAg: a 44-year-old Asian woman with genotype
A infection who was receiving TAF tested negative for HBsAg at
week 64 and achieved seroconversion to anti-HBs at week 80
which persisted through week 96. At baseline, mean HBsAg
levels were similar between treatment groups (3.4 log10 IU/ml
in both groups); small and similar mean declines in HBsAg
levels were observed at week 96 (
0.14 and
0.10, for the
TAF and TDF groups, respectively; p = 0.50).
Response in subgroups
Among patients with HBeAg-positive infection, differences in
the proportion of patients with HBV DNA <29 IU/ml at week
96 were not significantly different between treatment groups
in predefined subgroups according to age (<50 years or ≥50
years), sex, race (Asian or non-Asian), baseline HBV DNA level
(<8 log10 IU/ml or ≥8 log10 IU/ml), treatment status
(treatment-experienced or treatment naïve), genotype (A/D or
B/C), baseline ALT level (≤ULN or >ULN by central laboratory
normal range), and baseline FibroTest score (<0.75 or ≥0.75)
(Fig. S3). In the small subgroup of patients with <95% adherence
by pill count, a lower response rate was seen in the TAF group
(40% or 8/20 patients) compared with the TDF group (82% or 9
of 11 patients); however, this difference is due in a large part

4 Journal of Hepatology 2018 vol. xxx j xxx–xxx

Please cite this article in press as: Agarwal K et al. 96 weeks treatment of tenofovir alafenamide vs. tenofovir disoproxil fumarate for hepatitis B virus infection. J Hepatol (2018), https://doi.org/
10.1016/j.jhep.2017.11.039
 JOURNAL
OF HEPATOLOGY

Proportion of HBeAg-positive patients with
A HBV DNA <29 IU/ml by study visit
Tenofovir alafenamide 25 mg
Tenofovir disoproxil fumarate 300 mg
100
Proportions of patients (%)
breakthrough (i.e. persistent viremia above 69 IU/ml), with 36
patients qualifying with virologic breakthrough (confirmed
HBV DNA ≥69 IU/ml after achieving <69 IU/ml, or >1 log10 IU/
ml increase in HBV DNA from nadir). Of these, 11 of 36 (31%)
experienced virologic breakthrough associated with nonadher-

ence to study medication. Overall, no HBV pol/RT amino acid

80 substitutions associated with resistance to tenofovir were
detected through week 96 in the TAF or TDF groups in either
60 study.
p = 0.47
40 Safety
The pooled safety analysis populations included 866 patients
20
receiving TAF and 432 receiving TDF. Both treatments were well
tolerated; the majority of patients experienced only adverse
0
events that were mild to moderate in severity (Table 3). The
0 16 32 48 64 80 96
Time (weeks) proportion of patients who discontinued treatment due to
adverse events was low in both groups: 13 patients (2%) receiv-
Proportion of HBeAg-negative patients with
B HBV DNA <29 IU/ml by study visit
ing TAF and four patients (1%) receiving TDF. The types and fre-
quencies of adverse events did not differ from those previously
Tenofovir alafenamide 25 mg
Tenofovir disoproxil fumarate 300 mg
reported at week 48.24,25 The most common adverse events
were headache, nasopharyngitis, and upper respiratory tract
100
Proportions of patients (%)

infection (Table 3). Seven percent of patients in both groups,

80
60
40
20
0 to presumed cardiopulmonary arrest at week 64).
0 16 32 48 64
Time (weeks)
Fig. 1. Viral suppression by visit week. (A) shows proportion of HBeAg-
positive patients with HBV DNA <29 IU/ml by study visit. (B) Shows
proportion of HBeAg-negative patients with HBV DNA <29 IU/ml by study
visit. p value by Cochran-Mantel-Haenszel tests stratified by baseline HBV
DNA categories and oral antiviral treatment status. HBeAg, hepatitis B e
antigen; HBV, hepatitis B virus.
to a high proportion of TAF patients (7 of the 12 treatment fail-
ures) having missing data (i.e. early study drug discontinuation)
at week 96.
The proportion of HBeAg-negative patients with HBV DNA
<29 IU/ml at week 96 was not significantly different between
the two treatments in predefined subgroups, including age
(≥50 or <50), sex, race (Asian or non-Asian), HBV genotype
(A/D or B/C), treatment status (naïve or experienced), baseline
HBV DNA (<7, or ≥7 log10 IU/ml), baseline ALT (> or ≤ULN by
central laboratory), baseline FibroTest score (≥ or <0.75), and
study drug adherence (<95% or ≥95%) (Fig. S3).
Resistance surveillance
Of the 1,298 patients who were randomized and treated in both
studies, 1,242 entered year two of the study. Of these, 132 (11%)
met the criteria for resistance testing at week 96, 87 patients
receiving TAF and 45 receiving TDF. The types of sequence
changes observed were similar for the TAF and TDF groups, with
the majority of patients having virus that was unable to
sequence, due to low viral load, or having no sequence changes
from baseline at the consensus sequence level (59%). Most
patients who qualified had viremia in the absence of virologic
60 patients receiving TAF and 29 receiving TDF experienced
serious adverse events, none of which were deemed by the
p = 0.84
investigator to be related to study treatment. No patient died
during treatment, but five patients (two TAF and three TDF) died
while off treatment (two deaths were due to HCC, 1 TAF patient
and 1 TDF patient, at weeks 66 and 56, respectively; 1 TAF
patient due to H1NI influenza at week 14; 1 TDF patient due
to bilateral bronchopneumonia at week 59; 1 TDF patient due
80 96 Similar percentages of patients receiving both drugs experi-
enced grade 3 or 4 laboratory abnormalities, 36% of patients
receiving TAF and 34% of patients receiving TDF. The most com-
mon grade 3 and 4 laboratory abnormalities were elevations in
ALT (8% and 10% of patients receiving TAF and TDF, respectively)
and AST (3% and 5% of patients, respectively). Five (1%) patients
receiving TAF and 4 (1%) patients receiving TDF experienced an
ALT flare (elevation in serum ALT value of >2 x baseline and >10
x ULN and confirmed upon retesting) during treatment; these
events occurred early in treatment (within the first one to two
months) and all resolved without sequelae. In the TAF group,
50 patients (6%) experienced grade 3 elevations in fasting LDL
cholesterol (no patients had a grade 4 elevation) which were
mostly isolated events seen in individuals with a history of dys-
lipidemia, an elevated LDL level at baseline, or both. Three
patients (1%) receiving TDF had grade 3 elevations in fasting
LDL cholesterol. For fasting glucose, 11 patients (1%) in the
TAF group experienced grade 3 elevations compared to none
in the TDF group; no patients had a grade 4 elevation. These ele-
vations were mostly isolated events seen in individuals with a
history of diabetes mellitus, an elevated fasting glucose level
at baseline, or both. No clinically meaningful differences were
detected in median (Q1, Q3) changes from baseline in fasting
glucose levels at week 96 between TAF and TDF groups in both
HBeAg-positive and HBeAg-negative patients.
The mean percentage decrease in hip BMD from baseline to
week 96 was
0.33% (95% CI
0.51 to
0.14) for patients
receiving TAF, which was significantly less than the reduction
of
2.51% (95% CI
2.82 to
2.21) for patients receiving TDF
(p <0.001) (Fig. 3A). Similarly, the mean percentage decrease
in spine BMD from baseline to week 96 was
0.75% (95% CI

Journal of Hepatology 2018 vol. xxx j xxx–xxx 5

Please cite this article in press as: Agarwal K et al. 96 weeks treatment of tenofovir alafenamide vs. tenofovir disoproxil fumarate for hepatitis B virus infection. J Hepatol (2018), https://doi.org/
10.1016/j.jhep.2017.11.039
Research Article Viral Hepatitis

Table 2. Efficacy outcomes at week 96.

HBeAg-positive patients HBeAg-negative patients
TAF 25 mg TDF Difference in p value TAF 25 mg TDF Difference in p value
(n = 581) 300 mg proportions (n = 285) 300 mg proportions
(n = 292) (95% CI) (n = 140) (95% CI)
HBV DNA <29 IU/ml 423 (73%) 218 (75%)
2.2% 0.47 257 (90%) 127 (91%)
0.6% 0.84
(
8.3% to 3.9%) (
7.0% to 5.8%)
HBeAg loss, n/N (%)* 123/565 (22%) 51/285 (18%) 3.7% 0.20 — — — —
(
1.9% to 9.4%)
HBeAg seroconversion, 99/565 (18%) 35/285 (12%) 5.1% 0.05 — — — —
n/N (%)* (0.2% to 10.1%)
HBsAg loss, n/N (%)y 7/576 (1%) 4/288 (1%)
0.1% 0.88 1/281 (<1%) 0 0.1% 0.72
(
2.0% to 1.8%) (
2.5% to 2.7%)
HBsAg seroconversion, 6/576 (1%) 0 1.1% 0.078 1/281 (<1%) 0 0.1% 0.72
n/N (%)y (
0.3% to 2.4%) (
2.5% to 2.7%)
Normalized ALT by 405/537 (75%) 181/268 (68%) 8.0% 0.017 191/236 (81%) 86/121 (71%) 9.8% 0.038
Central Lab (1.2% to 14.7%) (0.2% to 19.3%)
Normal Range, n/N (%)à
Normalized ALT by 299/572 (52%) 121/290 (42%) 10.6% 0.003 139/276 (50%) 55/138 (40%) 10.9% 0.035
AASLD Normal Range, n/N (%)§ (3.6% to 17.6%) (0.8% to 21.0%)
AASLD, American Association for the Study of Liver Diseases; ALT, alanine aminotransferase; HBeAg, hepatitis B e antigen; HBsAg, hepatitis B surface antigen; HBV, hepatitis
B virus; TAF, tenofovir alafenamide; TDF, tenofovir disoproxil fumarate.
*
Among patients who were seropositive for HBeAg and negative for anti-HBe at baseline.
y
Among patients who were seropositive for HBsAg and negative for anti-HBs at baseline.
à
Among patients with ALT at baseline above the central lab normal range.
§
Among patients with ALT at baseline above AASLD defined normal range.

1.01 to
0.49) for patients receiving TAF, which was signifi-
cantly less than the mean percentage change of
2.57% (95%
CI
2.97 to
2.18) in patients receiving TDF (p <0.001)
(Fig. 3B). Moreover, the magnitude of the difference in BMD
decreases between the TAF and TDF groups was significantly
greater at week 96 compared to the difference in decline
observed at week 48 (p <0.001; from mixed-model repeated
measures) when assessed at hip but not at spine
(Fig. 3A and B). These data, at least for hip, suggest that the
gap in difference in bone loss between the TDF and TAF groups
continues to widen over time.
When categorical percentage changes in hip and spine BMD
are evaluated, decreases of 7% or greater for hip and 5% or
greater for spine are considered clinically relevant. At week
96, 1.1% (8 of 740 patients) of the TAF group vs. 6% (21 of 369
patients) TDF patients demonstrated a ≥7% decrease in hip
BMD; for spine, 11% (82 of 746 patients) in the TAF group com-
pared to 25% (93 of 371 patients) in the TDF group were
observed to have a ≥5% decline in BMD (Table S2). Clinically, a
T-score is used to diagnose osteopenia (T-score ≥
2.5 to
<
1.0) or osteoporosis (<
2.5). At baseline, 570 patients in
the TAF group had a normal T-score (≥
1.0) and 285 patients
were normal in the TDF group with regard to hip BMD (Table 1).
At week 96, in the TAF group, 6% (28 patients) with available
data developed osteopenia whereas 16% (39 patients) devel-
oped osteopenia in the TDF group; no patients with a normal
T-score at baseline in either group developed osteoporosis. Of
the 256 TAF-treated patients with osteopenia at baseline, two
patients (1%) with available data at week 96 shifted to osteo-
porosis, compared with 4 of 131 (4%) of TDF-treated patients
(Table S3). Biomarkers associated with bone resorption (C-
type collagen sequence), formation (procollagen type 1 N-
terminal propeptide, bone-specific alkaline phosphatase, and
osteocalcin), and metabolism (parathyroid hormone) either
showed significantly smaller median percentage increases or
larger median percentage decreases at week 96 in patients
receiving TAF than those receiving TDF (Table S4). Fracture
events were uncommon in both groups and were generally
the result of trauma: nine patients (1%) receiving TAF and seven
patients (2%) receiving TDF experienced a fracture event. None
of the fractures were deemed related to the study drugs by
the investigators, and none resulted in discontinuation of study
drugs.
Patients in both groups had small mean increases in serum
creatinine from baseline to week 96; the mean increase of
0.003 mg/dl in patients receiving TAF was significantly smaller
than the increase of 0.019 mg/dl in patients receiving TDF (p
= 0.001). Patients receiving TAF had a significantly smaller med-
ian decrease in estimated glomerular filtration rate (by
Cockcroft-Gault equation; eGFRCG) than patients receiving TDF
(
1.2 ml/min vs.
4.8 ml/min, p <0.001) (Fig. 4). When assessed
as the percentage of patients experiencing a 25% or greater
decline in eGFRCG, a significantly smaller proportion of patients
receiving TAF compared with TDF met this endpoint (10% vs.
18%; p <0.001), and a smaller proportion of TAF patients experi-
enced a confirmed decline in eGFRCG below 50 ml/min com-
pared to TDF patients (0.1% TAF [1 patient] and 1.2% TDF [5
patients], respectively; p = 0.017). Independent predictors of
eGFRCG decline of ≥25% from baseline were identified by multi-
variate analysis and included the following characteristics: dia-
betes mellitus, treatment with TDF, vitamin D level below the
lower limit of the normal range, and baseline ALT value >5 times
ULN by AASLD criteria (Tables S5 and S6).
A similar proportion of patients in each group experienced a
confirmed decrease in serum phosphorus level below 2.0 mg/dl
(0.5% each group), and the median (Q1, Q3) change from base-
line at week 96 in serum phosphorus levels was also similar
for the TAF and TDF groups (
0.1 [
0.4, 0.2] vs.
0.1 [
0.4,
0.3]). The percentage of patients in each group with at least
one graded event of proteinuria by dipstick during the study

6 Journal of Hepatology 2018 vol. xxx j xxx–xxx

Please cite this article in press as: Agarwal K et al. 96 weeks treatment of tenofovir alafenamide vs. tenofovir disoproxil fumarate for hepatitis B virus infection. J Hepatol (2018), https://doi.org/
10.1016/j.jhep.2017.11.039
 JOURNAL
OF HEPATOLOGY

A Central Lab criteria B AASLD criteria

HBeAg-positive patients HBeAg-negative patients HBeAg-positive patients HBeAg-negative patients

Proportions of patients (%)

Proportions of patients (%)

100 Tenofovir alafenamide 25 mg 100 Tenofovir alafenamide 25 mg 100 Tenofovir alafenamide 25 mg 100 Tenofovir alafenamide 25 mg
Tenofovir disoproxil fumarate 300 mg Tenofovir disoproxil fumarate 300 mg Tenofovir disoproxil fumarate 300 mg Tenofovir disoproxil fumarate 300 mg

80 80 80 80
60 60 60 60
p = 0.017 p = 0.038
40 40 40 40
p = 0.003 p = 0.035
20 20 20 20

0 0 0 0
0 16 32 48 64 80 96 0 16 32 48 64 80 96 0 16 32 48 64 80 96 0 16 32 48 64 80 96
Time (weeks) Time (weeks) Time (weeks) Time (weeks)

Fig. 2. ALT Normalization by visit week. (A) shows proportion of patients achieving ALT normalization by central laboratory (Covance) criteria (≤34 U/L for
women <69 years or ≤32 for women ≥69 years; ≤43 U/L for men <69 years or ≤35 U/L for men ≥69 years) by study visit. (B) Shows proportion of patients
achieving ALT normalization by AASLD criteria (≤19 U/L for women and ≤30 U/L for men) by study visit. p value by Cochran-Mantel-Haenszel tests stratified by
baseline HBV DNA categories and oral antiviral treatment status. AASLD, American Association for the Study of Liver Diseases; ALT, alanine aminotransferase;
HBeAg, hepatitis B e antigen; HBV, hepatitis B virus.

Table 3. Safety data. increases from baseline to week 96 in the markers of proximal
tubular dysfunction urine retinol-binding protein to creatinine
TAF 25 mg TDF 300 mg
(n = 866) (n = 432) ratio and urine beta-2-microglobulin to creatinine ratio were
Patients with any adverse event 670 (77%) 327 (76%) significantly smaller among patients receiving TAF than among
Adverse event leading to study drug 13 (2%) 4 (1%) those receiving TDF (p <0.001 for the differences at every time-
discontinuation point through week 96) (Table S7). No patient in either group
Deaths 0 0 experienced a renal serious adverse event, a renal adverse event
Patients with grade 3 or 4 adverse events 58 (7%) 22 (5%) resulting in discontinuation of study drugs, an event of proximal
Patients with serious adverse event 60 (7%) 29 (7%) tubulopathy (including Fanconi syndrome), or an adverse event
Adverse events occurring in ≥5% of patients
of renal failure.
in any treatment group
Headache 104 (12%) 43 (10%)
Nasopharyngitis 105 (12%) 44 (10%)
Upper respiratory tract infection 98 (11%) 45 (10%) Discussion
Cough 70 (8%) 34 (8%) In reporting the 48-week outcomes for these large, randomized,
Back pain 54 (6%) 27 (6%)
phase III clinical trials, we noted that the interpretation of the
Fatigue 52 (6%) 23 (5%)
results was limited by the relatively short follow-up and that
Nausea 52 (6%) 24 (6%)
Dyspepsia 43 (5%) 22 (5%)
the durability of the favorable effects of TAF over TDF treatment
Diarrhea 47 (5%) 22 (5%) would need confirmation at a later timepoint. The present
Grade 3 or 4 laboratory abnormalities in ≥1% 96-week findings confirm these earlier results. Efficacy and
of patients in any treatment group* safety outcomes were consistent with those at week 48 for both
Alanine aminotransferase >5 ULN 72 (8%) 41 (10%) HBeAg-positive and HBeAg-negative patients, confirming that
Aspartate aminotransferase >5 ULN 30 (3%) 23 (5%) treatment with TAF resulted in a similar rate of viral suppres-
Amylase >2ULN 28 (3%) 13/427 (3%)
sion compared to that of TDF. Consistent with week 48 results,
Creatine kinase ≥10 ULN 28 (3%) 13 (3%)
treatment effects between TAF and TDF did not differ statisti-
Fasting cholesterol >300 mg/dl 10/857 0
(1%) cally in prespecified subgroups including age, race, region,
Fasting LDL cholesterol >190 mg/dl 50/843 3/418 (1%) HBV genotype, baseline HBV DNA level and prior oral antiviral
(6%) treatment status. Through 96 weeks of double-blind treatment,
Gamma glutamyl transferase >5x ULN 4 (<1%) 6 (1%) no resistance development was seen in either treatment group.
Hemoglobin <9.0 g/dl 7 (1%) 9/426 (2%) Further, the superior safety profile of TAF relative to TDF with
Segmented neutrophils <750/mm3 9 (1%) 3 (1%)
regard to bone and renal parameters seen at week 48 is con-
Fasting glucose >250 mg/dl 11 (1%) 0
firmed through 96 weeks of double-blind treatment.
Nonfasting glucose >250 mg/dl 31/856 7/426 (2%)
(4%) Another effect seen at both weeks 48 and 96 was that more
Occult blood 81 (9%) 39/426 (9%) patients in the TAF groups who had elevated ALT levels at base-
Urine erythrocytes 75/798 39/397 line achieved ALT normalization than those in the TDF groups.
(9%) (10%) At week 48, the difference was only significant when using
Urine glucose 44/859 7/426 (2%) the normal ranges for men and women proposed by AASLD. In
(5%)
the current week 96 analysis, the rate of ALT normalization
LDL, low-density lipoprotein; TAF, tenofovir alafenamide; TDF, tenofovir disoproxil was also significantly higher in both HBeAg-negative and
fumarate; ULN, upper limit of normal.
*
Laboratory results are based on 859 patients for TAF 25 mg, and 428 patients for HBeAg-positive patients receiving TAF when using the normal
TDF 300 mg, unless otherwise noted. ranges of the central laboratory which conducted the testing
(Covance). Given the consistency of this effect over time – the
was 72% (620 of 859) for patients receiving TAF and 75% (319 of rate of ALT normalization was higher for TAF than TDF patients
426) for patients receiving TDF; the difference was not statisti- at every visit after week 8 in both studies – there can be little
cally significant (p = 0.41). In contrast median percentage doubt that it is a treatment effect and not due to some

Journal of Hepatology 2018 vol. xxx j xxx–xxx 7

Please cite this article in press as: Agarwal K et al. 96 weeks treatment of tenofovir alafenamide vs. tenofovir disoproxil fumarate for hepatitis B virus infection. J Hepatol (2018), https://doi.org/
10.1016/j.jhep.2017.11.039
Research Article
A HIP
Mean change from baseline, % (SD) Tenofovir alafenamide 25 mg
Tenofovir disoproxil fumarate 300 mg
4
p <0.001
2
-0.15
0 -0.33
p <0.001
-2 -1.86
-4
-6
-8 24 48 72
Time (weeks)
SPINE
B Tenofovir alafenamide 25 mg
Tenofovir disoproxil fumarate 300 mg
Mean change from baseline, % (SD)
4 p = 0.80
2
0 -0.57
p <0.001
-2
-2.38
-4
-6
-8 24 48 72
Time (weeks)
Fig. 3. Changes in bone mineral density. (A) shows mean percentage change
in hip bone mineral density at weeks 24, 48, 72, and 96 of treatment. (B)
shows mean percentage change in spine bone mineral density at weeks 24,
48, 72, and 96 of treatment. p value to compare percent change from baseline
between treatment groups was calculated by ANOVA model including
treatment as a fixed effect. P value to compare the magnitude of the
difference in percent BMD decline between treatment groups at week 48 vs.
Week 96 was calculated by mixed-model repeated measures. BMD, bone
mineral density.
undetected bias in the randomized populations. Several
hypotheses about the cause of this unexpected effect have been
considered, and while exploratory investigations are currently
underway, the mechanism of this effect remains unknown.
TDF treatment is known to have a ‘‘lipid lowering effect” as
previously described in HIV infected patients wherein levels of
fasting total cholesterol, LDL cholesterol, and HDL cholesterol,
are all significantly reduced in patients who initiate or are
switched to TDF-containing therapy.26,27 However, the ratio of
total cholesterol to HDL is not significantly different following
TDF treatment; therefore, the clinical relevance of this lipid lower-
ing effect is unclear and a precise mechanism for these changes
has not been ascertained. In the integrated analysis of these two
phase III studies, median changes in fasting lipid parameters were
small in the TAF group while declines in all three fasting lipid
parameters and triglycerides were observed in the TDF group, con-
sistent with results seen in HIV patients (Table S8). Thus, com-
pared to TDF, TAF seems to demonstrate a ‘‘lipid neutral”
effect. As previously reported, at week 48, a higher proportion of
TAF-treated patients experienced grade 3 or higher levels of fast-
ing LDL (≥300 mg/dl) compared with the TDF group.25,28 Inte-
grated analysis at week 48 of available data from both studies
for 1,254 patients (data on file, Gilead Sciences) showed rates of
≥grade 3 fasting LDL levels were 4% with TAF and 1% with TDF.
At week 96 (Table 3), the rates were 6% with TAF and 1% with
TDF treatment, representing a small change after two years of
treatment.
8 Journal of Hepatology 2018 vol. xxx j xxx–xxx
Please cite this article in press as: Agarwal K et al. 96 weeks treatment of tenofovir alafenamide vs. tenofovir disoproxil fumarate for hepatitis B virus infection. J Hepatol (2018), https://doi.org/
10.1016/j.jhep.2017.11.039
Viral Hepatitis
10 Tenofovir alafenamide 25 mg
Median change from baseline,
Tenofovir disoproxil fumarate 300 mg
5
ml/min (Q1, Q3)
0
-1.2
p <0.001
p <0.001 -5 -4.8
-2.51
-10
-15
24 48 72 96
96 Time (weeks)
Fig. 4. Median change from baseline in eGFR (Cockcroft-Gault). The figure
shows median (Q1, Q3) change from baseline in estimated glomerular
filtration rate (ml/min, by Cockcroft-Gault) by study visit. p value calculated
by two-sided Wilcoxon rank sum test to compare the two treatment groups.
eGFR, estimated glomerular filtration rate.
Serologic responses were similar for TAF compared with TDF,
albeit among patients positive for HBeAg, the rates of HBeAg
-0.75
p <0.001 loss and anti-HBe seroconversion were numerically higher in
-2.57
patients receiving TAF than in those receiving TDF and in both
groups these rates increased from week 48 to week 96 and
are consistent with results from previous studies of TDF, partic-
ularly those in which treatment-experienced patients were
96 included.26,29 Also consistent with prior studies the rates of
HBsAg loss were low (approximately 1% in HBeAg-positive
patients) through two years of treatment, and mean declines
in HBsAg levels were small in both patient populations.
Safety outcomes at week 96 were also consistent with those
of week 48. Overall, both treatments were well tolerated with
the same rate of serious adverse events (7%) and low rates of
discontinuations due to adverse events (1–2%). There were,
however, significant differences between the groups in favor
of TAF in renal and bone safety. As noted, TAF was specifically
designed to substantially reduce systemic exposure to tenofovir,
which was thought to be causing these known abnormalities
associated with long-term TDF use.10,19–21 Regarding bone loss,
over two years minimal declines in hip and spine BMD were
observed with TAF treatment compared with progressive decli-
nes in BMD with TDF. This difference is particularly evident at
the hip, which continues to demonstrate ongoing significant
BMD decline with TDF therapy compared to TAF from week
48 to week 96. While the overall clinical implications of these
data will require longer term studies and follow-up, preventing
further BMD decline in patients is a meaningful clinical goal as it
is known that fracture risk increases exponentially as BMD
decreases.30 Similar to BMD findings, over two years of treat-
ment, the significant differences in declines in estimated
glomerular filtration rate and smaller changes in biomarkers
of proximal tubular function support that TAF has less of an
impact on renal function than TDF. A limitation of this renal
analysis is that the patients were all relatively healthy from a
renal perspective – all patients enrolled had creatinine clear-
ances ≥50 ml/min and most patients were ≤65 years old and
without comorbidities. While longer term follow-up will be
needed to fully characterize the renal safety profile of TAF, these
findings of lower renal impact compared to TDF are important
given the reports that link TDF use to kidney injury.19,31,32,20
This analysis has several limitations; while 96 weeks of treat-
ment has yielded similar findings to the week 48 analysis, longer
term data are required to better determine differences in clinical
outcomes. In both of these studies, double-blind treatment will be

continued through three years (week 144) in a substantial subset
of patients (approximately 58%) who had signed informed con-
sent for a recently enacted amendment to the study protocol
which allows another year of blinded therapy. Further, in both
studies all patients who roll over to open-label TAF treatment
(at either week 96 or week 144) will have the ability to continue
this therapy through eight years (week 384). Across both study
populations the proportion of patients considered to be at higher
risk of TDF-associated bone and renal complications (i.e. age over
60 years, history of clinically significant bone and/or renal dis-
ease)9 is relatively small (estimated to be less than 20%) and addi-
tional studies in these populations are warranted. Further, our
studies enrolled only viremic patients with elevated levels of
serum ALT at screening who are considered candidates for initiat-
ing antiviral treatment by all current guidelines.8,9,33 Whether the
safety advantages and comparable antiviral efficacy we observed
for TAF relative to TDF in these studies can be duplicated in virally
suppressed patients who switch treatment from TDF to TAF
remains to be determined. A preliminary analysis of 541 patients
enrolled in these two trials who switched from double-blind TDF
to open-label TAF at week 96 has shown significant improve-
ments in bone and renal parameters as early as 24 weeks follow-
ing switch.34 Of note, a large randomized, controlled trial to
evaluate the efficacy and safety of switching chronic HBV patients
who are suppressed on long-term TDF 300 mg once daily to TAF
25 mg once daily has been recently initiated (NCT02979613).
In conclusion, after two years of treatment, TAF remained as
effective in suppressing HBV replication as TDF with no viro-
logic resistance, and was associated with significantly less bone
and renal toxicity. The mechanism behind the superior rates of
ALT normalization for TAF over TDF remains to be elucidated.
Financial support
The study sponsor (Gilead Sciences) was involved with the
study design, collection, analysis, and interpretation of data.
Conflict of interest
Kosh Agarwal: Advisory Board and Speaker – AbbVie, Achillion,
BMS, GSK, Gilead, Intercept, Janssen, Merck, Novartis, Roche;
Consultant – AbbVie, Achillion, BMS, GSK, Gilead, Intercept,
Janssen, Merck, Novartis, Roche. Grant – BMS, Gilead, Roche.
Maurizia Brunetto: Advisory Board – Gilead, Merck, AbbVie,
Janssen; Speaker – AbbVie, BMS, Gilead, Janssen, Merck, Roche.
Wai Kay Seto: Advisory Board-Gilead, AbbVie, Bristol-Myers
Squibb; Speaker’s Bureau-Gilead, AbbVie, Bristol-Myers Squibb,
Novartis, AstraZeneca, Alfa Wassermann. Young-Suk Lim: Advi-
sory Board – Bayer, Bristol-Myers Squibb, Gilead; Research –
Bayer, Bristol-Myers Squibb, Gilead Sciences, Novartis; Speaker
– Bayer, Gilead. Sang Hoon Ahn: Advisory Board – Bristol-Myers
Squibb, Gilead, AbbVie, MSD; Research – Bristol-Myers Squibb,
Gilead Sciences, Roche. Namiki Izumi: Advisory Board-Gilead;
Speaker-Gilead, AbbVie, Shionogi, Otsuka, Bayer, MSD. Wan-
Long Chuang: Advisory board–Gilead, AbbVie, BMS, MSD,
PharmaEssentia; Speaker–Gilead, AbbVie, BMS, MSD,
PharmaEssentia, Roche. Ho Bae: Speaker and research grant for
Gilead. Harry L.A. Janssen: Grants – AbbVie, Bristol-Myers Squibb,
Gilead Sciences, Innogenetics, Janssen, MedImmune, Medronic,
Merck, Roche; Consultant – AbbVie, Benitec, Bristol-Myers
Squibb, Gilead Sciences, Janssen, MedImmune, Merck, Roche,
Arbutus. Calvin Q. Pan: Consultant – Gilead, AbbVie; Advisory
Journal of Hepatology 2018 vol. xxx j xxx–xxx
Please cite this article in press as: Agarwal K et al. 96 weeks treatment of tenofovir alafenamide vs. tenofovir disoproxil fumarate for hepatitis B virus infection. J Hepatol (2018), https://doi.org/
10.1016/j.jhep.2017.11.039
JOURNAL
OF HEPATOLOGY
Board – Gilead, BMS, AbbVie; Research – Gilead, Merck. Employ-
ees and stockholders of Gilead Sciences: John F. Flaherty, Anuj
Gaggar, Audrey H. Lau, Vithika Suri, Andrea L. Cathcart, Neeru
Bhardwaj, Lanjia Lin, and G. Mani Subramanian. Huy Trinh:
Research—Gilead, Intercept; Advisory Board and Speaker—Gilead.
Edward J. Gane: Advisory Board – AbbVie, ALIOS, Gilead, Janssen,
Roche; Speaker—Gilead, AbbVie. Maria Buti: Advisory Board and
Speaker – Gilead, MSD, BMS, Janssen, AbbVie. Henry L.Y. Chan:
Advisor and speaker for AbbVie, BMS, Gilead and Roche; Advisor
for Janssen; Speaker for MSD. No relevant conflicts of interest to
disclose: Scott Fung, Patrick Marcellin, Manoj Sharma, Mustafa
Kemal Çelen, Norihiro Furusyo, Dr. Shalimar, Ki Tae Yoon.
Please refer to the accompanying ICMJE disclosure forms for
further details.
Authors’ contributions
John F. Flaherty, Anuj Gaggar, G. and Mani Subramanian con-
tributed to the study concept and design. Kosh Agarwal, Maur-
izia Brunetto, Young-Suk Lim, Calvin Q. Pan, Maria Buti, Wai Kay
Seto, Scott Fung, Patrick Marcellin, Sang Hoon Ahn, Namiki
Izumi, Wan Long Chuang, Ho Bae, Manoj Sharma, Harry L.A.
Janssen Mustafa Kemal Çelen, Norihiro Furusyo, Dr. Shalimar,
Ki Tae Yoon, Huy Trinh, Edward Gane, and Henry L.Y. Chan con-
tributed to the acquisition of data. Lanjia Lin contributed to the
statistical analysis. All authors contributed to the analysis and
interpretation of data, drafting of the manuscript, critical revi-
sion of the manuscript for important intellectual content.
Acknowledgements
This study was sponsored by Gilead Sciences. Writing assistance
was provided by David McNeel of Gilead Sciences.
Supplementary data
Supplementary data associated with this article can be found, in
the online version, at https://doi.org/10.1016/j.jhep.2017.11.
039.
References
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