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HCV/HIV Co-infection: Understanding our Challenges and Opportunities. Kay Schwebke, MD, MPH Infectious Diseases HCMC HIV/AIDS Program. Case Presentation. 35 year old woman, HIV/HCV co-infected History of depression and polysubstance use disorder with ongoing alcohol use CD4 = 199

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Hcv hiv co infection understanding our challenges and opportunities

HCV/HIV Co-infection:Understanding our Challenges and Opportunities

Kay Schwebke, MD, MPH

Infectious Diseases

HCMC HIV/AIDS Program


Case presentation
Case Presentation

  • 35 year old woman, HIV/HCV co-infected

  • History of depression and polysubstance use disorder with ongoing alcohol use

    • CD4 = 199

    • HIV = 34,000

    • HCV genotype 3a, high viral level

    • Liver biopsy stage 2 (Sept 2004)


Case presentation1
Case Presentation

  • 46 year old man, HIV/HCV co-infected

  • Strong needle aversion

    • CD4 = 364 (HIV undetectable)

    • HCV genotype 3a, high viral level

    • Liver biopsy stage 2


Hiv hcv co infection
HIV/HCV Co-infection

  • HIV-infected persons are living longer

  • Approximately 30% of HIV-infected persons are co-infected with HCV

  • Liver-related problems complicate HAART

  • HIV accelerates the progression of HCV-related liver disease

  • End-stage liver disease has become a leading cause of death in persons with HIV infection


BaselineCharacteristics


Effect of hcv on hiv progression
Effect of HCV on HIV Progression

  • The effect of HCV on HIV disease is less clear

    • Does appear to impair immune recovery after starting HAART

    • HCV can complicate ability to provide HAART

    • Most studies show that HCV does not directly accelerate HIV disease progression


Steps to take after hcv diagnosis
Steps to take after HCV diagnosis

  • Patient education

  • Discuss alcohol and marijuana use - encourage abstinence

  • Baseline laboratory evaluation including liver function, platelet count, HCV genotype, and HCV quantitative RNA

  • Vaccinate against hepatitis A and B if indicated

  • Screen for hepatocellular carcinoma (HCC)

  • Discuss liver biopsy

  • Discuss treatment risks and benefits

  • Identify barriers to care

  • Define members of the healthcare team


ExclusionCriteria

InclusionCriteria



Percent change from baseline



Hiv hcv co infection treatment questions
HIV/HCV Co-infectionTreatment Questions

  • Who should be treated?

  • Which virus should be treated first ?

  • Are there unique adherence or safety concerns?

  • What are barriers to treatment?


Hiv hcv co infection who should be treated
HIV/HCV Co-infection: Who should be treated?

  • All patients with HIV and HCV should be considered for treatment

  • Patients with well controlled HIV disease

    • CD4 count > 200 cells/mm3 OR

    • CD4 count > 100 cells/mm3 but < 200 cells/mm3 HIV RNA < 5000 copies/mL

  • Patients with advanced liver disease by biopsy

  • No significant treatment contraindications


Treatment considerations individualize risks and benefits
Treatment Considerations:individualize risks and benefits

  • Any genotype but recognize different treatment responses

    • genotype 2/3 = 60-80%

    • genotype 1, LVL = 60%

    • genotype 1, HVL = 15%

  • Advanced liver disease (stage 2, 3, and stable 4)

  • Very motivated person

  • Stable

  • Adherent to medications and appointments


Hiv hcv co infection treatment order
HIV/HCV Co-Infection: Treatment Order?

  • Generally done on a case-by-case basis

  • Control of HIV disease should be given priority

  • If there is not an immediate need to initiate HIV-infection therapy, consider HCV treatment

  • Initiating treatment for both HCV and HIV infection simultaneously is not encouraged

    (wait 2-6 months)


262/326

171/262

Treatment Rates Among HCV/HIV Patients in an Urban Medical Center

60% Advanced Fibrosis

100

80%

80

65%

60% Completed Treatment

60

Number of Patients

40

32%

20

262/326

171/262

84/262

0

Evaluated for Treatment

Biopsy Performed

Treated for HCV

Suwandhi P, et al. Presented at AASLD 2008. Nov 1-4, 2008; San Francisco, CA. Poster #1265.


Hcmc co infection clinic
HCMC Co-infection Clinic

  • Identify potential barriers to treatment

  • Pharmacist provides extensive drug education

    • Informed consent

    • Discuss treatment protocol

    • Emphasize side-effect management

    • Emphasize importance of adherence

  • RN provides injection and injection education

    • Encourage initial weekly RN visits

    • Opportunity to check labs and side-effects

  • CBC week 1, 2, 4, then monthly if appropriate

  • MD encounter week 2, 4, then monthly if appropriate


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