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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
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
slide23

ExclusionCriteria

InclusionCriteria

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)

slide45

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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