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HIV and Hepatitis B/C Co-infection Audit

HIV and Hepatitis B/C Co-infection Audit. Audit & Standards Sub-Committee: M Johnson (chair), M Backx, C Ball, G Brook, D Churchill, A De Ruiter, S Ellis, A Freedman, L Garvey, P Gupta, K Foster, V Harindra, C O’Mahony, E Monteiro,

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HIV and Hepatitis B/C Co-infection Audit

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  1. HIV and Hepatitis B/C Co-infection Audit Audit & Standards Sub-Committee: M Johnson (chair), M Backx, C Ball, G Brook, D Churchill, A De Ruiter, S Ellis, A Freedman, L Garvey, P Gupta, K Foster, V Harindra, C O’Mahony, E Monteiro, E Ong, K Orton, R Pebody, F Post, C Sabin, A Schwenk, A Sullivan, R Weston, E Wilkins, D Wilson, M Yeomans

  2. Background Chronic viral hepatitis: Global problem 350 million HBV and 170 million HCV UK prevalence 0.3% HBV, 0.44% HCV Many undiagnosed HIV and hepatitis B/C co-infection: Similar transmission routes Estimates HIV/HBV 3-10% in UK, higher elsewhere HIV/HCV rates vary by risk group Accelerated liver disease progression Increased risk of drug hepatotoxicity

  3. BHIVA Guidelines (2005) Screening of all HIV+ patients: At HIV diagnosis, non-immune HBV should be vaccinated Thereafter check serology and anti-HBs titre annually (aim > 100 IU/L) HIV+ patients with chronic HBV / HCV: Appropriately vaccinate (HAV / HBV) Discuss avoidance of alcohol, transmission prevention Trace and vaccinate contacts Clinical assessment, LFT and clotting. If significant liver disease subjects should be under joint care of HIV team and Hepatologist Screen for HCC in cirrhotics 6-monthly

  4. BHIVA Guidelines (2005) For HIV/HBV patients: HBeAg, HBV DNA Consider biopsy if active replication >2000 IU/mL (104 copies/mL) Consider treating HBeAg+ve (or high ALT + HBV DNA) TDF but not 3TC/FTC as sole anti-HBV agent (within HAART) Consider including TDF + 3TC/FTC in those on HAART Note Guidelines 2010: Recommend treatment if fibrosis present (at any HBV DNA level) or if HBV DNA >2000 IU/mL (CD4 based treatment algorithms) Liver imaging and biopsy or non-invasive fibrosis assessment

  5. BHIVA Guidelines (2005) For HIV/HCV patients: HCV RNA and genotype Consider biopsy to stage disease Consider HCV treatment especially if moderate disease (mild may defer) Treat HCV before commencing HAART if CD4+ >200 cells/uL Note Guidelines 2010: Liver imaging and biopsy or non-invasive fibrosis assessment Treat HCV before HAART if CD4+ >350 cells/uL

  6. Aims and Methods To describe care arrangements for HIV and hepatitis co-infected patients in the UK To assess adherence to BHIVA Guidelines (2005) Survey Sent to HIV Clinical Lead at each site Questions regarding type of centre, caseload, service provision for co-infected patients, issues or concerns Case note review Computerised questionnaire collecting clinical data and details of HIV and hepatitis treatment

  7. Methods Inclusion criteria: HIV Ab +ve adult patients Attended HIV services between April-September 2009 HBsAg +ve and/or HCV Ab +ve Exclusion criteria: HIV diagnosis pre-1999 Hepatitis cleared prior to HIV diagnosis HBV DNA or HCV RNA negative at time of first positive hepatitis serology and never subsequently positive

  8. Clinic Survey

  9. Results - response Clinic survey 140 sites responded to the survey 68 (49%) Outpatient HIV department 59 (42%) HIV centre 13 (9%) neither

  10. Arrangement for providing hepatitis treatment % sites NB totals do not add to 100% because respondents could select more than one option.

  11. Hepatitis testing at sites

  12. Annual hepatitis testing in HIV+ subjects BHIVA Guidelines: Check hepatitis B/C serology or titre annually (2005)

  13. Availability of tests BHIVA Guidelines: Check HBV DNA if HBsAg+ve (2005) Check HCV RNA and genotype if HCV Ab+ve Note: 15 sites in total reported some test restrictions (site not included if all co-infected patients referred elsewhere)

  14. Issues and concerns Positive comments: 39 sites - good liaison between HIV and Hepatology Co-infection clinics and specialist nurses appreciated, where available Concerns: 10 sites - communication could be improved 7 sites - concerns about referral delays/waiting times 4 sites - networks could be strengthened Other concerns: Lengthy travel distances, lost referrals, lack of language support, high DNA rates

  15. Patient case note review

  16. Patient characteristics 975 eligible patients (121 sites)

  17. Patient demographics

  18. Patient characteristics Some totals add to less than 100% due to missing data

  19. Prevention and health promotion

  20. Prevention and health promotion BHIVA Guidelines: Documented discussion alcohol avoidance and (2005) transmission reduction Documented discussion alcohol: 50% overall, (HBV 41%, HCV 58%) For majority the most recent documented discussion 2008-9 Transmission reduction: 58% documented evidence of discussion

  21. Prevention and health promotion BHIVA Guidelines: Documented discussion contact tracing (2005) and vaccination Contact tracing: 53% HBV cases had attempts to trace household/sexual contacts for immunisation 52% HCV cases had attempts to trace sexual/parenteral contacts for testing After excluding those known to be childless, evidence that 75 (40%) female patients had children tested for hepatitis

  22. Immunisation BHIVA Guidelines: Hepatitis A immunisation for all susceptible (2005) co-infected subjects % subjects

  23. Immunisation BHIVA Guidelines: Hepatitis B immunisation for all susceptible (2005) HCV -infected subjects % subjects

  24. Immunisation BHIVA Standards: Hepatitis B immunisation for all susceptible (2005) HCV -infected subjects % subjects

  25. Staging hepatitis disease

  26. Assessment using PCR tests BHIVA Guidelines: Check HBeAg and HBV DNA if HBsAg+ (2005) Check HCV RNA and genotype if HCV Ab+ % subjects

  27. Investigation of fibrosis • BHIVA Guidelines: HCV: consider biopsy to stage disease • (2005) HBV: consider if HBeAg+ (or high DNA and ALT) • Guidelines : biopsy / fibrosis assessment for all HBV/HCV Biopsy / fibrosis assessment: 205 (21%) all HBV/HCV patients had liver biopsy 32 (3%) had declined 354 (36%) patients had had biopsy, elastography or serum fibrosis markers assessed (47% of HCV, 25% of HBV)

  28. Markers of significant liver disease* • BHIVA Guidelines: Clinical assessment for evidence of cirrhosis (2005) LFT and clotting Markers of significant liver disease: 202 (21%) had ever had markers consistent with significant liver disease (134 HCV, 58 HBV, 10 HBV/HCV) ALT >5x ULN only marker for 126, including 56 acute HCV cases Of those with disease markers other than isolated ALT: 49 (64%) were under the care of a hepatologist / liver specialist 67 (88%) had documented management plan for care of HIV and liver disease *Markers were: cirrhosis, deranged clotting, serum ALT >5x normal, ascites, varices, splenomegaly, evidence of HCC *Markers were: cirrhosis, deranged clotting, serum ALT >5x ULN, ascites, varices, splenomegaly, evidence of hepatocellular carcinoma

  29. HCC screening in cirrhotic patients • BHIVA Guidelines: 6-monthly USS and AFP if cirrhotic • (2005) HCC screening: 33 (77%) of 43 cirrhotic patients had USS and AFP in past year 3 patients had HCC (2 HCV, 1 HBV)

  30. Hepatitis treatment

  31. Treatment of HBV BHIVA Guidelines: Consider treatment for HBeAg+ve subjects (2005) (or high HBV DNA+ALT) 477 HBV co-infected patients 415 (87%) on anti-HBV therapy 413 on HAART 62 (13%) not on anti-HBV therapy 1 on HAART

  32. Treatment of HBV BHIVA Guidelines: 3TC/FTC not sole anti-HBV agent (2005) If using HAART consider including TDF + 3TC/FTC 415 on HBV therapy 371(89%) TDF + FTC/3TC 7 (2%) other drugs 3 entecavir + 3TC/FTC 2 adefovir + 3TC 1 adefovir + telbivudine 1 adefovir 26 (6%) 3TC alone 11 (3%) TDF alone Most recent HBV DNA on 3TC alone: undetectable in 16, <2000 IU/ml in 3, >2000 IU/ml in 2 (TDF intolerance in 3 of 5 detectable)

  33. Treatment of HBV BHIVA Guidelines: Consider treatment for HBeAg+ve (2005) (or high DNA+ALT) 62 patients not on HBV therapy 16 (26%) HBeAg +ve • Most recent HBV DNA: • 16 >2000 IU/mL • 26 detectable <2000 IU/ml • 11 undetectable • 9 unavailable • Reasons given for not treating HBV: • 11 assessment/referral in process • 4 patient declined/wished to delay • 4 poor attendance/adherence • 16 considered unnecessary

  34. Treatment of HCV • BHIVA Guidelines: Consider treatment especially if moderate disease • (2005) Treat HCV before starting HAART if CD4+ >200 522 HCV co-infected patients 225 (43%) past or current HCV therapy 297 (57%) no HCV therapy

  35. Treatment of HCV • BHIVA Guidelines: Consider treatment especially if moderate disease • (2005) Treat HCV before starting HAART if CD4+ >200 297 (57%) no HCV therapy • Reasons given for non-treatment: • Patient declined (19%) • Clinical decision- genotype 1 or 4 with mild liver disease (17%) • Referral/assessment in process (16%) • Poor attendance (15%) • Spontaneous clearance (9%) • Mental illness (7%) • Low CD4/waiting to stabilise on HAART (5%) • Others included current/planned pregnancy, alcohol/drugs, medical/co-morbidity and social issues

  36. Conclusions

  37. Conclusions Overall audit achieved excellent participation Majority of co-infected patients diagnosed and managed according to BHIVA Guidelines Areas of concern: Hepatitis testing Approximately a third of sites do not re-test serology / titres annually Failure to vaccinate non-immune patients: 13% for HAV and 5% for HBV Areas of concern: Prevention and health promotion Documented discussion on alcohol avoidance and transmission reduction only in ~50%

  38. Conclusions Areas of concern: management of co-infected patients 64% co-infected patients had not had liver biopsy or fibrosis assessment ?wider availability / awareness non-invasive tests Some patients with markers of significant liver disease were not under the care of a liver specialist Some cirrhotic patients had not been screened for HCC within past year 6% of HBV/HIV patients on anti-HBV treatment were on 3TC monotherapy, some with detectable HBV DNA

  39. Conclusions

  40. Follow-up of TB co-infection audit Short questionnaire sent to participating sites 6 months after audit results 63 (48%) sites responded 50 (79%) discussed results within HIV department Of sites where TB managed by other teams, 15 (48%) had discussed results with relevant colleagues Comments: some improvements since audit, ongoing concerns regarding HIV-testing for all TB cases and delays in processing sputum smears Recommend: All sites should discuss results within HIV department and with relevant colleagues / departments

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