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Hepatitis C and HIV/HCV Coinfection. Alan Franciscus Executive Director, Hepatitis C Support Project Editor-in-Chief, HCV Advocate—www.hcvadvocate.org Editor-in-Chief, HBV Advocate –www.hbvadvocate.org Follow us on Twitter and Facebook : hcvadvocate hbvadvocate. Agenda.

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Hepatitis c and hiv hcv coinfection
Hepatitis C and HIV/HCV Coinfection

Alan Franciscus

Executive Director, Hepatitis C Support Project

Editor-in-Chief, HCV Advocate—www.hcvadvocate.org

Editor-in-Chief, HBV Advocate –www.hbvadvocate.org

Follow us on Twitter and Facebook:

hcvadvocate

hbvadvocate

www.hcvadvocate.org


Agenda
Agenda

Overview of hepatitis C

Please hold questions until the end of the first session

HIV and Hepatitis C – differences and similarities

HIV and Hepatitis Coinfection

New Advances in hepatitis C care

www.hcvadvocate.org


Hepatitis c overview
Hepatitis C Overview

HCV Statistics

HCV Diagnostics

HCV transmission & Prevention

HCV Symptoms, Disease Progression, Management

HCV Treatment

www.hcvadvocate.org


Hepatitis c statistics
Hepatitis C Statistics

U.S. Population

  • 1.6% overall

    • ~4 million Americans infected

      • 3.2 million chronically infected

        • 2.1% Mexican Americans

        • 3.4% African Americans

www.hcvadvocate.org


Hepatitis c statistics montana
Hepatitis C Statistics - Montana

  • Montana

    • 967, 440 x 1.6% = ~15,500 people with HCV in Montana

  • 948 case of hepatitis C (chronic and acute) reported in 2008

    • Compare to HIV – 895 cases reported since 1985

  • Highest rates seen in American Indians and persons age 45-54 (2008)

www.hcvadvocate.org


Hcv diagnostics antibody tests
HCV Diagnostics: Antibody tests

  • HCV Elisa (EIA)

    • Most common antibody test

  • A positive antibody test indicates exposure

    • It does not indicate current hepatitis C infection

    • Orasure HCV Antibody Test – more later

www.hcvadvocate.org


Hc v diagnostics viral load tests
HC V Diagnostics: Viral Load Tests

  • Viral Load tests

    • PCR and TMA 5-10 IU/mL

    • HCV RNA by branched DNA Assay – > 500 IU/mL

  • Why Is a Viral Load Test Important?

    • To confirm active infection

    • Helps to predict treatment response

    • Indication that treatment is working

      ** Viral load does not correlate with disease progression**

www.hcvadvocate.org


Hcv diagnostics genotype test
HCV Diagnostics: Genotype Test

  • Genotypes (1,2,3,4,5,6)

    • U.S. population

      • 70% genotype 1

      • 30% genotypes 2 & 3

  • Why Is a Genotype Test Important?

    • Helps predict treatment response

    • Dictates treatment duration of 24 or 48 weeks

www.hcvadvocate.org


Hcv diagnostics liver biopsy
HCV Diagnostics: Liver Biopsy

  • Gold Standard for Determining the Health of the Liver

    • Measure of inflammation

    • Extent of scarring (if any)

  • Non-invasive methods – not as accurate

www.hcvadvocate.org


Transmission prevention
Transmission & Prevention

www.hcvadvocate.org


Transmission prevention1
Transmission & Prevention

  • HCV is not spread by breast feeding, sharing eating utensils or drinking glasses, kissing, hugging

  • Direct blood to blood transmission route

www.hcvadvocate.org


Transmission prevention tips
Transmission & Prevention: Tips

  • Injection and Non-Injection Drugs

    • Do not share needles, cookers, cottons, straws, pipes or any items that might come into contact with blood

    • Use bleach to clean

  • People in Stable Long-Term Monogamous Sexual Relationships

    • CDC – no need to change current sexual practices – but there is a risk

www.hcvadvocate.org


Transmission prevention tips1
Transmission & Prevention: Tips

  • Safer Sex

    • For so called “high risk groups”

      • Multiple sexual partners, people with sexually transmitted diseases, coinfection with HIV or HBV

      • Any situation where blood is present

www.hcvadvocate.org


Transmission prevention tips2
Transmission & Prevention: Tips

  • Mother to Child Transmission

    • Low risk – about 5-6%

    • Given the low rate of transmission, pregnancy should not be avoided.

      • Note: pregnant women can not take interferon or ribavirin

  • Health-Care Settings

    • Follow standard/universal precautions

www.hcvadvocate.org


Transmission prevention tips3
Transmission & Prevention: Tips

  • Tattoos & Piercing

    • Considered a low risk in commercial setting

      • Make sure disposable needles and separate ink pots are used and that general safety precautions are followed

    • Considered a higher risk in other settings

      • Non-commercial settings such as in prison or on the streets

www.hcvadvocate.org


Hepatitis c and hiv hcv coinfection

HCV Transmission & Prevention: Tips

  • Household

    • Cover cuts or sores

    • Do not share personal hygiene items (toothbrushes, razors, etc.)

  • Professional Personal Care Settings

    • Standard precautions

    • Disposable equipment

    • Bring own equipment

www.hcvadvocate.org


Chronic symptoms

Fatigue – mild to severe

Flu-like symptoms (muscle/joint/fever)

‘Brain Fog’

Liver pain

Loss of appetite

Headaches

Gastro problems

Chronic Symptoms

  • and more……

www.hcvadvocate.org


Hcv disease progression
HCV Disease Progression

  • 10-25% of HCV positive people progress on to serious disease over 10-40 years

    • Fibrosis

      • Light scarring

    • Cirrhosis

      • Compensated vs. decompensated

    • Steatosis

      • Fatty deposits in the liver

www.hcvadvocate.org


Disease progression managing hepatitis c
Disease Progression: Managing Hepatitis C

  • Regular medical monitoring

  • Get vaccinated – Hep A & Hep B

  • Healthy balanced diet www.mypyramid.gov

  • Exercise

  • Stress Reduction

  • Support Groups

  • Alcohol – Avoid or reduce

www.hcvadvocate.org


Hcv treatment
HCV Treatment

  • What is interferon?

    • General antiviral – immune booster

      • By injection

  • What is ribavirin?

    • Antiviral

      • Used only in combination with interferon

      • Pill or capsule

www.hcvadvocate.org


Treatment standard of care

Merck/Schering – PEG-Intron + Rebetol (800mg)

Genotype 1- 41% SVR (48 weeks)

Genotypes 2 thru 6 – 75% (48 weeks)

Genentech/Roche – Pegasys + Copegus (1000-1200 mg)

Genotype 1 – 44-51% SVR (48 weeks)

Genotypes 2 & 3 – 82% SVR (24 weeks)

Genotypes 2 thru 6 – 70% SVR (48 weeks)

*FDA Package Insert

Treatment - Standard of Care

www.hcvadvocate.org


Side effects

Interferon

Fatigue

Muscle/Joint pain

Nausea

Headaches

Anxiety

Depression

Dry Skin/Rashes

And more…..

Ribavirin

seems to make interferon side effects worse – especially fatigue – Anemia

**(both men & women must use birth control)

Side-effects

www.hcvadvocate.org


Managing side effects

Inject before bedtime

Drink lots of water

Low doses of ibuprofen or acetaminophen

Pain medications

Small frequent meals

Light exercise

Daily moisturizing

Vary injection sites

Anti-Depressants

Plenty of rest

Managing Side-Effects

Key: support from medical providers, family, friends, work – all areas of life

www.hcvadvocate.org


Complementary medicine
Complementary Medicine

  • Herbs – milk thistle, licorice root, etc.

    • Always check with your doctor and herbalist – some herbs are unsafe

  • Acupuncture / Acupressure

  • Traditional Chinese Medicine

www.hcvadvocate.org


Comparisons
Comparisons

HIV

HCV

  • Single stranded RNA

  • Retrovirus

  • Integrates into DNA

  • Single stranded RNA

  • Flavivirus

  • Does not integrate into DNA

www.hcvadvocate.org


Comparisons1
Comparisons

HIV

HCV

  • Mainly infects CD 4 cells

  • Daily – replicates billions

  • High mutation rate

  • Mainly infects liver cells

  • Daily – replicates trillions

  • Very high mutation rate

www.hcvadvocate.org


Comparisons2
Comparisons

HIV

HCV

  • Chronic – 100%

  • US – 1 major strain

  • High sexual transmission rate

  • High IDU transmission rates (Blood)

  • Chronic rates - 55-85%

  • US – 3 major strains

  • Low Sexual transmission rate

  • Very high IDU transmission rates (Blood)

www.hcvadvocate.org


Comparisons con t
Comparisons – Con’t

HIV

HCV

  • Cure?

    • No

  • Treatment - lifelong

  • Can become resistant

  • Cure?

    • Virological Cure

  • Treatment 24 to 48 weeks

  • No resistant issues yet

    • New direct antivirals will lead to resistance

www.hcvadvocate.org


Comparisons prevalence
Comparisons – Prevalence

HIV

HCV

U.S. –

  • ~1,000,000

  • U.S. –

  • ~4,000,000

www.hcvadvocate.org


Guidelines for prevention of opportunistic infections
Guidelines for Prevention of Opportunistic Infections

  • HIV – Infected persons should be screened for HCV

  • Patients should be advised on alcohol use

  • Patients should be screened for HAV & HBV if negative, they should be vaccinated

  • Patients should be evaluated for liver disease and possible need for treatment

  • Liver enzymes should be monitored after initiation of HAART

    *U.S. Public Health Service and the Infectious Disease Society of America

www.hcvadvocate.org


Hepatitis c vs hiv hcv coinfection
Hepatitis C vs. HIV/HCV Coinfection

Transmission / Prevention

Diagnosing HCV

HCV Disease Progression

HCV Treatment Response

www.hcvadvocate.org


Hcv transmission
HCV Transmission

HCV

HIV/HCV Coinfection

  • Sexual transmission is low (0-3%)

  • Mother-to-Child Transmission ~5-6%

    • HCV meds can cause birth defects

  • Sexual transmission is higher ~ 15-25%

  • Mother-to-Child Transmission ~25%

    • HCV meds can cause birth defects

www.hcvadvocate.org


Diagnosing hcv
Diagnosing HCV

Hepatitis C

HIV/HCV Coinfection

  • Antibody Test

  • HCV Viral load to confirm active infection

  • Antibody Test

    • Note: If low cd4 cell count use HCV RNA

  • HCV RNA to confirm active infection

*People with a comprised immune system may not develop HCV antibodies

www.hcvadvocate.org


Hcv disease progression1
HCV Disease Progression

Hepatitis C

HIV/HCV Coinfection

  • Slow rate of disease progression – usually over 10, 20, 30 years

  • Faster rate of disease progression to cirrhosis – up to 2-3 times faster & can occur in as little as 10 years

  • HCV coinfection is the leading cause of death among people with HIV

www.hcvadvocate.org


Does hcv make hiv worse
Does HCV Make HIV Worse?

  • Still a controversial issue but most experts do not believe that HCV makes HIV worse

    • HCV may blunt immune reconstitution

www.hcvadvocate.org


Does hiv make hcv worse
Does HIV Make HCV Worse?

  • HIV accelerates HCV disease progression – doubles the risk for cirrhosis and increases the chance for liver cancer

  • Some evidence suggests that when HIV is stable – HCV disease progression is slowed in people with HIV/HCV coinfection

www.hcvadvocate.org


When and which to treat
When and Which to Treat?

  • Generally, HIV should be under control

    • Most recommend treat HIV first

  • HCV – People with HIV/HCV should be considered for HCV treatment

    • Unless:

      • CD4 counts less than 200

      • Active opportunistic illness

www.hcvadvocate.org


Hiv meds and the liver
HIV Meds and the Liver

  • Generally, some medications including HIV medications can be difficult for a liver to process

  • HIV meds temporarily increase liver enzymes and HCV viral load – usually stabilize over time

    • If ALT’s 4 to 5 times baseline –

      • Change to more liver friendly HIV medications

www.hcvadvocate.org


Recommendations
Recommendations

  • HIV specialist and liver specialist should closely follow co-infected people

  • Monitor liver functions especially when on HIV treatment

  • Switch to more liver friendly HIV medications

www.hcvadvocate.org


Hcv treatments
HCV Treatments

  • Treatment response rates lower in people with HIV

    • Genotype 1 up to 29%; Genotype 2,3 up to 62%

  • Closely monitored for:

    • Anemia rates up to 50% caused by ribavirin

    • Thrombocytopenia (low platelets) caused by interferon

    • Neutropenia (low white blood cells) caused by interferon

www.hcvadvocate.org


Ribavirin and hiv medications
Ribavirin and HIV Medications

  • Ribavirin originally developed for HIV, but not effective

  • HIV medications that should be avoided or used with caution when combined with ribavirin:

    • D4T (Zerit)

    • AZT (Retrovir)

    • DDI (Videx)

www.hcvadvocate.org


Psychological impact
Psychological Impact

  • Two or more potentially life-threatening conditions

  • Lack of awareness

  • Lack of support

www.hcvadvocate.org


Advances in hcv diagnostic tools
Advances in HCV: Diagnostic Tools

HCV OraQuick Rapid HCV Antibody Test

Venous – whole blood only – clinics

$20.00 ?

Available some time in 2010

Results in 20 minutes

Finger prick and oral swab

Filing for marketing approval likely by end of 2010

Approval expected in 2011

www.hcvadvocate.org


Advances in hcv diagnostic tools1
Advances in HCV: Diagnostic Tools

The Biosensor - handheld

Detect infections – HIV, Hepatitis, HINI, STI, Anthrax

Tests blood, saliva, urine – the fluid is injected into a small hole in the device

Runs on AA batteries - results in 5 seconds

Developed by University of New Mexico and Sandia National Laboratories

Estimated cost - $5,000 device - $10.00 for chips – 2 years away?

www.hcvadvocate.org


Advances in hcv treatment
Advances in HCV: Treatment

IL28B

A variation in IL28B called CC genotype = 2-fold increase in response

~80% of those who achieved response (SVR) had CC genotype

Partly explained SVR differences in African Americans and Hispanics

Test commercially available in August 2010?

www.hcvadvocate.org


Advances in hcv treatment1
Advances in HCV : Treatment

HCV Protease Inhibitors

Telaprevir and boceprevir - genotype 1 - in combination with pegylated interferon and ribavirin

Increase efficacy by 10 to 30%

Treatment duration - response guided therapy

Telaprevir – skin rash – may be whole body rash

Boceprevir – higher rates of anemia

www.hcvadvocate.org


Advances in hcv treatment2
Advances in HCV: Treatment

Medication burden:

Telaprevir – every 8 hours

Pegylated interferon (sq) once-a-week

Ribavirin – taken twice a day

Adherence

Resistance

www.hcvadvocate.org


Advances in hcv oral meds only
Advances in HCV: Oral Meds Only

Some unanswered questions – are all oral medications viable?

Probably a combination of different HCV protease and polymerase inhibitors

At least 5 to 10 years away

www.hcvadvocate.org


The end
The End

Thanks!

www.hcvadvocate.org