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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


Hcv hiv co infection understanding our challenges and opportunities

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


Hcv hiv co infection understanding our challenges and opportunities

ExclusionCriteria

InclusionCriteria



Hcv hiv co infection understanding our challenges and opportunities

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)


Hcv hiv co infection understanding our challenges and opportunities

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