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The Viral A,B, C’s of Hepatitis & HIV/HCV Coinfection

The Viral A,B, C’s of Hepatitis & HIV/HCV Coinfection . Alan Franciscus Executive Director, Hepatitis C Support Project Editor-in-Chief, HCV Advocate Website www.Hepatitistattoos.org Join me on Twitter & Facebook – HCVAdvocate BLOG: hcvadvocate.blogspot.com/. www.hcvadvocate.org.

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The Viral A,B, C’s of Hepatitis & HIV/HCV Coinfection

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  1. The Viral A,B, C’s of Hepatitis &HIV/HCV Coinfection Alan Franciscus Executive Director, Hepatitis C Support Project Editor-in-Chief, HCV Advocate Website www.Hepatitistattoos.org Join me on Twitter & Facebook – HCVAdvocate BLOG: hcvadvocate.blogspot.com/ www.hcvadvocate.org

  2. www.hcvadvocate.org www.hbvadvocate.org www.hepatitistattoo.org

  3. Hepatitis A (HAV) US—Acute: estimated at 22,000 (US – 2008) Estimated at 180, 000 in 1997 (US): Colorado: 212 in 2000 to 26 in 2007 Symptoms – typical liver type symptoms Children typically do not exhibit symptoms Resolves (not chronic) www.hcvadvocate.org

  4. Transmission: Fecal/Oral Transmitted via fecal matter that gets into the mouth and body --- Contact with an individual with HAV Sexual transmission (anal/oral sex) Drinking or eating HAV contaminated food or drinks Lives for months outside of the body Incubation period: 15 to 50 days (average 28 days) www.hcvadvocate.org

  5. Prevention Vaccination: Adults: 2 dose series (0, 6 month) Age: 12 mos – 18 yo (1/2 dose) ≥19 yo – 100% Dose (Twinrix – HAV/HBV - more later) HAND WASHING – soap and water for 20 to 30 seconds SAFER SEX www.hcvadvocate.org

  6. At Risk Populations& Vaccination Recommendations Travelers to areas at intermediate or high risk Sexual contact with HAV-infected person Household/caregivers of infected person Men who have sex with men People who share injection and non-injection drug equipment Persons with bleeding disorders www.hcvadvocate.org

  7. Recommendations for Vaccination-continued All Children at age 1 year Persons with Chronic Liver Disease (HBV & HCV) with Chronic Disease Person Who Work with HAV-infected Primates or with HAV in a Research Laboratory Anyone Else Seeking Long-term Protection www.hcvadvocate.org

  8. HEPATITIS B (HBV) US - 38,000 Acute infections (CDC – 2008) US chronic: 800,000 –1.4 MILLION Colorado: 240,00 ever infected Worldwide: 400-800 million US - 3,000 deaths a year Worldwide 660,000 annual deaths www.hcvadvocate.org

  9. HBV TransmissionHBV is 50 to 100 times more infectious than HIV Blood borne –can live outside the body for at least 7 days Highly infectious in semen and vaginal secretions-50% - sexual transmission in US Sharing needles to inject drugs Needle stick and blood exposure accidents Sharing personal items Mother-to-child transmission www.hcvadvocate.org

  10. Epidemiologic Characteristics of Patients With Acute Hepatitis B - US, 2007* More than 70% of acute infections reported in 2007 were attributed to sexual activity injection drug use (IDU) Sexual activity accounts for most HBV transmission in the US § *Values total > 100% because multiple risk factors could be reported for a single case Daniel D. Acute Viral Hepatitis in US, 2007. MMWR 2009;58(No.SS-3).

  11. CDC Recommends Screening Adults at High Risk for HBV Infection § Weinbaum CM, et al. MMWR Recomm Rep. 2008;57(RR-8):1-20 11

  12. CDC Recommends Screening Adults at High Risk for HBV Infection--continued www.hcvadvocate.org

  13. CDC: Prevention – Vaccinate • Vaccination at birth • Screening of all pregnant women • Vaccination of all previously unvaccinated children and adolescents • Vaccination of previously unvaccinated adults at risk • Sexual exposure www.hcvadvocate.org

  14. CDC: Prevention – Vaccinate - continued • Blood/mucosal exposure • International travelers • People with liver disease (HAV and HCV) • Persons with HIV • All persons seeking protection from HBV infection

  15. HBV Prevention Get vaccinated Do not share needles or works Safer sex Standard safety precautions Do not share personal items HBV infected mother to child intervention www.hcvadvocate.org

  16. www.hcvadvocate.org

  17. Diagnosing HBV WWW.HBVAdvocate.org

  18. Keep it Simple! • HBV Antibodies (proteins made by body) • HBV Antigens (HBV viral proteins) • No HBV surface antibody and no surface antigen – susceptible – vaccinate • HBV surface antibody – protected • HBV DNA (viral load) > 6 months – chronic • Gray areas????

  19. Acute Chronic Symptoms • Fever • Fatigue • Loss of appetite • Nausea • Vomiting • Dark urine • Clay-colored stools • Jaundice • And more…… • Children typically exhibit no symptoms • Window period: 46 to 160 days (average: 120 days) • Fatigue • Fever • Abdominal pain • Muscle & joint pain • Nausea • And more……….. • Chronic – most people have no symptoms WWW.HBVAdvocate.org

  20. Progression Acute to Chronic • ~90% of Infants born to HBV-infected Mothers • Intervention decreases chronic rate to ~10% • 25 to 50% of children aged 1-5 years • ~5-6% of Adults Disease Progression • ~15-25% develop serious disease progression (cirrhosis, liver failure or liver cancer) usually after 20-30 years

  21. Monitoring Chronic HBV • Liver biopsy • Regular office visits and tests • Medical provider will set up a regular schedule of visits and tests • Common tests: ALT levels, HBV DNA (viral load), HBV viral markers, HBV genotype • Screen every 6 to 12 months for liver cancer (AFP / Ultrasound) • Avoid alcohol, tobacco and anything that can harm the liver • Exercise, support, healthy diet

  22. Goals of Treatment for Chronic HBV* • Sustained suppression of HBV • Lowering or normalization of ALT levels • Prevent or delay complications of chronic HBV: cirrhosis, hepatocellular carcinoma (HCC = liver cancer), death • Resolve infection • No Cure, but a manageable chronic condition *Colorado Clinical Guidelines Collaborative – Hepatitis B and C Guideline

  23. Keep It Simple! • Treat: • Elevated ALT • Elevated HBV DNA • Treatment, however, is a complicated process that takes into account many factors….see Colorado Clinical Guidelines Collaborative – Hepatitis B and C Guideline

  24. Approved HBV Medications & Drug Resistance Profile *These drugs are recommended as first line of treatment www.hcvadvocate.org

  25. Patient Assistance Programs • Needymeds.org • Partnership for Prescription Assistance • Gilead • Pegasys • GSK • BMS • Idenix/Norvartis

  26. HCV Prevalence: CDC New (acute) infections: 18,000 Total infections: ~4 million Colorado: 76, 000 acute/chronic Total chronic infections: UP TO 3. 9 million Worldwide: 170 million *Not factored into above: Prisoners, homeless, people in mental institutions www.hcvadvocate.org

  27. HCV Transmission / Prevention The hepatitis C virus lives for at least 16 hours, but no longer than 4 days outside the body In syringes up to 63 days www.hcvadvocate.org

  28. Transmission/Prevention Sharing needles and drug preparation tools Blood products & solid organ transplantation before 1992 Clotting factors before inactivation in 1987 Sexual transmission (0-3%) Mother-to-child (~4-5%) Healthcare workers (~2%) Hemodialysis www.hcvadvocate.org

  29. Possible Transmission Routes • Tattoo & piercing* • Personal care salons • Shared household (hygiene) items • Coke/crank straws & crack pipes • 10% of routes can not be identified * Higher in unsafe non-commercial settings: prisons/mental institutions/on the streets/home grown

  30. Little or no data……. • Dental and other procedure before universal precautions • Jet gun injections • Transgender people • Sharing needles and operations

  31. HCV is Not Spread by: Breast feeding Food or water Sharing eating utensils or drinking glasses Sneezing Hugging *Not spread by casual contact* www.hcvadvocate.org

  32. Prevention: Do not share anything: Needles, cookers, cotton, tourniquets, water, etc – Wash hands www.hcvadvocate.org

  33. Prevention - more • Do not share non-injection drug equipment • Coke/crank straws • Crack pipes • Tattoo / Piercing • Sterilization, autoclave, separate ink pot, new needles

  34. Prevention - more Sexual: 0-3%-monogamous partners– counsel Safer sex – additional risk through sex: Multiple partners Coinfection with HIV or HBV Having herpes, lesions, sores, open cuts, wounds Sexually transmitted diseases Mother-to-child www.hcvadvocate.org

  35. More Prevention • Health care workers • blood borne pathogen protection • Razors / toothbrushes covered • Cover all wounds • Transfusions – estimated that less than one per 2 million transfused units of blood tainted with HCV • People with HCV: Do not donate blood, sperm, eggs or organs – EXCEPTIONS…..

  36. Diagnostic Tests:HCV Antibody Tests HCV Elisa III (EIA), CIA: Detects antibodies Signal to cut off ratio = 95% chance true antibody + Home Access test kit OraQuick Rapid Antibody Test - whole blood & finger prick approved! Waiting on CLIA waiver Oral swab approval expected 2011 www.hcvadvocate.org

  37. Diagnostic Tests Confirm active infection Confirm HCV medications are working Guide for treatment duration *Does Not Correlate with Disease Progression* Liver Tests Viral Load • ALT: non-specific marker of liver inflammation • Not a good test to monitor HCV disease • AST, AP, GGT, bilirubin, platelet, prothrombin time (PT) • Liver Biopsy www.hcvadvocate.org

  38. Diagnostic Tests:Genotype Six major genotypes (plus sub-types) Genotypes numbered 1,2,3,4,5,6, (1a, 1b, etc) Genotype 1 – 70% of US population with HCV Genotype 2,3 – 30% of US population with HCV Guides type of medication(s) and treatment duration

  39. Future Disease Burden • *Institute of Medicine (IOM) Report – 2010 • **Milliman Report-Annual cost of advanced liver disease to $85 billion in the next two decades and Medicare costs will increase 500%, from $5 billion to $30 billion • ***Aging of the Hepatitis C Virus-Infected Persons in the United States: A Multiple Cohort Model of HCV Prevalence and Disease Progression --Progression to cirrhosis will peak at 1.0 million in 2020 *http://www.iom.edu/Reports/2010/Hepatitis-and-Liver-Cancer-A-National-Strategy-for-Prevention-and-Control-of-Hepatitis-B-and-C.aspx **http://www.milliman.com/expertise/healthcare/publications/rr/pdfs/consequences-hepatitis-c-virus-RR05-18-09.pdf ***GL Davis and colleagues; PMID: 19861128 [PubMed - as supplied by publisher]

  40. Liver Specialists GASTROENTEROLOGIST HEPATOLOGIST THE FUTURE? Primary care, infectious disease specialists and others www.hcvadvocate.org

  41. Acute vs. Chronic HCV • Initial or acute infection • Many people have no symptoms • Flu-like—fatigue, nausea, fever, indigestion, loss of appetite, night sweats, jaundice • Lasts up to 6 months • Treatment of acute HCV—the majority of people with acute HCV can clear the virus with interferon monotherapy. • Chronic: • HCV RNA longer than 6 months • 55 to 85% become chronic

  42. Chronic Symptoms • Fatigue – mild to severe • “Brain Fog” • Flu-like symptoms • Depression • Liver pain • Loss of appetite • Headaches • Gastro problems • And more…. Symptoms don’t necessarily correlate with disease progression with the exception of end-stage liver disease. www.hcvadvocate.org

  43. Disease Progression • 10 to 25% have serious disease progression over a 10 to 40 year period – disease progression is not linear • Fibrosis • Cirrhosis (compensated vs. decompensated) – Portal Hypertension / Ascites & Edema / Varices / Encephalopathy • Liver Cancer • 3% to 5% of people with chronic HCV will develop liver cancer - after severe fibrosis or cirrhosis • Transplantation: 250,000 to $314,000 – up to $500,000 – Annual costs of medications: ~$21,900

  44. Disease Management Lifestyle Changes HAV and HBV vaccinations Avoid alcohol Avoid or reduce: Cigarette smoking, drugs or any substance that can harm the liver Do not eat raw or undercooked shellfish Exercise Eat a healthy well-balanced diet www.mypyramid.gov www.hcvadvocate.org

  45. Vitamins / Supplements/ Herbs • Avoid high doses of vitamins and supplements • General recommendations: • Vitamin supplement (daily requirements with no iron) • Always inform the medical provider of any herbs, supplements, prescribed, OTC, etc.

  46. HCV Medical Treatment

  47. Response to Therapy • Adherence: Important to increase treatment response and to prevent drug resistance • Rapid Virological Response (4 week – HCV RNA negative) • Will now be used to drive treatment duration (genotype 1) • Early virologic response (12 week rule) • Decrease (2 log drop) or elimination of virus at week 12 • Example of 2 log drop: 10,000,000 to 100,000 • Sustained virological response (SVR) HCV RNA negative 24 weeks after completion of therapy = viral cure

  48. Programs • Patient Assistance Programs • Partnership for Prescription Assistance • www.pparx.org • Needy Meds: www.needymeds.org • Genentech: www.genentechaccesssolutions.com • Merck: www.beincharge.com

  49. HIV/HCV Coinfection US: Approximately 300,000 people coinfected with HIV and hepatitis C Recommendations to test everyone with HIV for HCV Diagnosing HCV HCV Antibody test – may be false-negative if CD4 cells are under 100 HCV viral load test to confirm active infection Higher rates of HCV chronicity

  50. Disease Progression • HCV Disease progression is faster in someone who also is infected with HIV • Coinfected patients more than twice as likely to develop cirrhosis - The lower the CD4 cell count the faster HCV progresses • Greater risk for liver cancer • Six times greater risk for decompensation www.hcvadvocate.org

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