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Co- infections: Hepatitis C

Co- infections: Hepatitis C. What is hepatitis?. ‘ hepat ’ = liver ‘ itis ’ = inflammation Viral hepatitis… A Faeco-oral - never chronic B Blood, sexually transmitted - can be chronic C Blood, sexually transmitted - often chronic D Only with B - usually chronic

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Co- infections: Hepatitis C

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  1. Co-infections: Hepatitis C

  2. What is hepatitis? • ‘hepat’ = liver • ‘itis’ = inflammation • Viral hepatitis… • A Faeco-oral - never chronic • B Blood, sexually transmitted - can be chronic • C Blood, sexually transmitted - often chronic • D Only with B - usually chronic • E Faeco-oral - rarely chronic VACCINE PREVENTABLE

  3. What is hepatitis C (HCV)? • Known as ‘non A non-B’ hepatitis before 1989 • ‘Non-A non-B’ transfusion-related hepatitis • RNA virus that infects liver cells causing inflammation and, if untreated, liver scarring fibrosis • Since 1991 all UK blood transfusions have been screened

  4. HCV genotypes • There are at least seven different types of HCV, known as genotypes • Genotypes are numbered from G1 to G7, in the order that they were discovered • These genotypes also have variations, called subtypes, which are named by lower-case letter (i.e. a, b, c, etc), also in the order that they were discovered

  5. Understanding liver biopsy scores • The Two scoring systems, Metavir and Ishak, are commonly used to grade and stage liver biopsy results • Metavir system scores inflammation from A0-A3 and fibrosis from F0-F4 • The Ishak system scores inflammation from 0 to 18 and fibrosis from 0 to 6 • UK (BHIVA) guidelines define mild liver damage as a modified Ishak fibrosis score of 3 or less and a Metavir fibrosis score of 2 or less • Moderate liver damage is an Ishak inflammatory score of 4 or more and/or a fibrosis score of 3 to 5 • However, these scoring systems are not used in every hospital and some clinics prefer to just stage biopsies as mild, moderate or cirrhosis HIV i-base Hepatitis C for people living with HIV

  6. FibroScan • Measures liver stiffness by measuring how quickly vibration waves pass through the liver • In the UK, scans such as FibroScan are recommended for monitoring liver health in people with co-infection • Results are presented as a number in kilopascals (kPa) • A higher number indicates more liver damage • A score of over 7.2 kPa indicates higher likelihood of significant fibrosis. • A score over 14.5 kPa in someone with HCV/HIV co-infection indicates cirrhosis HIV i-base Hepatitis C for people living with HIV, April 2017 accessed January 2018

  7. Hepatitis A & B • Hepatitis A: is caught from infected water or food and although it can be serious, it only lasts for a short time • It is advisable to get vaccinated before travelling to areas such as Asia, the Middle-East, Africa or Eastern Europe (check with GP/travel clinic) • Hepatitis B: is not caught from infected water or food but from infected blood or other body fluids. It often becomes an ongoing disease that could lead to liver cancer

  8. How is HCV transmitted? • Most infectious fluid is blood • Predominantly through injecting drug use • Blood products, unclean surgical/injecting equipment • Non-injecting drug equipment such as straws, diluting agents • Piercing, tattooing (clean needles AND ink!) • Or through sex • Blood > sexual fluids; LOW levels in semen – Men who have sex with men (MSM) with rough sex practices particular risk • Risk for heterosexual partners of HCV+, 0.07% a year[1] • Mother-to-child but NOT via saliva or breast milk [1] Terrault NA et al. Hepatology 2013. [2] Bradshaw et al. Current Opinion 2013. [3] Wandeler G et al. CID 2012.

  9. Who is at higher risk of acquiring HCV? • People undergoing medical procedures in settings where infection control is poor • People who inject drugs (PWID) > people who snort drugs • People with Tattoos & Piercings • Sexual partners of people living with HCV • HIV positive people (particularly men who have sex with men) • Infants of HCV+ mothers

  10. How/Why is HCV transmission continuing among MSM? • ‘Bare-backing’ • Rough sex causing bleeding • Other traumatic practices like piercing during sex, or saline scrotal inflation • Accidental or intended needle sharing • Sharing sex toys • Lack of testing for HCV • Sex with those with acute HCV/ seroconverters (ie with high viral loads)

  11. Global hepatitis C prevalence

  12. Globally: How do HCV & HIV overlap? HIV HCV 37million 71million 10million

  13. What is the impact of HIV on HCV? • More rapid liver fibrosis (scarring of the liver leading to Cirrhosis) • Worse at lower CD4 • Effective HIV treatment may negate this • HCV more infectious (PLWHA typically have higher HCV viral load in blood and semen) • Lower response rates to interferon-based treatment

  14. Deaths (%) AIDS Cardio-vascular or other heart disease Non-AIDS malignancies Other Liver-related disease Liver-related death in HIV positive people • Liver-related death is a frequent cause of non-AIDS death in HIV positive people D:A:D Study: Causes of death in n=49,734 HIV-infected patients followed 1999–2011 Weber R, et al. AIDS 2012. Washington USA. Oral presentation THAB0304 accessed January 2018.

  15. HCV Treatment - Old and New • Interferon/ Ribavirin was standard treatment for years • Lots of new drugs available now (DAA = direct acting antivirals) • But VERY EXPENSIVE so access is currently limited • Approaching 100% success rates for many groups, including those who are more difficult to treat e.g • HIV+ • Fatty liver/cirrhosis • Older age • Diabetes

  16. UK currently available HCV drugs HIV i-base Hepatitis C for people living with HIV, April 2017 accessed January 2018

  17. UK currently available HCV drugs HIV i-base Hepatitis C for people living with HIV, April 2017 accessed January 2018

  18. UK currently available HCV drugs HIV i-base Hepatitis C for people living with HIV, April 2017 accessed January 2018

  19. What do EASL Guidelines recommend? • All treatment-naïve and treatment-experienced patients with compensated or decompensated chronic liver disease due to HCV must be considered for therapy

  20. Conclusions • Liver disease is an important cause of morbidity and mortality in HIV positive people • Key issues = ART, HCV and lifestyle • HCV • Approaching 100% success rates for many groups, including those who are more difficult to treat • The era of direct acting antiviral hepatitis therapy has arrived • Interferon-sparing and Interferon-free therapy a reality • Responses in HIV positives similar to HIV negative • Beware drug-drug interactions between HIV and HCV medicines • People with HIV are still a ‘Special Population’ despite similar response • as HCV aggressive, multi-system disease, urgent need of therapies • Need for improved cascade of care and access to therapies

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