Transcript 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
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Agenda
•O V E R V I E W O F H E P A T I T I S C
•
Please hold questions until the end of the first session
•H I V A N D H E P A T I T I S C – D I F F E R E N C E S A N D
SIMILARITIES
•H I V A N D H E P A T I T I S C O I N F E C T I O N
•N E W A D V A N C E S I N H E P A T I T I S C C A R E
www.hcvadvocate.org
Hepatitis C Overview
•H C V S T A T I S T I C S
•H C V D I A G N O S T I C S
•H C V T R A N S M I S S I O N & P R E V E N T I O N
•H C V S Y M P T O M S , D I S E A S E P R O G R E S S I O N , M A N A G E M E N T
•H C V T R E A T M E N T
www.hcvadvocate.org
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
 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 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
 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
 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
 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
Shared Needles
All Drug
Paraphernalia
Blood Before
1992 - transfused,
Sexual
Transmission
(1-3%)
Healthcare
Workers –
needle sticks
Shared Household items – razors
Mother to Child
<5%
Tattoos /
Piercing
<10% of routes
can not be
identified
www.hcvadvocate.org
products, procedures
& toothbrushes
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
 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: Tips
 Safer Sex
 For
so called “high risk groups”
Multiple
sexual partners, people with sexually
transmitted diseases, coinfection with HIV or
HBV
Any
www.hcvadvocate.org
situation where blood is present
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: 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
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
 Liver pain
 Fatigue – mild to
severe
 Loss of appetite
 Flu-like symptoms
(muscle/joint/fever)
 Gastro problems
 ‘Brain Fog’

www.hcvadvocate.org
 Headaches
and more……
HCV Disease Progression
 10-25% of HCV positive people progress on to
serious disease over 10-40 years

Fibrosis


Cirrhosis


Light scarring
Compensated vs. decompensated
Steatosis

Fatty deposits in the liver
www.hcvadvocate.org
Disease Progression: Managing Hepatitis C
 Regular medical
 Exercise
monitoring
 Stress Reduction
 Get vaccinated – Hep
A & Hep B
 Healthy balanced diet
www.mypyramid.gov
www.hcvadvocate.org
 Support Groups
 Alcohol – Avoid or
reduce
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
www.hcvadvocate.org
Side-effects
 Interferon








Fatigue
Muscle/Joint pain
Nausea
Headaches
Anxiety
Depression
Dry Skin/Rashes
And more…..
www.hcvadvocate.org
 Ribavirin
 seems to make
interferon side effects
worse – especially
fatigue – Anemia
**(both men & women
must use birth control)
Managing Side-Effects
 Inject before bedtime
 Light exercise
 Drink lots of water
 Daily moisturizing
 Low doses of ibuprofen
 Vary injection sites
or acetaminophen
 Pain medications
 Anti-Depressants
 Plenty of rest
 Small frequent meals
Key: support from medical providers, family, friends, work – all areas of life
www.hcvadvocate.org
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
HCV
HIV
 Single stranded RNA
 Single stranded RNA
 Retrovirus
 Flavivirus
 Integrates into DNA
 Does not integrate into
DNA
www.hcvadvocate.org
Comparisons
HIV
HCV
 Mainly infects CD 4 cells
 Mainly infects liver cells
 Daily – replicates billions
 Daily – replicates trillions
 High mutation rate
 Very high mutation rate
www.hcvadvocate.org
Comparisons
HCV
HIV
 Chronic – 100%
 Chronic rates - 55-85%
 US – 1 major strain
 US – 3 major strains
 High sexual transmission
 Low Sexual transmission
 High IDU transmission
 Very high IDU
rate
rates (Blood)
www.hcvadvocate.org
rate
transmission rates (Blood)
Comparisons – Con’t
HCV
HIV
 Cure?
 No
 Cure?
 Virological Cure
 Treatment - lifelong
 Treatment 24 to 48 weeks
 Can become resistant
 No resistant issues yet

www.hcvadvocate.org
New direct antivirals will
lead to resistance
Comparisons – Prevalence
HCV
HIV
U.S. –
 U.S. –
 ~1,000,000
 ~4,000,000
www.hcvadvocate.org
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
•T r a n s m i s s i o n / P r e v e n t i o n
•D i a g n o s i ng H C V
•H C V D i s e a s e P r o g r e s s i o n
•H C V T r e a t m e n t R e s p o n s e
www.hcvadvocate.org
HCV Transmission
HCV
 Sexual transmission is
low (0-3%)
 Mother-to-Child
Transmission ~5-6%

HCV meds can cause birth
defects
www.hcvadvocate.org
HIV/HCV Coinfection
 Sexual transmission is
higher ~ 15-25%
 Mother-to-Child
Transmission ~25%

HCV meds can cause birth
defects
Diagnosing HCV
Hepatitis C
HIV/HCV Coinfection
 Antibody Test
 Antibody Test
 Note: If low cd4 cell
count use HCV RNA
 HCV Viral load to
 HCV RNA to confirm
confirm active
infection
active infection
*People with a comprised immune system may not develop HCV antibodies
www.hcvadvocate.org
HCV Disease Progression
Hepatitis C
 Slow rate of disease
progression – usually
over 10, 20, 30 years
www.hcvadvocate.org
HIV/HCV Coinfection
 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
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?
 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?
 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
 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
 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
 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 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
 Two or more potentially life-threatening conditions
 Lack of awareness
 Lack of support
www.hcvadvocate.org
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
Tools
•T H E B I O S E N S O R - H A N D H E L D
•
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
•I L 2 8 B
•
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 : Treatment
•H C V P R O T E A S E I N H I B I T O R S
•
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: Treatment
•M E D I C A T I O N B U R D E N :
•
•
•
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
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
THANKS!
www.hcvadvocate.org