25/04/2020

HIV and Hepatitis

Ray Poll

Nurse Consultant for Viral Hepatitis Sheffield Teaching Hospitals NHS Foundation Trust 1

Introduction

• In 93% of 100 clinics dual HIV/HBV infection rate 3 10% • Cases of acute HCV infection in HIV+ gay men • Incidence of HCV infection high in HIV+ IDUs (83%) • HIV causes HBV and HCV to progress more quickly • People with co-infection have higher risk of liver disease from ART but benefits of HIV treatment seem to outweigh risks from additional liver-related side effects 25/04/2020 2

Cirrhosis

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What does the liver do?

• Stores energy • Produces bile • Stores vitamins and minerals, including iron • Destroys and deals with poisons and drugs • Produces chemicals for most of the chemical reactions in the body • Repair damage and renew itself 25/04/2020 4

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Liver tests

• Diagnostic blood tests • Liver function tests • Ultrasound scan • Liver biopsy sometimes 5

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Liver biopsy

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Hepatitis B

• Routes of transmission • Chronic infection – inversely proportionate to age • About 25% develop liver disease including cirrhosis • Treatment – lower levels of virus, not everyone needs it but for many life-long • All HBV patients screened for HIV and HDV • Immunisation 25/04/2020 7

Hepatitis B - epidemiology

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Hepatitis B tests

• Hepatitis B surface antigen (HBsAg) • Hepatitis B core antibody (HBcAb) • Hepatitis B surface antibody (HBsAb) • Hepatitis B ‘e’ antigen (HBeAg) • Hepatitis B ‘e’ antibody (HBeAb) • HBV DNA

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Hepatitis C

• Virus mainly found in blood • Common risk factors • Liver disease usually takes many years • Many with chronic infection are asymptomatic • Genotypes • Treatment – curative for many 25/04/2020 10

HCV screening

• All HIV-infected pts should be screened for HCV antibodies • Repeat screening – Annually – Three monthly in MSM (minimum) – Patients with abnormal LFTs • Negative HCV antibody may be associated with blunted immune response • HCV RNA should be performed for some individuals 25/04/2020 11

Case study 1

• 38yr old HIV+ gay man • ART since 2002 • Nov 2011 abnormal LFTs – unable to do HCV antibody • Dec 2011 – HCV antibody neg – unable to do HCV RNA • Jan 2012 – HCV RNA 111 • Feb 2012 – HCV RNA 281 • March 2012 – HCV RNA 3548 • HCV genotype 1 • Previous samples – HCV RNA neg Aug 2011; pos Nov 2011 • Acute or chronic infection – what treatment approach?

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Case study 2

• Local outbreak of HIV among IDUs • 29 yr old male former IDU • Known HCV genotype 3a • Previously attended RHH but lost to follow-up • 2008 HIV neg • 2010 Re-engaged after seen in outreach • Found to be HIV positive • Had HCV treatment for 48 weeks and EOT response – awaiting SVR 25/04/2020 13

When to start treatment

CD4 cells/μL >500 ≤500 HBV requiring Rx HBV not requiring Rx Start ART in some patients (2C) (Include tenofovir and emtricitabine) Defer ART Start ART (1B) (Include tenofovir and emtricitabine) Start ART (1B) (Include tenofovir and emtricitabine) HCV with immediate plan to start HCV Rx Defer ART HCV with no immediate plan to start HCV Rx Defer ART 350 –500 Start ART after HCV treatment commenced (1C) <350 Start ART before HCV treatment (1B). Discuss with HIV and viral hepatitis specialist Start ART (1C)

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Response rates to HCV therapy

SVR rates

Overall

HCV Monoinfection

56-61%

HIV/HCV Co-infection

27-40% Genotype 1 42-44% 14-38% Genotype 2 and 3 25/04/2020 70-82% Up to 73% 15

Case study 2 - Treatment

• Cannot be sure if acute or chronic infection • Discussed merits of treatment now or later using triple therapy • Consider change of ART regime – lessen anaemia and reduce liver toxicity • Going on holiday and wishes to defer HCV treatment • In meantime stabilise on new ART regime 25/04/2020 16

HCV Antivirals in Development ANA773 MK5172 M iglustat Clemizole MK-1220 RG 7348 NIM-811 Nov-205 CF-102 Golotimod (SCV 07) sc BMS-824393 ATI-0180 NA-808 SPC-3649 BMS-791325 CB-5300 GI-5005 PRO 206 CYT-107 FGI 103723 ITX 5061 SCY-635 BIT-225 Debio025 Nitazoxanide Celgosivir Taribavirin PF 4878691 IMO-2125 IPH 1101 ACH 2928 BMS 790052 PPI-461 EDP-239 AZD-7295 Albuferon PhI PhIIa PhIIb PhIII AVL-181 ABT 450 VX-813 SCH 900518 IDX-375 VX-985 VBY376 BI-201335 BMS-650032 IDX-136 and IDX-316 MK-7009 Telaprevir Boceprevir TMC435350 GS 9256 ITMN-191/R7227 IDX-320 PHX-1766 ACH-1095 TaigGen Bio ACH-1625 R7128 IDX-184 IFN alpha, Medgenics (Biopump SR) P-1101 HDV-IFN (Hepasome) sr-IFN-alpha (LG Life Sciences) PEG-IL-29 ITCA-638 IFN-alpha-2b-medtronics IFN-alpha-2b-XL Locteron CR Interferon-alpha (buccal lozenge, Amarillo) VCH-222+ Telaprevir GS9190+GS9256 RG7227+RG7128 Belerofon BMS-790052 + BMS-650032

Suspended / Discontinued

IDX184+IDX320

Sources: GBI Analysis (August 4, 2010), Pipeline Sources, Company Press Releases, Reuters Knowledge Analyst Reports

GS 9190 PF868554 AZD 2795 MK3281 VCH 759 ABT-072 ANA598 BI-207127 ABT-333 VCH-222 VCH 916 BI-201335+BI20127 PSI-7977 BMS PSI-879 PSI-7851 PSI-938 IDX-102 IDX-189 Non nuc

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Summary

• All HIV + persons should be screened for HBV and HCV, and visa versa • Offer HAV/HBV immunisation to non-immune individuals • ‘Cure’ rates in HIV/HCV co-infection promising • Newer HCV drugs in development • HCV treatment response guided • Side-effects well managed with support of MDT 25/04/2020 18

References

• BHIVA (2010)

Guidelines for the management of co infection with HIV-1 and hepatitis B or C virus.

• BHIVA (2012)

Guidelines for the treatment of HIV-1 infected adults with antiviral therapy.

• EASL (2012)

Clinical Practice Guidelines: Management of chronic hepatitis B virus infection.

• National AIDS Trust (2012)

Hepatitis C and HIV Co infection.

www.NAT.org.uk

• NICE (guidance for treatment of HBV and HCV monoinfection) www.nice.org.uk

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Thank you for listening!

Does anyone have any questions?

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Contact details

25/04/2020 Ray Poll Nurse Consultant for Viral Hepatitis Room E86, Department of Infection and Tropical Medicine, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF Tel: 0114 271 1776 Pager: 07623 857909 E-mail: [email protected]

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