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Alan FranciscusExecutive Director, Hepatitis C Support Project
Editor-in-Chief, HCV Advocate—www.hcvadvocate.org
Editor-in-Chief, HBV Advocate –www.hbvadvocate.org
Follow us on Twitter and Facebook:hcvadvocatehbvadvocate
Hepatitis C and HIV/HCV Coinfection
www.hcvadvocate.org
•OVERVIEW OF HEPATITIS C • Please hold questions until the end of the first session
•HIV AND HEPATITIS C – DIFFERENCES AND SIMILARITIES
•HIV AND HEPATITIS COINFECTION
•NEW ADVANCES IN HEPATITIS C CARE
Agenda
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•HCV STATISTICS
•HCV DIAGNOSTICS
•HCV TRANSMISSION & PREVENTION
•HCV SYMPTOMS, DISEASE PROGRESSION, MANAGEMENT
•HCV TREATMENT
Hepatitis C Overview
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Hepatitis C Statistics
U.S. Population1.6% overall
~4 million Americans infected
3.2 million chronically infected
2.1% Mexican Americans
3.4% African Americans
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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)
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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 laterwww.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**
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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
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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
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Transmission & Prevention
Shared Needles
All Drug Paraphernalia
Blood Before 1992 - transfused, products, procedures
Sexual Transmission(1-3%)
Healthcare Workers – needle sticks
Shared House-hold items – razors & toothbrushes
Mother to Child <5%
Tattoos / Piercing
<10% of routes can not be identified
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Transmission & Prevention
HCV is not spread by breast feeding, sharing eating utensils or drinking glasses, kissing, hugging
Direct blood to blood transmission route
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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
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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 situation where blood is present
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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
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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
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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
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HCV Transmission & Prevention: Tips
Chronic Symptoms
Fatigue – mild to severe
Flu-like symptoms (muscle/joint/fever)
‘Brain Fog’
Liver pain
Loss of appetite
Headaches
Gastro problems
and more……
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HCV Disease Progression
10-25% of HCV positive people progress on to serious disease over 10-40 years
Fibrosis Light scarring
Cirrhosis Compensated vs. decompensated
Steatosis Fatty deposits in the liver
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Disease Progression: Managing Hepatitis C
Regular medical monitoring
Get vaccinated – Hep A & Hep B
Healthy balanced diet www.mypyramid.gov
Exercise
Stress Reduction
Support Groups
Alcohol – Avoid or reduce
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HCV Treatment
What is interferon? General antiviral – immune booster
By injection
What is ribavirin? Antiviral
Used only in combination with interferon Pill or capsule
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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
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Side-effects
Interferon Fatigue Muscle/Joint pain Nausea Headaches Anxiety Depression Dry Skin/Rashes And more…..
Ribavirin seems to make
interferon side effects worse – especially fatigue – Anemia
**(both men & women must use birth control)
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Managing Side-Effects
Inject before bedtime
Drink lots of water
Low doses of ibuprofen or acetaminophen
Pain medications
Small frequent meals
Light exercise
Daily moisturizing
Vary injection sites
Anti-Depressants
Plenty of rest
Key: support from medical providers, family, friends, work – all areas of life
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Complementary Medicine
Herbs – milk thistle, licorice root, etc. Always check with your doctor and herbalist – some
herbs are unsafe
Acupuncture / Acupressure
Traditional Chinese Medicine
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HIVHIV HCVHCV
Single stranded RNA
Retrovirus
Integrates into DNA
Single stranded RNA
Flavivirus
Does not integrate
into DNA
Comparisons
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HIVHIV HCV HCV
Mainly infects CD 4 cells
Daily – replicates billions
High mutation rate
Mainly infects liver cells
Daily – replicates trillions
Very high mutation rate
Comparisons
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HIV HIV HCV HCV
Chronic – 100%
US – 1 major strain
High sexual transmission rate
High IDU transmission rates (Blood)
Chronic rates - 55-85%
US – 3 major strains
Low Sexual transmission rate
Very high IDU transmission rates (Blood)
Comparisons
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HIVHIV HCV HCV
Cure? No
Treatment - lifelong
Can become resistant
Cure? Virological Cure
Treatment 24 to 48 weeks
No resistant issues yet New direct antivirals
will lead to resistance
Comparisons – Con’t
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HIV HIV HCV HCV
U.S. –
~1,000,000
U.S. –
~4,000,000
Comparisons – Prevalence
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Guidelines for Prevention of Opportunistic Infections
HIV – Infected persons should be screened for HCV
Patients should be advised on alcohol usePatients should be screened for HAV & HBV if
negative, they should be vaccinatedPatients should be evaluated for liver disease
and possible need for treatmentLiver enzymes should be monitored after
initiation of HAART
*U.S. Public Health Service and the Infectious Disease Society of Americawww.hcvadvocate.org
•Transmission / Prevention
•Diagnosing HCV
•HCV Disease Progression
•HCV Treatment Response
Hepatitis C vs. HIV/HCV Coinfection
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HCVHCV HIV/HCV Coinfection HIV/HCV Coinfection
Sexual transmission is low (0-3%)
Mother-to-Child Transmission ~5-6% HCV meds can cause
birth defects
Sexual transmission is higher ~ 15-25%
Mother-to-Child Transmission ~25% HCV meds can cause
birth defects
HCV Transmission
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Hepatitis C Hepatitis C HIV/HCV Coinfection HIV/HCV Coinfection
Antibody Test
HCV Viral load to confirm active infection
Antibody Test Note: If low cd4 cell
count use HCV RNA
HCV RNA to confirm active infection
Diagnosing HCV
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*People with a comprised immune system may not develop HCV antibodies
Hepatitis C Hepatitis C HIV/HCV Coinfection HIV/HCV Coinfection
Slow rate of disease progression – usually over 10, 20, 30 years
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
HCV Disease Progression
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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
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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
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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
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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
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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
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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
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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)
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Psychological Impact
Two or more potentially life-threatening conditions
Lack of awareness
Lack of support
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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 swabFiling for marketing approval likely by end of 2010
Approval expected in 2011
Advances in HCV: Diagnostic Tools
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•THE BIOSENSOR - HANDHELD• 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?
Advances in HCV: Diagnostic Tools
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•IL28B• 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?
Advances in HCV: Treatment
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•HCV PROTEASE INHIBITORS• 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
Advances in HCV : Treatment
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•MEDICATION BURDEN:• Telaprevir – every 8 hours
• Pegylated interferon (sq) once-a-week
• Ribavirin – taken twice a day • Adherence• Resistance
Advances in HCV: Treatment
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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
Advances in HCV: Oral Meds Only
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THANKS!
The End
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