HCV/HIV Co-infection: Understanding our Challenges and Opportunities

1. HCV/HIV Co-infection:Understanding our Challenges and Opportunities Kay Schwebke, MD, MPH Infectious Diseases HCMC HIV/AIDS Program

2. Case Presentation • 35 year old woman, HIV/HCV co-infected • History of depression and polysubstance use disorder with ongoing alcohol use • CD4 = 199 • HIV = 34,000 • HCV genotype 3a, high viral level • Liver biopsy stage 2 (Sept 2004)

3. Case Presentation • 46 year old man, HIV/HCV co-infected • Strong needle aversion • CD4 = 364 (HIV undetectable) • HCV genotype 3a, high viral level • Liver biopsy stage 2

5. HIV/HCV Co-infection • HIV-infected persons are living longer • Approximately 30% of HIV-infected persons are co-infected with HCV • Liver-related problems complicate HAART • HIV accelerates the progression of HCV-related liver disease • End-stage liver disease has become a leading cause of death in persons with HIV infection

11. BaselineCharacteristics

14. Effect of HCV on HIV Progression • The effect of HCV on HIV disease is less clear • Does appear to impair immune recovery after starting HAART • HCV can complicate ability to provide HAART • Most studies show that HCV does not directly accelerate HIV disease progression

18. Steps to take after HCV diagnosis • Patient education • Discuss alcohol and marijuana use - encourage abstinence • Baseline laboratory evaluation including liver function, platelet count, HCV genotype, and HCV quantitative RNA • Vaccinate against hepatitis A and B if indicated • Screen for hepatocellular carcinoma (HCC) • Discuss liver biopsy • Discuss treatment risks and benefits • Identify barriers to care • Define members of the healthcare team

23. ExclusionCriteria InclusionCriteria

28. All Genotypes

31. Percent change from baseline

32. Back

37. HIV/HCV Co-infectionTreatment Questions • Who should be treated? • Which virus should be treated first ? • Are there unique adherence or safety concerns? • What are barriers to treatment?

38. HIV/HCV Co-infection: Who should be treated? • All patients with HIV and HCV should be considered for treatment • Patients with well controlled HIV disease • CD4 count > 200 cells/mm3 OR • CD4 count > 100 cells/mm3 but < 200 cells/mm3 HIV RNA < 5000 copies/mL • Patients with advanced liver disease by biopsy • No significant treatment contraindications

39. Treatment Considerations:individualize risks and benefits • Any genotype but recognize different treatment responses • genotype 2/3 = 60-80% • genotype 1, LVL = 60% • genotype 1, HVL = 15% • Advanced liver disease (stage 2, 3, and stable 4) • Very motivated person • Stable • Adherent to medications and appointments

40. HIV/HCV Co-Infection: Treatment Order? • Generally done on a case-by-case basis • Control of HIV disease should be given priority • If there is not an immediate need to initiate HIV-infection therapy, consider HCV treatment • Initiating treatment for both HCV and HIV infection simultaneously is not encouraged (wait 2-6 months)

45. 262/326 171/262 Treatment Rates Among HCV/HIV Patients in an Urban Medical Center 60% Advanced Fibrosis 100 80% 80 65% 60% Completed Treatment 60 Number of Patients 40 32% 20 262/326 171/262 84/262 0 Evaluated for Treatment Biopsy Performed Treated for HCV Suwandhi P, et al. Presented at AASLD 2008. Nov 1-4, 2008; San Francisco, CA. Poster #1265.

47. HCMC Co-infection Clinic • Identify potential barriers to treatment • Pharmacist provides extensive drug education • Informed consent • Discuss treatment protocol • Emphasize side-effect management • Emphasize importance of adherence • RN provides injection and injection education • Encourage initial weekly RN visits • Opportunity to check labs and side-effects • CBC week 1, 2, 4, then monthly if appropriate • MD encounter week 2, 4, then monthly if appropriate