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HIV/HCV Co-Infecion
“Today if you are not confused, you are just not thinking clearly”
»HIV Researcher – NYC
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The Liver Largest internal organ
Approximately 3 lbs (men)
Size of a football
1.5 quarts of blood flow through it every minute
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Liver Functions Bile
Immune System
Chemical Factory-
>500 chemical functions
Detoxifies
Clotting Factors
Hormones
Regenerates Itself!
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Keep Your Liver Healthy (Healthy People) No more than:
2 alcoholic drinks daily for men 1 alcoholic drink daily for women
Be cautious about mixing drugs – especially with alcohol
Healthy, balanced diet Get HAV & HBV vaccinations Avoid toxic substances / fumes
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Some Statistics 3% of world has HCV (150-200 million) 3.9 Million in U.S. infected with HCV * Chronic – 2.7 Million in U.S. 8,000 to 10,000 in U.S. die of
complications from HCV – in 10 years this # will triple
HCV is the leading cause for liver transplants
50-80% of HCV infected become chronic* Does not include prisoners, homeless
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More Statistics
U.S. Population 1.8% overall
2.1% Mexican-Americans
3.4 African Americans
California 500,000 infected
with HCV
85-95% - IDU’s
Prisons – 63,500 inmates infected or (41%)
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What Does It Mean? Only 10-25%
progress on to serious liver disease
Treatment choices do work for some
Hopefully better treatment options will be available within 5 years
Lifestyle changes can make a big difference
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Diagnostic Tools Elisa II / Riba – Test for anti-body Hepatitis C RNA by PCR - >50
particles Hep C RNA by branched DNA Assay –
>200,000 particles TMA – more sensitive, less expensive Genotype (six major subtypes – 72%
of U.S. population have genotype 1) Liver Biopsy
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Transmission / Prevention
<10% of routes cannot be identified
Tattoos / Piercing
Neonatal – <5%
Shared House-hold items – razors & toothbrushes
Healthcare workers – needle sticks
Sexual Transmission(1-3%)
Blood before 1992 - transfused, products, procedures
All Drug Paraphernalia
Shared Needles
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Harm Reduction Prevention –
Needle exchange – clean needles and drug preparation tools – cookers & cottons
Bleach – Does it work? 10 minutes!
Safer Sex Cover wounds
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HCV CAN NOT BE SPREAD BY: BREAST FEEDING
SNEEZING
HUGGING
COUGHING
FOOD OR WATER
SHARING EATING UTENSILS OR DRINKING GLASSES
CASUAL CONTACT
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Symptoms Acute vs. Chronic
Fatigue – mild to severe
Flu-like symptoms (muscle/joint/fever)
‘Brain Fog’
Liver Pain
Loss of appetite
Headaches
Gastro Problems
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Treatment Medications
Interferon – by injection - first FDA approved treatment (3 MU, thrice weekly for 48 weeks)
Genotype 1 - 9% SVR Genotype other than 1 –30% SVR
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Interferon and Ribavirin Interferon and ribavirin(capsule)-
‘combo therapy’ INF – 3 mu units, thrice weekly -
Ribavirin 800-1200 mg daily Overall SVR up to 45% Genotype 1 – 12 mos – 29% SVR Genotype Non 1 – 6 mos - 62% SVR
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Pegylated Interferon Schering- PEG-Intron
Approved by FDA – 1-2001 25% sustained response rate
Genotype 1 – 14% Genotype 2 & 3 – 47%
ROCHE – Pegasys – FDA approval pending 39% sustained response rate
Genotype – 1 – 28% Genotype – 2 & 3 – 56%
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Pegylated and Ribavirin Schering – PEG-Intron plus ribavirin
Phase III clinical data – 54% sustained response rates
One group improved SVR - Genotype 1 low viral load FDA Approved
Roche – Pegasys plus ribavirin Phase III clinical data – 56% sustained
response rate – Genotype 1 – 46% - Genotype 2-3, 76%
Pending FDA Approval
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Treatment Decisions General
Treatment Guidelines
Healthy Active HCV Elevated ALT’s Compensated liver
disease
Optimal Response Younger Female Low visceral fat Low viral load Minimal liver
damage Genotype 2 or 3
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Side-effects Interferon
Fatigue Muscle/Joint pain Nausea Headaches Anxiety Depression Dry Skin/rashes
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
Light exercise Daily moisturizing Vary injection
sites Anti-Depressants Plenty of rest Frequent small
meals
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Experimental Therapies Amantadine - pill Maxamine – by injection (phase II
studies) Ribozymes Helicase Inhibitors Protease Inhibitors Interleukin-10
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Complementary Medicine Herbs – milk thistle
Always check with your doctor and herbalist – some herbs are TOXIC
Acupuncture / Acupressure
Traditional Chinese Medicine
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Lifestyle Changes That Help! Alcohol - Avoid
Get vaccinated – Hep A & Hep B
Healthy balanced diet
Exercise
Stress Reduction
Support Groups
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Advocate for Yourself and Your Client! Educate yourself
Establish a good relationship with your doctor
Bring an advocate for doctor’s visits
Ask questions
Keep copies of all medical tests
Keep a diary
Keep an open mind
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Comparisons – HIV & HCV
HIV Single stranded
RNA Retrovirus Mainly infects
CD4 cells Daily-replicates
millions
HCV Single stranded
RNA Flavivirus Mainly infects
liver cells Daily – replicates
in trillions
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Comparisons HIV/HCV, cont.
HIV is: Chronic = 100% US-1 major strain High sexual
transmission rate High IDU
transmission (blood)
HCV is: Chronic – 60-85% US-3 major strains Low sexual
transmission rates Very high IDU
transmission rates (blood to blood)
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HIV/HCV Comparisons, cont.
HIV
Curable?
Can become resistant to antiviral drugs
HCV
Curable?
Does not become resistant to current drugs
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HIV/HCV Co-Infection
Statistics: US
HIV Infections = 750,000 Up to 40% of people with HIV also infected
with HCV = 300,000
Worldwide HIV infections = 170 million
Estimated 23-75% of people with HIV also infected with HCV = 8-27 million
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Guidelines for Prevention of Opportunistic Infections*
HIV – All should be screened for HCV Patients should be counseled on alcohol
use Patients should be screened for HAV – if
negative, should be vaccinated; Hep B, triage based on risk & expense
Patients should be evaluated for liver disease and possible need for treatment
Liver enzymes should be monitored after initiation of HAART *US PHS (CDC) & IDSA
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HIV Medications Known to Be Hard on the Liver Documented potential liver
toxicities: Ritonavir (Norvir) Crixivan (Indinavir) Viramune (Nevirapine) Sustiva (Efavirenz) Kaletra (Lopinavir)
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Recommendations
HIV specialist and liver specialist should jointly monitor co-infected patients
Monitor liver functions especially when on treatment for HIV
Switch medications to less liver toxic
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Interferon and HIV
History: Interferon unsuccessfully used to treat HIV – during and pre-AZT
Approved for use in Kaposi's Sarcoma Currently looking at INF again Why? High INF levels accelerate HIV
progression (Gallo et al at NIH) INF harms immune system in HIV+?
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HCV Transmission for HIV+
Higher risk of transmitting sexually – may be due to higher viral load burden among co-infected – unclear
Mother to child – vertical transmission up to 25% risk during delivery
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Diagnosis
HIV ELISA Western blot for confirmation
HCV ELISA II (RIBA to confirm – not rec'd) Viral load – test for active HCV disease
(small percentage of people with HIV/HCV do not develop antibodies to HCV)
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Does HCV Make HIV Worse? Still controversial but most experts
do NOT believe that HCV makes HIV worse
Exception – hemophiliacs (high viral burden)
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Does HIV Make HCV Worse? Most experts believe that HIV
accelerates HCV disease progression
Some data suggest that when HIV is stable – low viral load, higher CD4 – HCV disease progression is slowed in co-infected persons
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When & Which to Treat?
Generally, HIV should be under control Treat HIV first – with HAART
HCV – People with HIV/HCV should be considered for HCV treatment Exceptions:
CD4 counts <200 Active opportunistic infection
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HIV Medications & the Liver
In general, ALL medications can be hard on the liver
HIV meds temporarily increase liver enzymes (ALT) & HCV viral load – usually levels out in 3-6 mos. If ALTs 4-5x baseline --
Change or discontinue medicine
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Ribavirin & the Liver
Ribavirin originally developed for HIV – not effective
Anemia - ribavirin & AZT both cause anemia – AVOID together
Ribavirin decreases AZT and to a lesser extent D4T (ZeritTM)) in vitro (test-tube)
Ribavirin may make DDI work better
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HCV Treatments
Similar response rates to HCV mono-infected
Closely monitor patients for: Anemia – up to 50% of co-infected
(rbv) Thrombocytopenia - low platelets (inf) Neutropenia – low white blood cells
(inf)
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Psychological Impact ofCo-Infection
Two life-threatening diseases
Lack of awareness/denial among patients and existing HIV support systems
Lack of support among traditional HIV support systems/groups
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Conclusions
Hepatitis C is a manageable chronic illness; misunderstandings/stigma persist
Lifestyle changes can enhance treatment outcomes & side effects
Management of HIV/HCV co-infection is possible, do-able, and difficult
Misunderstandings/stigma & lack of support exist for drug users co-infected