Post on 01-Jan-2016
description
Hepatitis C Co-infection: A Review and a Look at Critical
Issues
Sharon Stancliff, MDAIDS Institute
New York State Department of Health&
Harm Reduction CoalitionNovember 2005
Hepatitis C
RNA virus isolated in 1988 but still not cultured in the laboratory
There are still many questions about: Transmission Who will progress to severe liver disease Who to treat
And we need better treatment options
Hepatitis C in the USA &NYS
USA: Estimated New infections/year: 30,000 USA: Persons with chronic infection: 2.7 million USA: Deaths from chronic disease/year:8,000-
10,000Based on these numbers NYS: Persons with chronic infection: 237,500
CDC
Epidemiology
Injecting Drug Use and HCV Transmission
The most common risk factor - high rates of conversion early in injection career
One NYC MMTP: 60% of patients are chronically infected
Incidence among IDUs decreasing but prevalence is high
HCV Transmission:HCV Transmission: It’s All About the It’s All About the BloodBlood
Hepatitis C Harm Reduction Project
HarHar
Harm Reduction Coalition
Bloodborne viral infections among injection drug usersBaltimore 1983–1988
0 6 12 18 24 30 36 42 48 54 60 66 720
20
40
60
80
100
Sero
pre
vale
nce (
%)
Duration of Injecting (months)
HCVHCV
HBVHBV
HIVHIV
Garfein RS. Am J Public Health. 1996;86:655.
Impact of Syringe Access and Education: Prevention works
NYC 1990: 54% of IDUs HIV positive;71% of all new (<5yrs) IDUs Hepatitis C positive
NYC 2002: 13% of IDUs HIV positive;39% of all new IDUs Hepatitis C positive
Des Jarlais 2005 AJPH, AIDS 2005
Sexual Transmission
Associated with: Infected partner, multiple partners, early sex,
non-use of condoms, other STDs, sex with trauma
But: MSM no higher risk than heterosexuals Low prevalence (1.5%) among long-term
partners Terrault 2002
Other risk factors
Perinatal About 5%, up to 17% if co-infected with HIV Infants probably do well
• Nosocomial: hemodialysis, • At least 10% of cases have no known risk
factor• Uncertain role of tattooing, piercing,
intranasal drug use
Corrections
HCV +: 16-41% Chronic infection: 12-35% Entrants into NYS prison: Men- 13%
Women- 23% Incidence while incarcerated: Estimated to
be 1.1/ 100 person yrs
MMWR 2003
Sentinel Counties Study of Acute Viral Hepatitis Reported Risk Factors for Acute Hepatitis C, 1991 – 1998
Transfusions *3%
Occupational3%
No Identified Risks**
9%
Household3%
Sexual20%
Illegal Drug Use
62%
*None since 1994 **6% Low SES
Clinical Aspects
Clinical Features
Incubation: 6-7 weeks Clinical illness: 20-40%
Malaise, jaundice, abdominal pain
Long term outcome: possible cirrhosis, liver failure after 20-40 years coagulopathy, encephalopathy, ascites
Hepatocellular carcinoma Leading indication for liver transplant
Progression
1-4% /yrH C C
10-20%serious liver d isease
80-90%asym ptom atic-m oderate d isease
70-85% H C V +:chronic in fection
15-30% c learthe v irus
H epatitis an tibody positive
Risk factors for progression
• Heavy use of alcohol• HIV positive- lower CD4 counts in
particular• Older age at infection• MaleProgression very hard to predict
HCV/HIV Co-infection
HIV both accelerates and increases risk of HCV progression
Liver disease is increasing as a cause of death in HIV+ persons
Impact of HCV on HIV continues to be investigated- impact may be greater in post- HAART era
Sulkowski 2002, Anderson 2004
Treatment
Weekly pegylated interferon with daily oral Ribavirin for 24-48 weeks;
Side effects: often very debilitating Flu-like syndrome, hair-loss, thyroid
dysfunction Depression and other psychiatric disorders Anemia, retinal bleeding
Effectiveness of Treatment
In clinical trials: 30-50% have sustained viral response (SVR), in some genotypes 2 and 3 up to 80%
May also slow progress and reduce risk of liver cancer regardless of SVR
Much lower response in the community especially with advanced disease, older, male, African American and heavy alcohol users
Who Should be Treated?
Goal: Find and treat those for whom the illness is worse than the treatment
D. Thomas
Current NIH standard includes presence of progression of illness on liver biopsy
HIV and HCV Treatment
HIV+ patients with relatively intact immune systems can respond to treatment
Sustained viral response in clinical trials for co-infected people Overall: 27% to 40% Genotype 1: 10-15% higher in some studies Genotypes 2 & 3: up to 73%
Torriani 2004, Chung 2004
HCV and HIV treatment
HCV+ patients may be less likely to receive HAART
While HAART increases the risk of hepatotoxicity most HCV+ patients can tolerate it
HAART therapy may protect the liver by maintaining higher CD4 counts
Anderson 2004, Mehta, 2005
Treating HCV in the co-infected
Recent recommendations Defer treatment if liver biopsy has minimal
damage Optimize CD4 prior to treatment
Kontorinis, 2005
Liver transplant in HIV
HIV+ persons are receiving transplants in various centers and are showing good survival rates
In 2003 NIH initiated a multi-center trial to evaluate strategies and outcomes of solid organ transplants in HIV+ individuals
Neef 2004
Challenges
Successful treatment rates much lower in community than in clinical trials
Relative contraindications common particularly among co-infected patients- Psychiatric illness Substance use
African Americans respond poorly to current treatment
(Injection) Drug Users
NIH Consensus Statement 1997: defer treatment of drug users until a
period of abstinence 2002: individualized decisions regarding
treatment of active drug users A review of 7 clinical trials found that drug
users were similar to controls or comparable groups in adherence and response
Schaefer 2004, Mehta 2005
African Americans
Higher incidence of HCV- particularly Genotype 1
Possibly less likely to progress Much less likely to respond to treatment
Independent of genotype, alcohol and adherence
Muir 2004
A Look at New York
ADAP users of interferon and/or interferon: 2003- 91 3/04- 3/05- 189
Challenge: Treating the typical co-infected patient
104 co-infected patients referred to GI for evaluation of HCV, at least 72% had IDU as risk factor
21 had a liver biopsy
16 received treatment
Restrepo, 2005
Reasons for non-treatment
Non-adherent to appointments: 40% Active substance users: 15% Active psychiatric conditions: 8% Medical contraindications: 37%Conclusion: “A majority of non-candidates
had potentially modifiable psychosocial factors leading to non-treatment”
Restrepo, 2005
Co-infection Clinic: Oakland
Chart review: of 228 co-infected patients found poor performance on vaccines and alcohol counseling and only 2 treated for HCV
Established co-infection clinic: Educate- journal clubs, mini-residencies case
conference Full time nurse specialist Increase availability of biopsy
Clannon CID 2005
Progress to date
15 patients initiated treatment 6 discontinued- one achieved SVR 7 all achieved SVR
Pearls: Aggressive management of side effects: epoitin and SSRIs Lot’s of water for systemic symptoms CD4 counts dropped a lot and cause distress
Clannon, 2005
Co-infection Clinic: Providence
Co-infection clinic 2x/month: HIV/HCV specialist, hepatologist, coinfection nurse and coordinator in collaboration with a community mental health and addiction treatment provider
Requirements: adherence to appointments and cooperating with psychiatric plan
No exclusion based on addiction- stability is a goal which may be harm reduction
Taylor CID 2005
Progress to date
146 referred, 92 seen once, 69 have had liver biopsies 97% history of addiction, 43% current users 85% with psychiatric disorder
17 in pretreatment, 17 treated 7 completed 1 SVR 5 in treatment 5 dropped out- none because of drug use
Taylor, 2005
NYS Clinical Guidelines
Co-infection guidelines- first in country, updated September 2004
Mono-infection: for primary care providers October 2005
Focus areas Risk assessment Diagnosis Treatment Medical management Prevention and counseling
Hepatitis C Conference
Two locations Buffalo – November 1, 2005 NYC - November 15, 2005
Agenda HCV in corrections HCV Transmission in the healthcare setting Consumer panel Ethnic disparities
African Americans and HCV Cross cultural care
The Hepatitis C Project
Focus on hepatitis C in IDUs Training, technical assistance, and policy
development for NYC needle exchange programs
Posters, brochures, website: www.hepcproject.org
Current initiatives on new models for HCV prevention, networks of HCV care and treatment for IDUs
Harm Reduction Coalition
Tasks
Patient and clinician education Research and guidelines on management of
current drug users Research and guidelines on management of
psychiatric disorders in HCV treatment Research on the impact of alcohol on treatment Research on resistance to treatment: focus on
African-Americans- initiated by NIH
For more HIV-related resources, please visit www.hivguidelines.org