HIV/HCV co-infection in Taiwan

Nai-Ying Ko RN. PhD., Hsin-Chun Lee MD, Shainn-Wei Wang PhD., Wen-Chien Ko MD,

National Cheng Kung University & Hospital

Taiwan

Topics

• Molecular epidemiology of HIV/HCV coinfection in Taiwan

• Treatment and care for patient with HIV/HCV coinfection in Taiwan

• Challenges of management of HIV/HCV coinfection in Taiwan

0

500

1000

1500

2000

2500

3000

1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

C

a

s

e

N

u

m

b

e

r

Heterosexual contactHomosexual contactInjecting drug useOther

1813

2462

629

2003

31%10%

6%

53%

200421%

40%

6%

33%

2005

9%

72%

14%

5%

2006

62%

1%

22%

15%

2007

37%

4%

38%

21%

713

Year

Annual Numbers of Newly Reported HIV Cases by Mode of Transmission, 1984-2007

Cumulative number of reported HIV cases: 15,866 (June 30, 2008)

Free HAART Harm reduction

0

500

1000

1500

2000

2500

3000

3500

4000

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006

0%

20%

40%

60%

80%

100%

120%

HIV(+)

AIDS

AIDS fatality rate*

Free HAARTFree HAART

Free AZTFree AZT

HIV/AIDS Reported Case Number and Fatality Rates in Taiwan, 1984 – 2006

*: AIDS-related deaths / AIDS case number

台北縣

嘉義縣

新竹縣

花蓮縣

台中縣

彰化縣南投縣

屏東縣

高雄縣

台南縣

台東縣

宜蘭縣

桃園縣

苗栗縣

雲林縣

Anti-HCV prevalence in Taiwan

Population: 157,720 adultsPeriod: 1996-2005Anti-HCV seropositivity: 4.4%

HCV genotype distribution 1b: 58~81.1 %2a: 7.4~12 %2b: 3.4~4.9 %

Chen CH at al., J Formos Med Assoc. 2007;106(2):148-55 Yu ML et al, J. Med. Virol. 2001;65:58-65

0 - 1%

Age-adjusted prevalence of anti-HCV

1 - 3%

3 - 5%

5 -10%

Extremely high prevalence of HCV infection among HIV-infected IDUs in Taiwan

Liu JY, et al. , Clinical Infectious Diseases 2008; 46:1761–8

The proposed route of HIV/HCV transmission from China and Southeast Asia to Taiwan

Liu JY, et al. , Clinical Infectious Diseases 2008; 46:1761–8

Co-Infections among HIV-Infected Adults

[J Formos Med Assoc 2008;107(5):404–411]

%, n/N

Total MSM Hetero IDU p value

HBs Ag (+) 16.8, 23/137 20.0, 13/65 20.0, 7/35 8.1, 3/37 0.255

HBs Ab (+) 59.6, 84/141 57.6, 38/66 53.8, 21/39 69.4, 25/36 0.35

HBc Ab (+) 79.7, 102/128 79.4, 50/63 75.7, 28/37 85.7, 24/28 0.606

Isolated HBc Ab (+) 14.1, 19/135 15.6, 10/64 10.5, 4/38 15.2, 5/33 0.747

HCV Ab (+) 32.6, 46/141 7.2, 5/69 11.4, 4/35 100, 37/37 < 0.001

HBs Ag (+) & HCV Ab (+) 3.5, 5/142 1.4, 1/69 2.8, 1/36 8.1, 3/37 0.238

HBc Ab (+) & HCV Ab (+) 24.8, 33/133 7.2, 5/69 11.1, 4/36 85.7, 24/28 <0.001

No. of cases with positive HCV-RNA/No. of cases being tested

37/141 5/64 3/39 29/38

Types of HCV

1a 12 0 0 12

1b 6 1 2 3

2a 4 1 1 2

2b 2 0 0 2

3a 7 0 0 7

6a 4 1 0 3

6g 1 1 0 0

Serological characteristics and types of HBV and HCV of 146 HIV-1-infected adults categorized by HIV risky groups in NCKUH

HCV infection is significantly associated with HIV infection among gay bathhouse attendees in Taiwan, 2004-2007

* Odds ratio: 7.1; 95% CI: 2.3-22.1

*

NY Ko, at al. (2008) unpublished data

Topics

• Molecular epidemiology of HIV/HCV coinfection in Taiwan

• Treatment and care for paitents with HIV/HCV conifection in Taiwan

• Challenges of management of HIV/HCV coinfection in Taiwan

HBV/HCV Treatment in Taiwan

• 1980s Department of Health – Hepatitis Prevention Act

• 2003 Bureau of National Health Insurance– program for strengthening treatment for chronic

hepatitis B and C

• 2007 National Health Research Institute– National Forum on screening, treatment and long-

term follow-up of patients with hepatitis B virus- or hepatitis C virus-related liver diseases

Criteria Anti-HCV (+) , ALT 2X, 3 M apart, within 6 M ≧Fibrosis F2≧ ( F1, since August, 2004 )

• PEG-IFN or IFN + RBV for 24 weeksPEG-IFN or IFN + RBV for 24 weeks

Treatment of Chronic Hepatitis C (National Health Insurance, Taiwan)

Screening for HIV/HCV coinfection in Taiwan

• Test of anti-HCV for all patients with HIV

• Test of HCV RNA for patients with HIV– Anti-HCV(+) and progression to chronic hepatitis– Anti-HCV(-), rapid progression with abnormal

liver function tests, and patients with low CD4 cell counts (< 200 cells/mm3)

– Anti-HCV(-), suspect acute HCV infection

(NHRI National Hepatitis BC Forum, 2008)

Preparation for HIV/HCV coinfection treatment in Taiwan

• Before treatment– Liver function tests (AST, ALT), HCV RNA, HCV

genotype, liver biopsy – HIV RNA, CD4 cell counts – Optimized HAART treatment

• When considering treatment – CD4 >350 cells/mm3, treat HCV first– If CD4 =201-350 cells/mm3, treat HIV first then HCV– CD4 < 200 cells/mm3, treat HIV

(NHRI National Hepatitis BC Forum, 2008)

Treatment for HIV/HCV coinfection in Taiwan

• Standard of care in coinfected patients is pegylated interferon plus ribavirin

• Optimal dosing of pegylated interferon and ribavirin– HCV genotype 1, ribavirin (1000 mg/day if < 75 kg and

1200 mg/day if > 75 kg)

– HCV genotype 2 & 3, ribavirin (800 mg/day)

• F/U HCV RNA at 12, 24, 48 wks, and 6 months

• F/U HIV RNA every 3-4 months(NHRI National Hepatitis BC Forum, 2008)

Topics

• Molecular epidemiology of HIV/HCV coinfection in Taiwan

• Treatment and care for patient with HIV/HCV coinfection in Taiwan

• Challenges of management of HIV/HCV coinfection in Taiwan

Needle-Syringe ProgrammingNeedle-Syringe Programming

Pilot stage (Nov. 2005 ) (76 NSP stations)

Expanding stage (Jul. 2006 ) (427 NSP stations)

Present stage (Jan. 2008) (1103 NSP stations)

Aug. 8 ~

Aug. 15, 2007

Nov. 1, 2005 ~

Aug. 15, 2007

Vistors(per persons time) 9308 313528

Number of Needle-

Syringes Dispatched78673 2198554

Number of Condoms

Dispatched37584 505228

Pilot stage (Feb. 2006 )(6 hospitals)

Expanding stage (Aug. 2006 )

(33 hospitals & clinics)

Present stage (Jan. 2008 )(68 hospitals & clinics)

Drug Substitution TreatmentDrug Substitution Treatment

基隆長庚醫院 /署立基隆醫院

八里療養院 */耕莘醫院 */亞東醫院 */署立台北醫院

*

羅東博愛 */署立宜蘭醫院

署立台東醫院 *

台北市立聯合醫院松德院區 */疾管院區*/三軍總醫院

桃園療養院 */國軍桃園總醫院 */桃園榮院 *

新竹馬偕醫院 *

為恭醫院 *

中國附設醫院 *

童綜合醫院 *

彰化基督教醫院 */署立彰化醫院

台大雲林分院 */中國北港 /若瑟醫院 *

署立朴子醫院 */大林慈濟醫院

嘉義榮民醫院 */署立嘉義醫院

署立嘉南療養院 */永康榮院 */署立新營醫院 *

署立台南醫院 */成大醫院 */奇美醫院

署立草屯療養院*

高雄長庚 * /慈惠醫院 *

市立凱旋醫院 */國軍高雄醫院

安泰醫院 *

國軍花蓮總醫院 */署立花蓮醫院

署立新竹醫院 /署立竹東醫院

Aug 15, 2007

Treatment cases 5470

Drop out cases 3173

Cumulative treatment cases 8643

Health seeking behaviors among patients with Health seeking behaviors among patients with HIV categorized by route of transmissionHIV categorized by route of transmission

Access to care (%)

0

20

40

60

80

100

2002 2003 2004 2005

%

Heterosexual

MSM

IDU

Annual health care visits

0

2

4

6

8

10

2002 2003 2004 2005

Heterosexual

MSM

IDU

CH Yang (2006) HIV-related Medical Expenditure Analysis in Taiwan

Challenges of management of HIV/HCV coinfection in Taiwan

• Harm reduction policy was implemented since 2006• HCV treatments founded by NHI were performed by

hepatologists, oncologists, and hematologists

• Current standards include presence of progression based on liver biopsy

• Some hepatologists still withhold treatment from patietns with HIV or IDUs

• Cost of test for HCV RNA and genotype

Conclusions

• HCV infection is highly prevalent in HIV-infected IDUs and exhibit great genetic diversity.

• HIV-1 CRF07_BC, HCV genotype-1a, 3 and 6 have been transmitted from China into Taiwan through drug trafficking route.

• Pegylated interferon plus ribavirin is available. • Some hepatologists still withhold treatment

from patients with HIV or IDUs.• Poor access to care and fewer clinical visits

among HIV infected IDUs.

Acknowledgements

• Taiwan CDC: Dr. CH Yang

• EDH: Dr. HH Lin

• NTUH: Dr. CC Hung, Dr. WH Sheng

• KMUH: Dr. ML Yu

• NHRI: Dr. IJ Su, Dr. FC Tseng

Thanks your attention