HIV and Hepatitis
Ray Poll
Nurse Consultant for Viral Hepatitis
Sheffield Teaching Hospitals NHS Foundation
Trust
08/04/2015
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Introduction
• In 93% of 100 clinics dual HIV/HBV infection rate 310%
• Cases of acute HCV infection in HIV+ gay men
• Incidence of HCV infection high in HIV+ IDUs (83%)
• HIV causes HBV and HCV to progress more quickly
• People with co-infection have higher risk of liver
disease from ART but benefits of HIV treatment seem
to outweigh risks from additional liver-related sideeffects
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Cirrhosis
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What does the liver do?
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Stores energy
Produces bile
Stores vitamins and minerals, including iron
Destroys and deals with poisons and drugs
Produces chemicals for most of the chemical
reactions in the body
• Repair damage and renew itself
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Liver tests
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Diagnostic blood tests
Liver function tests
Ultrasound scan
Liver biopsy sometimes
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Liver biopsy
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Hepatitis B
• Routes of transmission
• Chronic infection – inversely proportionate to
age
• About 25% develop liver disease including
cirrhosis
• Treatment – lower levels of virus, not
everyone needs it but for many life-long
• All HBV patients screened for HIV and HDV
• Immunisation
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Hepatitis B - epidemiology
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Hepatitis B tests
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Hepatitis B surface antigen (HBsAg)
Hepatitis B core antibody (HBcAb)
Hepatitis B surface antibody (HBsAb)
Hepatitis B ‘e’ antigen (HBeAg)
Hepatitis B ‘e’ antibody (HBeAb)
HBV DNA
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Hepatitis C
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Virus mainly found in blood
Common risk factors
Liver disease usually takes many years
Many with chronic infection are
asymptomatic
• Genotypes
• Treatment – curative for many
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HCV screening
• All HIV-infected pts should be screened for
HCV antibodies
• Repeat screening
– Annually
– Three monthly in MSM (minimum)
– Patients with abnormal LFTs
• Negative HCV antibody may be associated
with blunted immune response
• HCV RNA should be performed for some
individuals
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Case study 1
• 38yr old HIV+ gay man
• ART since 2002
• Nov 2011 abnormal LFTs – unable to do HCV
antibody
• Dec 2011 – HCV antibody neg – unable to do HCV
RNA
• Jan 2012 – HCV RNA 111
• Feb 2012 – HCV RNA 281
• March 2012 – HCV RNA 3548
• HCV genotype 1
• Previous samples – HCV RNA neg Aug 2011; pos
Nov 2011
• Acute or chronic infection – what treatment
approach?
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Case study 2
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Local outbreak of HIV among IDUs
29 yr old male former IDU
Known HCV genotype 3a
Previously attended RHH but lost to follow-up
2008 HIV neg
2010 Re-engaged after seen in outreach
Found to be HIV positive
Had HCV treatment for 48 weeks and EOT
response – awaiting SVR
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When to start treatment
CD4
cells/μL
HBV requiring Rx
HBV not requiring
Rx
HCV with
immediate plan to
start HCV Rx
HCV with no
immediate plan to
start HCV Rx
>500
Start ART in some
patients (2C)
(Include tenofovir and
emtricitabine)
Defer ART
Defer ART
Defer ART
≤500
Start ART (1B)
(Include tenofovir and
emtricitabine)
Start ART (1B)
(Include tenofovir
and emtricitabine)
350–500
Start ART after
HCV treatment
commenced (1C)
<350
Start ART before
HCV treatment
(1B).
Discuss with HIV
and viral hepatitis
specialist
Start ART (1C)
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Response rates to HCV therapy
SVR rates
HCV
Monoinfection
Overall
56-61%
HIV/HCV
Co-infection
27-40%
Genotype 1
42-44%
14-38%
Genotype
2 and 3
70-82%
Up to 73%
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Case study 2 - Treatment
• Cannot be sure if acute or chronic infection
• Discussed merits of treatment now or later
using triple therapy
• Consider change of ART regime – lessen
anaemia and reduce liver toxicity
• Going on holiday and wishes to defer HCV
treatment
• In meantime stabilise on new ART regime
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HCV Antivirals in Development
ANA773
PhI
Miglustat
Clemizole
AVL-181
RG 7348
NIM-811
MK-1220
Other HCV
Compounds
MK5172
CF-102
Golotimod (SCV 07) sc
ATI-0180
PRO 206
VBY376
PhIII
GS 9256
TMC435350
PHX-1766
ACH-1095
IDX-320
Taribavirin
Celgosivir
ITMN-191/R7227
Telaprevir
TaigGen Bio
ACH-1625
Boceprevir
IPH 1101
IMO-2125
IDX-136 and IDX-316
BMS-650032
MK-7009
BIT-225
PF 4878691
ACH 2928
VX-985
BI-201335
Nitazoxanide
SCY-635
ITX 5061
SCH 900518
GI-5005
CYT-107
FGI 103723
IDX-375
Nov-205
Debio025
CB-5300
NA-808
PIs
VX-813
ABT 450
PhIIb
SPC-3649
BMS-791325
BMS-824393
PhIIa
R7128
BMS 790052
PPI-461
EDP-239
Nuc
polymerases
PSI-7977
BMS
AZD-7295
Albuferon
IDX-184
NS5As
PSI-879
PSI-7851
HDV-IFN
(Hepasome)
PF868554
sr-IFN-alpha
(LG Life Sciences)
IFN alpha, Medgenics
(Biopump SR)
Locteron CR
MK3281
AZD 2795
ITCA-638
BI-207127
ABT-333
IFN-alpha-2b-medtronics
IFN-alpha-2b-XL
IF's
Interferon-alpha
(buccal lozenge, Amarillo)
Belerofon
Changed/additional info
08/04/2015
Suspended / Discontinued
IDX-102
IDX-189
VCH 759
PEG-IL-29
P-1101
PSI-938
GS 9190
VCH-222+ Telaprevir
GS9190+GS9256
ABT-072
ANA598
VCH-222
VCH 916
NonNon-nuc
polymerases
RG7227+RG7128
BMS-790052 + BMS-650032
IDX184+IDX320
Sources: GBI Analysis (August 4, 2010), Pipeline Sources, Company Press Releases, Reuters Knowledge Analyst Reports
BI-201335+BI20127
Combination
Products
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Summary
• All HIV + persons should be screened for HBV
and HCV, and visa versa
• Offer HAV/HBV immunisation to non-immune
individuals
• ‘Cure’ rates in HIV/HCV co-infection promising
• Newer HCV drugs in development
• HCV treatment response guided
• Side-effects well managed with support of MDT
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References
• BHIVA (2010) Guidelines for the management of coinfection with HIV-1 and hepatitis B or C virus.
• BHIVA (2012) Guidelines for the treatment of HIV-1
infected adults with antiviral therapy.
• EASL (2012) Clinical Practice Guidelines:
Management of chronic hepatitis B virus infection.
• National AIDS Trust (2012) Hepatitis C and HIV Coinfection. www.NAT.org.uk
• NICE (guidance for treatment of HBV and HCV
monoinfection) www.nice.org.uk
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Thank you for listening!
Does anyone have any
questions?
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Contact details
Ray Poll
Nurse Consultant for Viral Hepatitis
Room E86, Department of Infection and Tropical Medicine,
Royal Hallamshire Hospital,
Glossop Road, Sheffield
S10 2JF
Tel: 0114 271 1776
Pager: 07623 857909
E-mail: ray.poll@sth.nhs.uk
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