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Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents Hepatitis C Virus Disease Slide Set Prepared by the AETC National Coordinating Resource Center based on recommendations from the CDC, National Institutes of Health, and HIV Medicine Association/Infectious Diseases Society of America About This Presentation These slides were developed using recommendations published in July 2013. The intended audience is clinicians involved in the care of patients with HIV. Certain sections have been updated to reflect changes in the published guidelines. Users are cautioned that, because of the rapidly changing field of HIV care, this information could become out of date quickly. Finally, it is intended that these slides be used as prepared, without changes in either content or attribution. Users are asked to honor this intent. – AETC National Coordinating Resource Center http://www.aidsetc.org www.aidsetc.org July 2013 2 Hepatitis C Virus Epidemiology Clinical Manifestations Diagnosis Preventing Exposure Preventing Disease Treatment Preventing Recurrence Considerations in Pregnancy www.aidsetc.org July 2013 3 HCV Disease: Epidemiology HCV disease is a leading non-AIDS cause of death in HIV-infected persons 20-30% of HIV-infected U.S. patients have HCV coinfection HCV is a single-stranded RNA virus 7 genotypes Genotype 1: ~75% of HCV infections in United States; ~90% of HCV infections in U.S. blacks www.aidsetc.org July 2013 4 HCV Disease: Epidemiology (2) Transmission: percutaneous exposure, sexual exposure, perinatal, contaminated blood products or medical equipment Percutaneous transmission: HCV is 10 times more infectious than HIV through percutaneous blood exposures Injection drug use is most common risk in the U.S. (via syringes or injection paraphernalia) HCV can survive for weeks in syringes Other risks: intranasal cocaine use, tattoo placement www.aidsetc.org www.aidsetc.org July 2013 5 HCV Disease: Epidemiology (3) Sexual transmission HIV appears to increase risk of sexual transmission of HCV In HIV-infected MSM, multiple outbreaks of acute HCV Risk factors: unprotected receptive anal sex, sex toys, recreational drug use, concurrent STD In HIV-uninfected MSM, HCV transmission inefficient Heterosexual transmission uncommon; increased risk if partner is HIV/HCV coinfected www.aidsetc.org July 2013 6 HCV Disease: Epidemiology (4) Perinatal transmission HIV appears to increase transmission risk HCV incidence: 1-3% if HCV-infected mothers had detectable plasma HCV 4-7% if mothers had detectable plasma HCV RNA 10-20% if mothers had HIV/HCV coinfection www.aidsetc.org July 2013 7 HCV Disease: Epidemiology (5) HIV infection speeds progression of HCV to cirrhosis, especially if CD4 count is <200 cells/µL HIV speeds progression from cirrhosis to end-stage liver disease (ESLD) and hepatocellular carcinoma (HCC) www.aidsetc.org July 2013 8 HCV Disease: Clinical Manifestations Acute hepatitis C: Usually asymptomatic or mildly symptomatic; usually not recognized <20% have symptoms of acute hepatitis (eg, fever, right upper quadrant pain, nausea, vomiting, anorexia, jaundice) Liver transaminases may be elevated Recognizing possible acute HCV is important, given greater efficacy of treatment in early HCV www.aidsetc.org July 2013 9 HCV Disease: Clinical Manifestations (2) Chronic hepatitis C: Often asymptomatic Fatigue is common With progression, stigmata of portal hypertension (eg, spider angiomata, temporal wasting, splenomegaly, caput medusa, ascites, jaundice, pruritus, encephalopathy) May see skin abnormalities (leukocytoclastic vasculitis, porphyria cutanea tarda), renal disease www.aidsetc.org July 2013 10 HCV Disease: Diagnosis Screen all HIV-infected patients for HCV at entry into care: sensitive immunoassay For at-risk HCV uninfected, retest annually or as indicated by risk exposure To confirm infection: HCV RNA by sensitive quantitative assay HCV RNA does not correlate with HCV disease; should not be monitored serially unless on HCV treatment HCV RNA correlated with likelihood of response to HCV treatment www.aidsetc.org July 2013 11 HCV Disease: Diagnosis (2) False-negative HCV antibody results are possible in HIVinfected persons with advanced immunosuppression (<1%) Negative HCV antibody result can occur during acute infection Window period before seroconversion is 2-12 weeks Test for HCV RNA if risk of HCV, high ALT, but negative or indeterminate serologic test www.aidsetc.org July 2013 12 HCV Disease: Preventing Exposure Encourage injection drug users to enter substance abuse treatment program Advise IDUs not to share needles or drug preparation equipment if unable to stop using Needle exchange may facilitate access to sterile equipment Inform patients of risks associated with nonsterile body piercing, tattooing Encourage safer sex, especially condom use, to reduce sexual transmission of HCV www.aidsetc.org July 2013 13 HCV Disease: Preventing Disease No vaccine or recommended postexposure prophylaxis After acute HCV, treatment within 6-12 months may prevent chronic infection; high rates of HCV clearance Acutely infected patients should be offered treatment, unless contraindications Peginterferon (PegIFN) +/– ribavirin (RBV) Some experts recommend observation for ~3-6 months to see if HCV will clear spontaneously www.aidsetc.org July 2013 14 HCV Disease: Preventing Disease (2) Prevent liver damage: Avoid alcohol consumption Avoid hepatotoxins; limit acetaminophen intake (<2 g/day) Avoid iron supplementation unless iron deficiency Vaccinate against HAV, HBV if nonimmune If cirrhosis, consult with specialist Serial screening for HCC: Optimal strategy unknown; some recommend ultrasound every 6-12 months AFP has poor specificity and sensitivity; should not be used as the only screening method www.aidsetc.org July 2013 15 HCV Disease: Preventing Disease (3) Liver transplant is not absolutely contraindicated in HIV/HCV coinfection May refer coinfected patients with well-controlled HIV and liver decompensation or early HCC ART associated with reduced risk of liver disease progression Treat with ART in accordance with usual ART guidelines Dosage adjustment of some ARVs may be needed for patients with decompensated cirrhosis www.aidsetc.org July 2013 16 HCV Disease: Treatment Goals of treatment, therapy regimens, and monitoring parameters generally are the same for HIV/HCVcoinfected patients as for HCV monoinfected HCV treatment is evolving rapidly and a number of new drugs are now available, with more expected within the next few years See most recent HCV treatment guidelines (http://www.hcvguidelines.org) for current recommendations www.aidsetc.org July 2013 17 HCV Disease: Preventing Recurrence No protective immunity after infection; reinfection possible if new exposure to HCV (eg, via injection drug use or unprotected sex) Patients who achieve SVR should be counseled to avoid reinfection Methods that prevent sexual transmission of HIV should prevent sexual transmission of HCV www.aidsetc.org July 2013 18 HCV Disease: Considerations in Pregnancy All HIV-infected pregnant women should be tested for HCV Evaluation, including liver biopsy, can be delayed ≥3 months after delivery (pregnancy-related changes in HCV activity should resolve) Hepatitis A and hepatitis B vaccination can be given; should be given if not immune www.aidsetc.org July 2013 19 HCV Disease: Considerations in Pregnancy (2) HCV treatment with PegIFN and ribavirin is contraindicated during pregnancy IFN: has antigrowth and antiproliferative effects; is abortifacient in monkeys Ribavirin: FDA category X; teratogenic at low dosages in many animal species Both women and men must be counseled about risks and need for consistent and effective contraception during ribavirin therapy and for 6 months after completion of therapy BOC, TPV: pregnancy category B, but must be used with IFN and ribavirin, which are contraindicated www.aidsetc.org July 2013 20 HCV Disease: Considerations in Pregnancy (3) Perinatal HCV transmission: higher risk for HIVcoinfected women Limited data on efficacy of medical or surgical preventive measures Cesarean delivery does not decrease risk of perinatal HCV transmission, and may increase risk of maternal morbidity in HIV-infected women Cesarean delivery in HIV/HCV-coinfected women can be considered based on HIV-related indications; data insufficient to support routine use for prevention of HCV transmission www.aidsetc.org July 2013 21 Websites to Access the Guidelines http://www.aidsetc.org http://aidsinfo.nih.gov www.aidsetc.org July 2013 22 About This Slide Set This presentation was prepared by Susa Coffey, MD, for the AETC National Resource Center in July 2013. See the AETC NRC website for the most current version of this presentation: http://www.aidsetc.org www.aidsetc.org July 2013 23