Download Hepatitis C

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field of HIV care, this information could become out of date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
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Hepatitis C Virus
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Epidemiology
Clinical Manifestations
Diagnosis
Preventing Exposure
Preventing Disease
Treatment
Preventing Recurrence
Considerations in Pregnancy
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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
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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
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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
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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
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Websites to Access the Guidelines
 http://www.aidsetc.org
 http://aidsinfo.nih.gov
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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
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