GUIDELINES FOR INCORPORATING HIV/HCV PREVENTION INTO MEDICAL CARE - PowerPoint PPT Presentation

GUIDELINES FOR INCORPORATING HIV/HCV PREVENTION INTO MEDICAL CARE JOHN I. MCNEIL, MD, FACP MAXIMED ASSOCIATES MARYLAND JANUARY 25, 2018

CME Disclosures: Planning Committee And Speaker Speaker: The following speaker has nothing to disclose in relation to this activity: John I. McNeil, MD

Howard University CME Accreditation Sponsor Accreditation: Howard University College of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Credits for Physicians: Howard University College of Medicine, Office of Continuing Medical Education, designates this live activity for a maximum of 1.0 AMA PRA Category I Credit(s) TM . Physicians should claim only the credit commensurate with the extent of their participation in the activity. Goulda A. Downer, PHD, RD, LN, CNS – Principal Investigator/Project Director

CME Disclosures: Planning Committee And Speaker AETC-Capitol Region Telehealth Project Planning Committee: The following committee members have nothing to disclose in relation to this activity: Goulda A. Downer, PhD, RD, LN, CNS John I. McNeil, MD John Richards, MA-AITP Denise Bailey, MED Speaker: The following speaker has nothing to disclose in relation to this activity: John I. McNeil, MD

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TEST YOUR KNOWLEDGE 6

TestYour Knowledge Question #1 HIV Accelerates HCV related Fibrosis: A. True B. False

TestYour Knowledge Question #2 The following factors are associated with HIV/HCV Fibrosis Progression: A. Alcohol Consumption B. Male Gender C. Age D. Multiple Transfusions

TestYour Knowledge Question #3 HCV antibody test means the person is still infectious: A. True False B.

TestYour Knowledge Question #4 Which of the following is true about Hepatitis C? A. Cure protects for a life time B. Cannot be treated while treating HIV C. Cannot be treated in someone with cirrhosis D. Can be cured in as little as 8 weeks

CARE FOR PATIENTS WITH CHRONIC HCV/HIV COINFECTIONS

LEARNING OBJECTIVES 1. Describe the epidemiology of HCV 2. Describe progression of liver disease in the setting of HIV/hepatitis C virus (HCV) coinfection 3. Understand treatment objectives 4. Describe barriers to treatment, including drug-drug interactions

EPIDEMIOLOGY Ø Five major types, maybe six minor types Ø Estimated 3.5 million people in the US have chronic HCV Ø Yearly, 17,000 get infected Ø Long-term incubation can eventually result in liver failure, liver cancer Ø Every year approximately 12, 000 die from HCV related liver disease

WHERE DOES IT COME FROM? Ø It is typically spread when blood from a person infected with the hepatitis C virus enters the blood stream of a non-infected person. Ø Yes, and sex Ø Transfusions (before 1982)

RISK FACTORS FOR ACQUIRING HCV http://www.healthline.com/health/hepatitis-c/facts-statistics-infographic

SYMPTOMS Ø Silent for years Ø Signs of eventual liver damage o Fever o Fatigue o Jaundice o Dark urine o Grey colored stools o Joint pain

HIV/HCV COINFECTION Ø Compared to HCV monoinfection o Higher rates of susceptibility to mucosal transmission o Higher rates of persistence o Faster rates of fibrosis o Higher rate of cirrhosis o Increased liver related mortality

CARE CASCADE IN HCV

PROGRESSION OF FIBROSIS IN HCV www.hcvonline.org

IMPACT OF HIV COINFECTION http://hivinsite.ucsf.edu/InSite?page=kb-05-03-05#S1X

HIV ACCELERATES HCV RELATED FIBROSIS Kim and Chung Gastroenterology 2009

FACTORS ASSOCIATED WITH HIV/HCV FIBROSIS PROGRESSION Ø CD4 count less than 200 cells/mm 3 Ø Alcohol consumption Ø Older age at time of HCV acquisition Di Martino et al Hepatology 2001

MODIFIABLE RISK FACTORS FOR DISEASE PROGRESSION ¡ Diabetes/ insulin resistance ¡ Coinfection with HBV ¡ Marijuana

IMPACT OF HCV CURE

54 Y.O. WITH HCV ANTIBODIES ¡ 54 year old man was anti-HCV positive after elevated ALT was noted by the Primary Care Provider. He had a brief history of IDU when in his 20’s, and was now currently a moderate ETOH user, otherwise healthy. ¡ HCV RNA was 4 million IU/L; Genotype 1a, ALT 42 IU/ml, AST 65 IU/ml, TB 1.6 mg/dl, Alb 3.9 mg/dl, Hgb 13.4 mg/dl, PLT 110,000, Creatinine 1.2 mg/dl

54 Y.O. WITH HCV ANTIBODIES ¡ Which of the following is the net appropriate step: 1. Treat with oral regimen for 12 weeks 2. Check HCV 1a resistance test 3. Elastography 4. Confirm HCV antibody test

STAGING IS NEEDED FOR CHRONIC HCV ¡ Accepted Staging Methods ¡ Not for Staging Liver biopsy Viral Load 1. 1. Blood markers HCV genotype 2. 2. Elastography Ultrasound 3. 3. Combination of 1-3 CT scan or MRI 4. 4.

VALIDITY OF NONINVASIVE TESTS FOR DETECTING CIRRHOSIS T est % Sens %Spec AUROC Pos LR Neg LR Fibrotest >.56 85 74 .86 3.3 0.2 Fibrotest>.73 56 81 - 2.9 0.54 FIB4>1.45 90 58 .87 2.1 0.17 APRI 51 91 0.73 3.1 0.31 Elastography 12.5 87 91 0.95

54 Y.O. WITH HCV ANTIBODIES ¡ Elastography is 16.4 kPa ¡ FIB 4 = (Age x AST)/(PLT x √ ALT) ¡ FIB 4 = (54 x 65)/(110 x √ 42) = 4.92 ¡ What is the next step?

MANAGEMENT OF HCV WITH F3-4 1. Need US (or CT/MRI) to rule out Hepatocellular Carcinoma 2. Need UGI to assess for Esophageal Varicies 3. Need to assess if compensated – CPT: no encephalopathy or ascites; bilirubin <2 mg/dl, albumin >3.5 g/dl, and INR<1.7 4. Treat MELD = 3.8*log(serum bilirubin[mg/dL]) + 11.2*log(INR) + 9.6log(serum creatinine [mg/dL]) + 6.4

DOES HIV CHANGE THINGS? ¡ You are called back and told the patient is HIV coinfected and on TDF/FTC and darunavir/retonavir. What does that change? 1. Treat for 24 weeks vs 12 weeks 2. Use SOF/LDV to avoid drug interactions 3. Notify the patient treatment is the same, but chances of SVR is 85% instead of 95% 4. Treat with elbasvir/grazoprevir if no resistance

HCV AND HIV ¡ Treatment responses are the same ¡ Drug interaction often define treatment 1. HIV integrase inhibitors generally ok 2. HCV SOF Ok 3. HCV PI – avoid HIV PI, efavirenz and cobistat 4. HCV LDV and VEL – PPI reduces absorption

HCV GUIDELINES ¡ Test all born 1945-1965 and with risk ¡ For positives ¡ Vaccinate HAV and HBV ¡ Counsel regarding alcohol and transmission ¡ Stage ¡ Treat

54 YEAR OLD WITH HCV AND HIV ¡ Ultrasound and UGI are ok and you recommend treatment but he wants to know why. Which of the following is not true? 1. Successful treatment reduces the risk of reinfection 2. Successful treatment reduces the risk of death 3. Successful treatment reduces the risk of Hepatocellular Carcinoma 4. Successful treatment reduces the risk of lever failure

THERAPY IN HIV/HCV COINFECTION Ø When compared to HCV monoinfection: o Duration of treatment usually the same o Medication regimens often the same o Adverse events the same (almost none) o OUTCOMES the same o But…. Ø Drug-drug interactions may be significant

POOR HISTORICAL RESPONSE IN HIV/HCV Poordad F et al, NEJM 2011; 364:1195-1206 vs. Sulkowski et al. Lancet Infect Dis 2013; 13(7):597-605. Jacobson I et al, NEJM 2011; 364:2405-2416 vs. Sulkowski et al. Ann Intern Med 2013; 159(2): 86-96. Antiviral Drugs Advisory Committee Meeting, FDA review, 10/24/13 C208, C216, C206, C212, HPC3007, Dieterich et al. Clin Infect Disease 2014 (epub ahead of print) Lawitz et al. NEJM 2013 versus Torres-Rodriguez et al., IDSA 2013 Osinusi et al., JAMA 2013;310(8):804-11 versus Sulkowski et al. JAMA 2014;312(4):353-61.