Transcript Objectives of hepatitis C surveillance

Hepatitis C Co-infection: A
Review and a Look at Critical
Issues
Sharon Stancliff, MD
AIDS Institute
New York State Department of Health
&
Harm Reduction Coalition
November 2005
Hepatitis C
RNA virus isolated in 1988 but still not
cultured in the laboratory
There are still many questions about:
Transmission
Who will progress to severe liver disease
Who to treat
And we need better treatment options
Hepatitis C in the USA &NYS
USA: Estimated New infections/year: 30,000
 USA: Persons with chronic infection: 2.7 million
 USA: Deaths from chronic disease/year:8,00010,000
Based on these numbers
 NYS: Persons with chronic infection: 237,500

CDC
Epidemiology
Injecting Drug Use and HCV
Transmission



The most common risk factor - high rates
of conversion early in injection career
One NYC MMTP: 60% of patients are
chronically infected
Incidence among IDUs decreasing but
prevalence is high
HCV Transmission: It’s All About the Blood
Hepatitis C Harm Reduction Project H
Harm Reduction Coalition
a
Bloodborne viral infections among injection drug users
Baltimore 1983–1988
Seroprevalence (%)
100
HCV
80
HBV
60
40
HIV
20
0
0
6
12
18
24
30
36
42
48
54
Duration of Injecting (months)
Garfein RS. Am J Public Health. 1996;86:655.
60
66
72
Impact of Syringe Access and
Education: Prevention works
NYC 1990:
54% of IDUs HIV positive;
71% of all new (<5yrs) IDUs Hepatitis C
positive
NYC 2002:
13% of IDUs HIV positive;
39% of all new IDUs Hepatitis C positive
Des Jarlais 2005 AJPH, AIDS 2005
Sexual Transmission

Associated with:
 Infected partner, multiple partners, early
sex, non-use of condoms, other STDs,
sex with trauma
But:
 MSM no higher risk than heterosexuals
 Low prevalence (1.5%) among longterm partners

Terrault 2002
Other risk factors

Perinatal


About 5%, up to 17% if co-infected with HIV
Infants probably do well
• Nosocomial: hemodialysis,
• At least 10% of cases have no known risk
factor
• Uncertain role of tattooing, piercing,
intranasal drug use
Corrections




HCV +: 16-41%
Chronic infection: 12-35%
Entrants into NYS prison: Men- 13%
Women- 23%
Incidence while incarcerated: Estimated to
be 1.1/ 100 person yrs

MMWR 2003
Sentinel Counties Study of Acute Viral Hepatitis
Reported Risk Factors for Acute Hepatitis C,
1991 – 1998
Occupational
3%
Household
3%
Sexual
20%
Transfusions *
3%
No Identified
Risks**
9%
*None since 1994
**6% Low SES
Illegal
Drug Use
62%
Clinical Aspects
Clinical Features


Incubation: 6-7 weeks
Clinical illness: 20-40%


Long term outcome: possible cirrhosis,
liver failure after 20-40 years



Malaise, jaundice, abdominal pain
coagulopathy, encephalopathy, ascites
Hepatocellular carcinoma
Leading indication for liver transplant
Progression
Hepatitis antibody positive
70-85% HCV +:
15-30% clear
chronic infection
the virus
10-20%
80-90%
serious liver disease
asymptomatic-moderate disease
1-4%/yr
HCC
Risk factors for progression
• Heavy use of alcohol
• HIV positive- lower CD4 counts in
particular
• Older age at infection
• Male
Progression very hard to predict
HCV/HIV Co-infection




HIV both accelerates and increases risk
of HCV progression
Liver disease is increasing as a cause
of death in HIV+ persons
Impact of HCV on HIV continues to be
investigated- impact may be greater in
post- HAART era
Sulkowski 2002, Anderson 2004
Treatment


Weekly pegylated interferon with daily oral
Ribavirin for 24-48 weeks;
Side effects: often very debilitating



Flu-like syndrome, hair-loss, thyroid
dysfunction
Depression and other psychiatric disorders
Anemia, retinal bleeding
Effectiveness of Treatment



In clinical trials: 30-50% have sustained
viral response (SVR), in some
genotypes 2 and 3 up to 80%
May also slow progress and reduce risk
of liver cancer regardless of SVR
Much lower response in the community
especially with advanced disease, older,
male, African American and heavy
alcohol users
Who Should be Treated?
Goal: Find and treat those for whom the
illness is worse than the treatment
D. Thomas
Current NIH standard includes presence
of progression of illness on liver biopsy
HIV and HCV Treatment


HIV+ patients with relatively intact immune
systems can respond to treatment
Sustained viral response in clinical trials
for co-infected people

Overall: 27% to 40%
Genotype 1: 10-15% higher in some studies
Genotypes 2 & 3: up to 73%

Torriani 2004, Chung 2004


HCV and HIV treatment




HCV+ patients may be less likely to
receive HAART
While HAART increases the risk of
hepatotoxicity most HCV+ patients can
tolerate it
HAART therapy may protect the liver by
maintaining higher CD4 counts
Anderson 2004, Mehta, 2005
Treating HCV in the co-infected
Recent recommendations
 Defer treatment if liver biopsy has minimal
damage
 Optimize CD4 prior to treatment

Kontorinis, 2005
Liver transplant in HIV



HIV+ persons are receiving transplants in
various centers and are showing good
survival rates
In 2003 NIH initiated a multi-center trial to
evaluate strategies and outcomes of solid
organ transplants in HIV+ individuals
Neef 2004
Challenges


Successful treatment rates much lower in
community than in clinical trials
Relative contraindications common
particularly among co-infected patients


Psychiatric illness
Substance use
African Americans respond poorly to
current treatment
(Injection) Drug Users

NIH Consensus Statement


1997: defer treatment of drug users until a
period of abstinence
2002: individualized decisions regarding
treatment of active drug users

A review of 7 clinical trials found that drug
users were similar to controls or
comparable groups in adherence and
response

Schaefer 2004, Mehta 2005
African Americans



Higher incidence of HCV- particularly
Genotype 1
Possibly less likely to progress
Much less likely to respond to treatment


Independent of genotype, alcohol and
adherence
Muir 2004
A Look at New York

ADAP users of interferon and/or interferon:


2003- 91
3/04- 3/05- 189
Challenge: Treating the typical coinfected patient
104 co-infected patients referred to GI for
evaluation of HCV, at least 72% had IDU
as risk factor
21 had a liver biopsy
16 received treatment

Restrepo, 2005
Reasons for non-treatment
Non-adherent to appointments: 40%
 Active substance users: 15%
 Active psychiatric conditions: 8%
 Medical contraindications: 37%
Conclusion: “A majority of non-candidates
had potentially modifiable psychosocial
factors leading to non-treatment”

Restrepo, 2005
Co-infection Clinic: Oakland


Chart review: of 228 co-infected patients
found poor performance on vaccines and
alcohol counseling and only 2 treated for
HCV
Established co-infection clinic:


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Educate- journal clubs, mini-residencies case
conference
Full time nurse specialist
Increase availability of biopsy
Clannon CID 2005
Progress to date

15 patients initiated treatment


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6 discontinued- one achieved SVR
7 all achieved SVR
Pearls:

Aggressive management of side effects: epoitin and
SSRIs
Lot’s of water for systemic symptoms
CD4 counts dropped a lot and cause distress

Clannon, 2005
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Co-infection Clinic: Providence

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Co-infection clinic 2x/month: HIV/HCV
specialist, hepatologist, coinfection nurse
and coordinator in collaboration with a
community mental health and addiction
treatment provider
Requirements: adherence to appointments
and cooperating with psychiatric plan
No exclusion based on addiction- stability
is a goal which may be harm reduction
Taylor CID 2005
Progress to date


146 referred, 92 seen once, 69 have had
liver biopsies 97% history of addiction,
43% current users 85% with psychiatric
disorder
17 in pretreatment, 17 treated

7 completed 1 SVR
5 in treatment
5 dropped out- none because of drug use

Taylor, 2005
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NYS Clinical Guidelines

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Co-infection guidelines- first in country, updated
September 2004
Mono-infection: for primary care providers
October 2005
Focus areas

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Risk assessment
Diagnosis
Treatment
Medical management
Prevention and counseling
Hepatitis C Conference

Two locations

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
Buffalo – November 1, 2005
NYC - November 15, 2005
Agenda
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HCV in corrections
HCV Transmission in the healthcare setting
Consumer panel
Ethnic disparities


African Americans and HCV
Cross cultural care
The Hepatitis C Project

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Focus on hepatitis C in IDUs
Training, technical assistance, and policy
development for NYC needle exchange
programs
Posters, brochures, website:
www.hepcproject.org
Current initiatives on new models for HCV
prevention, networks of HCV care and treatment
for IDUs
Harm Reduction Coalition
Tasks

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Patient and clinician education
Research and guidelines on management of
current drug users
Research and guidelines on management of
psychiatric disorders in HCV treatment
Research on the impact of alcohol on treatment
Research on resistance to treatment: focus on
African-Americans- initiated by NIH
For more HIV-related resources,
please visit www.hivguidelines.org