HIV/HCV co-infection in Taiwan

1. HIV/HCV co-infection in Taiwan Nai-Ying Ko RN. PhD., Hsin-Chun Lee MD, Shainn-Wei Wang PhD., Wen-Chien Ko MD, National Cheng Kung University & Hospital Taiwan

2. Topics • Molecular epidemiology of HIV/HCV coinfection in Taiwan • Treatment and care for patient with HIV/HCV coinfection in Taiwan • Challenges of management of HIV/HCV coinfection in Taiwan

3. Annual Numbers of Newly Reported HIV Cases by Mode of Transmission, 1984-2007 Cumulative number of reported HIV cases: 15,866 (June 30, 2008) Harm reduction Free HAART 2462 1813 629 713 Year

4. Free AZT Free HAART HIV/AIDS Reported Case Number and Fatality Rates in Taiwan, 1984 – 2006 *: AIDS-related deaths / AIDS case number

5. 台北縣 桃園縣 新竹縣 Age-adjusted prevalence of anti-HCV 宜蘭縣 苗栗縣 0 - 1% 1 - 3% 3 - 5% 台中縣 5 -10% 彰化縣 南投縣 花蓮縣 雲林縣 嘉義縣 台南縣 高雄縣 台東縣 屏東縣 Anti-HCV prevalence in Taiwan • Population: 157,720 adults • Period: 1996-2005 • Anti-HCV seropositivity: 4.4% • HCV genotype distribution • 1b: 58~81.1 % • 2a: 7.4~12 % • 2b: 3.4~4.9 % • Chen CH at al., J Formos Med • Assoc. 2007;106(2):148-55 • Yu ML et al, J. Med. Virol. 2001;65:58-65

6. Extremely high prevalence of HCV infection among HIV-infected IDUs in Taiwan Liu JY, et al. , Clinical Infectious Diseases 2008; 46:1761–8

7. The proposed route of HIV/HCV transmission from China and Southeast Asia to Taiwan Liu JY, et al. , Clinical Infectious Diseases 2008; 46:1761–8

8. Co-Infections among HIV-Infected Adults [J Formos Med Assoc 2008;107(5):404–411]

9. Serological characteristics and types of HBV and HCV of 146 HIV-1-infected adults categorized by HIV risky groups in NCKUH

10. HCV infection is significantly associated with HIV infection among gay bathhouse attendees in Taiwan, 2004-2007 * * Odds ratio: 7.1; 95% CI: 2.3-22.1 NY Ko, at al. (2008) unpublished data

11. Topics • Molecular epidemiology of HIV/HCV coinfection in Taiwan • Treatment and care for paitents with HIV/HCV conifection in Taiwan • Challenges of management of HIV/HCV coinfection in Taiwan

12. HBV/HCV Treatment in Taiwan • 1980s Department of Health • Hepatitis Prevention Act • 2003 Bureau of National Health Insurance • program for strengthening treatment for chronic hepatitis B and C • 2007 National Health Research Institute • National Forum on screening, treatment and long-term follow-up of patients with hepatitis B virus- or hepatitis C virus-related liver diseases

13. Treatment of Chronic Hepatitis C (National Health Insurance, Taiwan) • Criteria • Anti-HCV (+) , • ALT ≧ 2X, 3 M apart, within 6 M • Fibrosis ≧ F2 • ( F1, since August, 2004 ) • PEG-IFN or IFN + RBV for 24 weeks

14. Screening for HIV/HCV coinfection in Taiwan • Test of anti-HCV for all patients with HIV • Test of HCV RNA for patients with HIV • Anti-HCV(+) and progression to chronic hepatitis • Anti-HCV(-), rapid progression with abnormal liver function tests, and patients with low CD4 cell counts (< 200 cells/mm3) • Anti-HCV(-), suspect acute HCV infection (NHRI National Hepatitis BC Forum, 2008)

15. Preparation for HIV/HCV coinfection treatment in Taiwan • Before treatment • Liver function tests (AST, ALT), HCV RNA, HCV genotype, liver biopsy • HIV RNA, CD4 cell counts • Optimized HAART treatment • When considering treatment • CD4 >350 cells/mm3, treat HCV first • If CD4 =201-350 cells/mm3, treat HIV first then HCV • CD4 < 200 cells/mm3, treat HIV (NHRI National Hepatitis BC Forum, 2008)

16. Treatment for HIV/HCV coinfection in Taiwan • Standard of care in coinfected patients is pegylated interferon plus ribavirin • Optimal dosing of pegylated interferon and ribavirin • HCV genotype 1, ribavirin (1000 mg/day if < 75 kg and 1200 mg/day if > 75 kg) • HCV genotype 2 & 3, ribavirin (800 mg/day) • F/U HCV RNA at 12, 24, 48 wks, and 6 months • F/U HIV RNA every 3-4 months (NHRI National Hepatitis BC Forum, 2008)

17. Topics • Molecular epidemiology of HIV/HCV coinfection in Taiwan • Treatment and care for patient with HIV/HCV coinfection in Taiwan • Challenges of management of HIV/HCV coinfection in Taiwan

18. Needle-Syringe Programming • Pilot stage (Nov. 2005 ) (76 NSP stations) • Expanding stage (Jul. 2006 ) (427 NSP stations) • Present stage (Jan. 2008) (1103 NSP stations)

19. 基隆長庚醫院/署立基隆醫院 台北市立聯合醫院松德院區*/疾管院區*/三軍總醫院 桃園療養院*/國軍桃園總醫院*/桃園榮院* 八里療養院*/耕莘醫院*/亞東醫院*/署立台北醫院* 新竹馬偕醫院* 羅東博愛*/署立宜蘭醫院 署立新竹醫院/署立竹東醫院 為恭醫院* 中國附設醫院* 署立草屯療養院* 童綜合醫院* 國軍花蓮總醫院*/署立花蓮醫院 彰化基督教醫院*/署立彰化醫院 嘉義榮民醫院*/署立嘉義醫院 台大雲林分院*/中國北港/若瑟醫院* 署立朴子醫院*/大林慈濟醫院 署立台東醫院* 署立嘉南療養院*/永康榮院*/署立新營醫院* 署立台南醫院*/成大醫院*/奇美醫院 高雄長庚* /慈惠醫院* 市立凱旋醫院*/國軍高雄醫院 安泰醫院* Drug Substitution Treatment Pilot stage (Feb. 2006 ) (6 hospitals) Expanding stage (Aug. 2006 ) (33 hospitals & clinics) Present stage(Jan. 2008 ) (68 hospitals & clinics)

20. Health seeking behaviors among patients with HIV categorized by route of transmission CH Yang (2006) HIV-related Medical Expenditure Analysis in Taiwan

21. Challenges of management of HIV/HCV coinfection in Taiwan • Harm reduction policy was implemented since 2006 • HCV treatments founded by NHI were performed by hepatologists, oncologists, and hematologists • Current standards include presence of progression based on liver biopsy • Some hepatologists still withhold treatment from patietns with HIV or IDUs • Cost of test for HCV RNA and genotype

22. Conclusions • HCV infection is highly prevalent in HIV-infected IDUs and exhibit great genetic diversity. • HIV-1 CRF07_BC, HCV genotype-1a, 3 and 6 have been transmitted from China into Taiwan through drug trafficking route. • Pegylated interferon plus ribavirin is available. • Some hepatologists still withhold treatment from patients with HIV or IDUs. • Poor access to care and fewer clinical visits among HIV infected IDUs.

23. Acknowledgements • Taiwan CDC: Dr. CH Yang • EDH: Dr. HH Lin • NTUH: Dr. CC Hung, Dr. WH Sheng • KMUH: Dr. ML Yu • NHRI: Dr. IJ Su,Dr. FC Tseng

24. Thanks your attention