Hepatitis B & Hepatitis C in HIV

1. Hepatitis B & Hepatitis C in HIV Dr K.Bujji Babu,MD Consultant HIV Physician Dr.Bujjibabu HIV Clinic.

2. 40 million worldwide 1 million in the US RNA retrovirus Integrates in genome 1y target CD4 cells Reverse Transcriptase Nucleoside Analogues Mutations=Resistance 400 million worldwide 1.25 million in the US DNA hepadna virus Integrates into genome 1y target hepatocytes Reverse Transcriptase Nucleoside Analogues Mutations=Resistance HIVHepatitis B

3. HIV HBV Co-infection • About 10% of HIV+ patients are HBSAg+ (Rustgi VK, Ann Int Med 1984) • HIV+ pts 3-6x more likely to develop chronic HBV than HIV- (Bodsworth JID 1991) • HIV/HBV is associated with more cirrhosis than HBV alone (Colin JF Hepatology 1999 )

6. HBV & HIV – Rx Guide lines • HBV DNA > 105 copies/ml • ALT consistently >2-fold above N • bioptic detection of liver fibrosis Healthy carriers don’t require treatment

7. HBV & HIV – Rx Guide lines • Lamivudine and Tenofovir are primarily indicated for HIV treatment, the status of HIV infection must be considered (e.g. necessity for treatment, prior therapies, resistance). • An individual decision must be reached.

8. HIV & HBV – Rx guide lines • Adefovir can be given as mono • Lamivudine or Tenofovir –no monotherapy • On HAART - lamivudine (possibly plus tenofovir) as a component of HAART • Resistance with Lam, Tenofovir can be used as an alternative component of HAART. • Treatment to continue till seroconversion or until there is loss of efficacy (renewed increase of transaminases and viral load)

9. Lamivudine in Pts Co- infected with HBV and HIV • 122 co-infected patients treated with lamivudine and antiretroviral therapy in CAESAR study • Safety data comparable across treatment arms • French study of 40 HIV/HBV co-infected patients (Benhamou, et al., Ann. Int. Med., Nov. 1996)

17. Conclusions • HBV infection has worse outcomes in HIV • Lamivudine resistance is becoming increasinly common • Newer drugs that have activity against LAM resistant HBV are coming soon • Treating HBV in HIV patients is getting more challenging daily

18. Prevention • Vaccine less effective due to immunosuppression - 30 % (2.5 %) • Vaccination repeated - double dose in four steps (months 0,1,6 and12) • Post Exposure Prophylaxis as in normal individuals

19. Worldwide Prevalence of Hepatitis C HCV Prevalence <1 1-2.49 2.5-4.99 5-10 >10 No data

20. HIV and HCV • 30 % of HIV pts can have HCV infection • Less likely to clear HCV in co-infected • Higher HCV RNA viral load • Rapid progression of liver disease - CD4 <100; 10 yrs vs 20 yrs for Cirrhosis • In Haemophiliacs – higher mortality in co-infected

21. HCV and HIV • More rapid deterioration of HIV disease • CD4 count may not rise much blunted immune response - HAART

22. HCV co infection & HAART • Drug induced heaptotoxicity more in co infected – protease inhibitors & ATT • 88% co infected pts tolerated HAART well without hepatotoxicity • Antiretrovirals safe in Chronic hepatitis C • Stop Rx – if symptomatic or Liver enzymes > 5 x normal

23. HIV & HCV • Screen by ELISA – Confirm by RNA PCR • If CD4 count < 100 – Anti HCV may be low or undetectable HCV RNA should be done if suspeected

24. HIV – HCV : Management • Avoid Alcohol • Vaccinate against HAV & HBV • Look for Chronic Liver disease • SGPT, HCV RNA – Limited usefulness • Liver Biopsy for disease activity Liver biopsy safe in HIV infected persons

25. HIV HCV - Treatment • HCV to be treated before HIV • Peg Interferons with Ribavarin ideal • Limited data on its safety in co infected • Significant side effects for Peg IFN and Ribavarin reported • Drug interactions – Ribavarin vs HIV drugs

26. CD4 count & HAART • If > 350 , IFN and HAART • 200 – 350, individual case • < 200 IFN relative contra indication might deteriorate • Didanosine contraindicated - Pancreatitis, mitochondrial toxicity,liver decompensation Zidovudine avoid - additive toxicities anemia and leukopenia Stavudine - due to mitochondrial toxicity

27. Guide lines for therapy-HIV HCV • Review HIV – CD4 counts • HCV RNA, SGPT, Liver Biopsy • Exclude co morbid conditions During therapy • Blood counts, SGPT, HCV RNA – Adjust • HCV RNA at 24 wks – If detected – stop • Birth control during & 6 months after Rx

28. HCV anti bodies negative Positive HCV RNA negative negative SGPT, Genotype elevated normal Peg IFN Liver Bx Positive negative

29. thank you