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Hepatitis C Overview

• Patricia Perkins, MS, MPH

• Tri City Institute: LA, CA• www.pperkins.org

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HIV/HCV Co-Infecion

“Today if you are not confused, you are just not thinking clearly”

»HIV Researcher – NYC

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The Liver Largest internal organ

Approximately 3 lbs (men)

Size of a football

1.5 quarts of blood flow through it every minute

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Liver Functions Bile

Immune System

Chemical Factory-

>500 chemical functions

Detoxifies

Clotting Factors

Hormones

Regenerates Itself!

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Keep Your Liver Healthy (Healthy People) No more than:

2 alcoholic drinks daily for men 1 alcoholic drink daily for women

Be cautious about mixing drugs – especially with alcohol

Healthy, balanced diet Get HAV & HBV vaccinations Avoid toxic substances / fumes

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Some Statistics 3% of world has HCV (150-200 million) 3.9 Million in U.S. infected with HCV * Chronic – 2.7 Million in U.S. 8,000 to 10,000 in U.S. die of

complications from HCV – in 10 years this # will triple

HCV is the leading cause for liver transplants

50-80% of HCV infected become chronic* Does not include prisoners, homeless

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More Statistics

U.S. Population 1.8% overall

2.1% Mexican-Americans

3.4 African Americans

California 500,000 infected

with HCV

85-95% - IDU’s

Prisons – 63,500 inmates infected or (41%)

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What Does It Mean? Only 10-25%

progress on to serious liver disease

Treatment choices do work for some

Hopefully better treatment options will be available within 5 years

Lifestyle changes can make a big difference

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Diagnostic Tools Elisa II / Riba – Test for anti-body Hepatitis C RNA by PCR - >50

particles Hep C RNA by branched DNA Assay –

>200,000 particles TMA – more sensitive, less expensive Genotype (six major subtypes – 72%

of U.S. population have genotype 1) Liver Biopsy

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Transmission / Prevention

<10% of routes cannot be identified

Tattoos / Piercing

Neonatal – <5%

Shared House-hold items – razors & toothbrushes

Healthcare workers – needle sticks

Sexual Transmission(1-3%)

Blood before 1992 - transfused, products, procedures

All Drug Paraphernalia

Shared Needles

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Harm Reduction Prevention –

Needle exchange – clean needles and drug preparation tools – cookers & cottons

Bleach – Does it work? 10 minutes!

Safer Sex Cover wounds

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HCV CAN NOT BE SPREAD BY: BREAST FEEDING

SNEEZING

HUGGING

COUGHING

FOOD OR WATER

SHARING EATING UTENSILS OR DRINKING GLASSES

CASUAL CONTACT

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Symptoms Acute vs. Chronic

Fatigue – mild to severe

Flu-like symptoms (muscle/joint/fever)

‘Brain Fog’

Liver Pain

Loss of appetite

Headaches

Gastro Problems

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Treatment Medications

Interferon – by injection - first FDA approved treatment (3 MU, thrice weekly for 48 weeks)

Genotype 1 - 9% SVR Genotype other than 1 –30% SVR

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Interferon and Ribavirin Interferon and ribavirin(capsule)-

‘combo therapy’ INF – 3 mu units, thrice weekly -

Ribavirin 800-1200 mg daily Overall SVR up to 45% Genotype 1 – 12 mos – 29% SVR Genotype Non 1 – 6 mos - 62% SVR

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Pegylated Interferon Schering- PEG-Intron

Approved by FDA – 1-2001 25% sustained response rate

Genotype 1 – 14% Genotype 2 & 3 – 47%

ROCHE – Pegasys – FDA approval pending 39% sustained response rate

Genotype – 1 – 28% Genotype – 2 & 3 – 56%

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Pegylated and Ribavirin Schering – PEG-Intron plus ribavirin

Phase III clinical data – 54% sustained response rates

One group improved SVR - Genotype 1 low viral load FDA Approved

Roche – Pegasys plus ribavirin Phase III clinical data – 56% sustained

response rate – Genotype 1 – 46% - Genotype 2-3, 76%

Pending FDA Approval

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Treatment Decisions General

Treatment Guidelines

Healthy Active HCV Elevated ALT’s Compensated liver

disease

Optimal Response Younger Female Low visceral fat Low viral load Minimal liver

damage Genotype 2 or 3

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Side-effects Interferon

Fatigue Muscle/Joint pain Nausea Headaches Anxiety Depression Dry Skin/rashes

Ribavirin seems to make

interferon side effects worse – especially fatigue-Anemia

(both men & women must use birth control)

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Managing Side-Effects Inject before

bedtime Drink lots of water Low doses of

ibuprofen or acetaminophen

Pain medications

Light exercise Daily moisturizing Vary injection

sites Anti-Depressants Plenty of rest Frequent small

meals

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Experimental Therapies Amantadine - pill Maxamine – by injection (phase II

studies) Ribozymes Helicase Inhibitors Protease Inhibitors Interleukin-10

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Complementary Medicine Herbs – milk thistle

Always check with your doctor and herbalist – some herbs are TOXIC

Acupuncture / Acupressure

Traditional Chinese Medicine

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Lifestyle Changes That Help! Alcohol - Avoid

Get vaccinated – Hep A & Hep B

Healthy balanced diet

Exercise

Stress Reduction

Support Groups

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Advocate for Yourself and Your Client! Educate yourself

Establish a good relationship with your doctor

Bring an advocate for doctor’s visits

Ask questions

Keep copies of all medical tests

Keep a diary

Keep an open mind

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Comparisons – HIV & HCV

HIV Single stranded

RNA Retrovirus Mainly infects

CD4 cells Daily-replicates

millions

HCV Single stranded

RNA Flavivirus Mainly infects

liver cells Daily – replicates

in trillions

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Comparisons HIV/HCV, cont.

HIV is: Chronic = 100% US-1 major strain High sexual

transmission rate High IDU

transmission (blood)

HCV is: Chronic – 60-85% US-3 major strains Low sexual

transmission rates Very high IDU

transmission rates (blood to blood)

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HIV/HCV Comparisons, cont.

HIV

Curable?

Can become resistant to antiviral drugs

HCV

Curable?

Does not become resistant to current drugs

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HIV/HCV Co-Infection

Statistics: US

HIV Infections = 750,000 Up to 40% of people with HIV also infected

with HCV = 300,000

Worldwide HIV infections = 170 million

Estimated 23-75% of people with HIV also infected with HCV = 8-27 million

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Guidelines for Prevention of Opportunistic Infections*

HIV – All should be screened for HCV Patients should be counseled on alcohol

use Patients should be screened for HAV – if

negative, should be vaccinated; Hep B, triage based on risk & expense

Patients should be evaluated for liver disease and possible need for treatment

Liver enzymes should be monitored after initiation of HAART *US PHS (CDC) & IDSA

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HIV Medications Known to Be Hard on the Liver Documented potential liver

toxicities: Ritonavir (Norvir) Crixivan (Indinavir) Viramune (Nevirapine) Sustiva (Efavirenz) Kaletra (Lopinavir)

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Recommendations

HIV specialist and liver specialist should jointly monitor co-infected patients

Monitor liver functions especially when on treatment for HIV

Switch medications to less liver toxic

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Interferon and HIV

History: Interferon unsuccessfully used to treat HIV – during and pre-AZT

Approved for use in Kaposi's Sarcoma Currently looking at INF again Why? High INF levels accelerate HIV

progression (Gallo et al at NIH) INF harms immune system in HIV+?

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HCV Transmission for HIV+

Higher risk of transmitting sexually – may be due to higher viral load burden among co-infected – unclear

Mother to child – vertical transmission up to 25% risk during delivery

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Diagnosis

HIV ELISA Western blot for confirmation

HCV ELISA II (RIBA to confirm – not rec'd) Viral load – test for active HCV disease

(small percentage of people with HIV/HCV do not develop antibodies to HCV)

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Does HCV Make HIV Worse? Still controversial but most experts

do NOT believe that HCV makes HIV worse

Exception – hemophiliacs (high viral burden)

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Does HIV Make HCV Worse? Most experts believe that HIV

accelerates HCV disease progression

Some data suggest that when HIV is stable – low viral load, higher CD4 – HCV disease progression is slowed in co-infected persons

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When & Which to Treat?

Generally, HIV should be under control Treat HIV first – with HAART

HCV – People with HIV/HCV should be considered for HCV treatment Exceptions:

CD4 counts <200 Active opportunistic infection

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HIV Medications & the Liver

In general, ALL medications can be hard on the liver

HIV meds temporarily increase liver enzymes (ALT) & HCV viral load – usually levels out in 3-6 mos. If ALTs 4-5x baseline --

Change or discontinue medicine

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Ribavirin & the Liver

Ribavirin originally developed for HIV – not effective

Anemia - ribavirin & AZT both cause anemia – AVOID together

Ribavirin decreases AZT and to a lesser extent D4T (ZeritTM)) in vitro (test-tube)

Ribavirin may make DDI work better

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HCV Treatments

Similar response rates to HCV mono-infected

Closely monitor patients for: Anemia – up to 50% of co-infected

(rbv) Thrombocytopenia - low platelets (inf) Neutropenia – low white blood cells

(inf)

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Psychological Impact ofCo-Infection

Two life-threatening diseases

Lack of awareness/denial among patients and existing HIV support systems

Lack of support among traditional HIV support systems/groups

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Conclusions

Hepatitis C is a manageable chronic illness; misunderstandings/stigma persist

Lifestyle changes can enhance treatment outcomes & side effects

Management of HIV/HCV co-infection is possible, do-able, and difficult

Misunderstandings/stigma & lack of support exist for drug users co-infected