Hepatitis coinfection

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Hepatitis coinfection

  1. 1. HIV/HBV and HIV/HCV Co-infectionsThailand Perspectives and Optimal Management Boonchai Kowadisaiburana Bamrasnaradura Institute 25 August 2010
  2. 2. Natural history of HBV infection
  3. 3. Vincent Soriano, HIV and Viral Hepatitis Coinfection2007
  4. 4. Conflicting results about telbivudineE Low, A Cox, M Atkins, and M Nelson. TelbivudineHas Activity against HIV. 16th Conference onRetroviruses and Opportunistic Infections (CROI 2009).Montreal, Canada. February 8-11, 2009. Abstract 813a.C Avila, S Karwowska, C Lai, and T Evans. TelbivudineHas No in vitro Activity against Laboratory and ClinicalHIV-1, including 5 Clades and Drug-resistant ClinicalIsolates. 16th Conference on Retroviruses andOpportunistic Infections (CROI 2009). Montreal, Canada.February 8-11, 2009. Abstract 813b
  5. 5. Hepatology2007;45(4)
  6. 6. Vincent Soriano, HIV and Viral Hepatitis Coinfection 2007
  7. 7. Frequency of 3TC resistance in a cohort of HIV/HBV coinfectd patients
  8. 8. Vincent Soriano, HIV and Viral Hepatitis Coinfection 2007
  9. 9. How to know “active liver disease” Transaminitis, ALT >/= 1.5 ULN Liver biopsy - invasive test, death = 1/10,000-1/12,000 - sample represents 1:50,000 of liver - 10-20% observer variation Noninvasive technique - hepatic elastography ( FibroScan ) - serum fibromarkers
  10. 10. When to stop treatmentHBeAg-positive CHB- HBeAg seroconversion and- HBV-DNA < 400 copies/ml x 2 (0, 6 m)and- continue treatment more 6-12 mHBeAg-negative CHB- HBsAg clearance or- undetectable HBV-DNA x 3 (0, 6, 12 m)
  11. 11. How to treat HBV infection (1)ARV- naïve, HAART- not indicated, HBV- active- avoid 3TC monotherapy- use interferon or ADV?- full HAART regimen (including TDF+3TC/FTC)ARV- naïve, HAART- indicated, HBV- inactive- TDF+3TC/FTC are NRTI backbone- avoid TDF, 3TC, FTC monotherapy for HBVinfection
  12. 12. How to treat HBV infection (2)ARV- naïve, HAART- indicated, HBV- active- full HAART regimen (including TDF+3TC/FTC)ARV- naïve, HAART- indicated, HBV-active/cirrhosis- use TDF+3TC/FTC first to reduce HBV-DNA ?- if high HBV-DNA and low CD4 risk of severehepatitis related to IRS after HAART initiation
  13. 13. www.liversocietythailand.org
  14. 14. AIDS 2006,20:1951-4
  15. 15. Causes of transminitis in HIV/HBV coinfected patientsDiscontinuation of anti-HBV drugsDevelopment of resistance to anti-HBV drugsHBeAg or HBsAg seroconversionHBV reactivationImmune reconstitution syndromeDelta superinfectionHepatotoxicity from ARV
  16. 16. Clin Infect Dis 2004;38:128-33
  17. 17. Vincent Soriano, HIV and Viral Hepatitis Coinfection 2007 AIDS 2007;21:1073- 89
  18. 18. How to treat HCV infectionCombination of PEG-IFN and RBV is thetreatment of choiceAnti-HCV treatment should be started beforeCD4 < 350 and before ART is startedAim of treatment is SVRAny ART should be stabilized before anti-HCV therapy is commencedDuration of treatment for all genotypesshould be 48 weeks
  19. 19. Terminology for treatment response Rapid virological response ( RVR )- HCV-RNA PCR at week 4 Early virological response ( EVR )- HCV-RNA at week 12- if PCR negative = complete EVR- if HCV-RNA decrease > 2 log = partial EVR End of treatment response ( ETR )- HCV-RNA PCR at the end of treatment Sustained virological response ( SVR )- HCV-RNA PCR at week 24 after treatment
  20. 20. AIDS 2007;21:1073-89
  21. 21. Contraindication for use of PEG- interferon and ribavirin Absolute Relative contraindication contraindication History of depressionPsychosis, severe Uncontrolled DM, HT depression RetinopathyUncontrolled seizures Active autoimmune diseaseLiver decompensation Symptomatic heart diseasePregnancy AnemiaRenal failure Ischemic vascular diseaseSevere heart disease
  22. 22. BHIVA guidelines 2010
  23. 23. http://www.who.int/hiv/pub/guidelines/artadultguidelines.pdf

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