Hepatitis And Hiv Co Infection Tonia Poteat 060508
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Hepatitis And Hiv Co Infection Tonia Poteat 060508

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A presentation by Tonia Poteat from the CDC Global AIDS Project on the topic of Hepatitis B & C and HIV Co-infection. This webcast was presented live to ECHO (Evaluation Center for HIV and Oral ...

A presentation by Tonia Poteat from the CDC Global AIDS Project on the topic of Hepatitis B & C and HIV Co-infection. This webcast was presented live to ECHO (Evaluation Center for HIV and Oral Health) grantees on June 5, 2008.

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Hepatitis And Hiv Co Infection Tonia Poteat 060508 Hepatitis And Hiv Co Infection Tonia Poteat 060508 Presentation Transcript

  • Tonia Poteat, MMSc, PA-C Thursday, June 5, 2008 ECHO Webinar HIV and Viral Hepatitis In Oral Health Settings
  • Objectives
    • Review basics of viral hepatitis
      • and HIV co-infection
      • Transmission and prevention
      • Disease progression/oral manifestations
      • Treatment (including drug interactions)
    • Describe post-exposure prophylaxis recommendations
  • HIV
  • HIV Transmission
    • Transmission Fluids
      • Blood
      • Semen
      • Vaginal secretions
      • Breast milk
    • Ports of Entry
      • Broken skin
      • Mucus membranes
    • Prevention
      • Universal precautions
      • Safer sex
      • Post-exposure prophylaxis
  • Periodontal Disease in HIV Disease
  • Oral Candidiasis (Thrush)
  • Oral Hairy Leukoplakia
  •  
  • Credit: I-TECH
  • Bleeding gums http://www.perio.org/consumer/children.htm
  •  
  • Idiopathic Thrombocytopenic Purpura
    • Pathogenesis unknown. Pt often asx
    • Sx: ecchymosis, petechiae, purpura, abnl menses, blood in urine or stool, epistaxis, bleeding gums
    • CBC, PT/PTT are normal
    • May or may not have anti-platelet antibodies
    • Tx: HAART, steroids, WinRho, splenectomy
    • Avoid NSAIDS, razor shaving, mild trauma
    Low platelets may also be a manifestation of advanced liver disease!
  • Comparison of Viral Hepatitides
  • HEPATITIS A
  • Hepatitis A
    • Transmission
      • fecal/oral
    • High Risk
      • day care, institutions, military, MSM
    • Incubation period last 2 - 4 weeks
      • transmission occurs during this asymptomatic time
    • Laboratory diagnosis
      • HAV IgM indicates current or recent infection
      • HAV IgG indicates past infection or vaccination
  • Jaundice http://www.gideononline.com/blog/2007/05/01/easier-diagnosis-with-symptom-images/
  • Hepatitis A
    • Infection is self-limited (8-12 weeks)
      • jaundice signals end of infectious period
      • vast majority recover with lifelong immunity (98-99%)
    • Treatment is supportive
      • post exposure immune globulin available
      • must give within 1-2 weeks of exposure
    • Vaccination recommended:
      • travelers to endemic areas, people with CLD (including HCV), MSM, day care workers, food handlers, sewage workers,
    • Prevention is key: WASH YOUR HANDS!!!
  • HIV and Chronic Viral Hepatitis HIV HCV HBV 30% DNA 6,000 1.25 million 4 million 1 million US Prevalence 3% 0.3% Percutaneous Transmission Risk RNA RNA Genetic Material 10,000 16,000 Annual US Deaths
  • HEPATITIS B
  • Hepatitis B
    • Transmission
      • sexual, blood, perinatal, occupational
      • more infectious than HIV
        • can survive on surfaces 1 wk or more
    • High Risk
      • health care workers
      • unprotected sex (including oral)
      • IN and Injection drug use
        • blood supply screened
    • Incubation period
      • 4 weeks to 6 months
      • average 12 weeks
  • Hepatitis B
    • Acute
      • Symptoms last 2 – 10 weeks
      • 90% recover with lifelong immunity
        • 50-80% among PLWHIV
      • Treatment is supportive
      • HBsAg resolves within 6 months
    • Chronic
      • Persistent HBsAg > 6 months
      • 10-20% will develop cirrhosis
      • 25% of these will decompensate
      • 6-15% of those with chronic disease will develop hepatocellular carcinoma
  • HBV/HIV Co-infection
    • Co-infected patients have
      • Higher HBV DNA levels
      • Lower ALT
      • Lower rate of seroconversion
      • Higher risk of cirrhosis
      • Immune Reconstitution
      • Reactivation with stopping ART
    • Hepatitis B vaccination recommended for all patients with HIV
    Thio C et al. Lancet 2002;360:9349.
  • Chronic Hepatitis B: Treatment Goals
    • Normalize transaminases
    • Eliminate/Suppress HBV replication
    • Loss of HBsAg with seroconversion to HBsAb (anti-HBs)
    • Prevent progression to ESLD and HCC
  • HBV Treatment Options in HIV www.medscape.com TDF/FTC coformula 3TC equivalent Low Middle Yes Emtricitabine* (Emtriva) Good for 3TC and adefovir failures High High Yes Tenofovir* (Viread) No studies in HIV Middle? High No Telbivudine (Tyzeka) Ok for 3TC failures Tolerable High High YES! Entecavir (Baraclude) Good for ESLD and 3TC failures Middle Middle No Adefovir (Hepsera) High tolerability Low Middle Yes Lamivudine (Epivir HB) Tx x 12 mo No use in ESLD No High Yes Peg-IFN Notes Resistance barrier HBV potency HIV Activity? Drug
  • HBV Treatment in HIV Patients
    • 2008 DHHS Guidelines lists
    • Hepatitis B
    • as an indication for
    • initiation of antiretroviral therapy
    • If ARV naïve and require HIV treatment
      • Tenofovir + emtricitabine or lamivudine
    • Individualization of therapy required in ARV experienced patients
    HIV-HBV consensus panel. AIDS 2005 DHHS Guidelines 2008
  • Hepatitis B: Prevention & Care
    • PREVENTION
      • Vaccination
      • Universal Precautions
      • Safer Sex
    • CARE
      • Vaccination against Hepatitis A
      • Avoidance of ETOH
      • Caution with hepatotoxic medications
      • Screening for HCC (+/- esophogeal varices) for cirrhotics, high HBV DNA, >40yo, FH
  • HEPATITIS C
  • Risk factors for Hepatitis C infection 20% 10% 5% 55% 10% IVDU Cocaine Exposure to infected sex partner or multiple partners Occupational, hemodialysis, household, perinatal No recognized source http://www.cdc.gov/ncidod/diseases/hepatitis/c_training/edu/transmission modes; 2000
  • Symptoms
    • Often none until decompensation
    • Otherwise symptoms are vague:
      • Fatigue
      • Mild RUQ discomfort
      • Nausea
      • Poor appetite
      • Muscle and joint pains
  • Extrahepatic Manifestations of Hepatitis C
    • Hematologic:
      • Cryoglobulinemia
      • Lymphoma
    • Rheumatologic: rheumatoid arthritis
    • Renal: Glomerulonephritis
    • Dermatologic:
      • Porphyria cutanea tarda
      • Cutaneous necrotizing vasculitis
      • Lichen planus
    • CNS: depression
    • Systemic: fatigue
    Management of Hepatitis C. NIH Consensus Statement, 2002.
  • Natural History of Hepatitis C Virus (HCV) Infection Exposure (Acute phase) Resolved Chronic Cirrhosis Stable Slowly Progressive HCC Transplant Death 20% (17) 15% (15) 85% (85) 25% (4) 80% (68) 75% (13) HIV and Alcohol HCC = hepatocellular carcinoma. Alter MJ. Semin Liver Dis . 1995;15:5-14. NIH Consensus Statement. Management of hepatitis C. National Institutes of Health; March 24-26, 1997.
  • HIV/HCV Co-infection
    • Impact of HIV on HCV
      • HCV Ab may be negative if low CD4
      • Higher HCV viral loads
      • Accelerates progression to cirrhosis
      • Increases risk of perinatal transmission
    • Impact of HCV on HAART Choices
      • Higher risk of hepatotoxicity from HAART
      • All classes associated with liver toxicity
      • Hepatotoxic potential varies for each individual antiretroviral medication
  • Hepatitis C Labs
    • HCV antibody for screening
      • 99% sensitive and specific
      • May be negative if low CD4,
    • HCV RNA by PCR:
      • qualitative PCR (dx and SVR)
      • quantitative PCR (likelihood of SVR)
    • Liver Enzymes
      • Do not correlate with extent of liver damage
      • Most patients have minimally elevated or normal liver enzymes
  • HCV Treatment: Standard of Care
    • Pegylated Interferon
      • Pegasys 180 mcg/week (FDA approved for treatment of HIV/HCV co-infection)
      • Peg-Intron 1.5 mcg/kg/week
    • Ribavirin
      • Weight based dosing (500-600mg BID)
      • Generic available
      • Rebetol capsules
      • Copegus tablets
    • All HIV co-infected patients should be treated for at least 48 weeks if . . .
      • 2 log reduction in HCV RNA at 12 weeks, and
      • HCV RNA undetectable at 24 weeks
  • Goals of treatment
    • Stable HIV disease with intact immune function (CD4 > 200)
      • Goal to eradicate HCV
    • Advanced fibrosis: Stage 3 or 4
      • Goal to delay progression
    • Recurrent ARV-associated hepatoxicity
      • Permit HAART treatment
  • Contraindications to IFN/RBV
    • Absolute Contraindications
      • pregnancy
      • decompensated liver disease
      • unstable heart disease
      • sickle cell
    • Relative contraindications
      • severe psychiatric problems
      • active substance abuse
      • untreated anemia/neutropenia
      • severe comorbid diseases
  • Adverse Effects: Interferon
    • IFN related
      • fatigue, flu syndrome
      • bone marrow
      • depression, lability
      • injection site reaction
      • alopecia, insomnia
      • anorexia/weight loss
      • thyroid dysfunction
      • neuropathy
      • retinopathy
    • Management
      • light exercise, H20
      • pre-injection Tylenol
      • Epoetin, GCSF
      • anti-depressants
      • small, frequent meals
      • night time dosing
      • most are self limited or resolve after treatment is stopped
  • Adverse Effects: Ribavirin
    • RBV related
      • hemolytic anemia
      • pruritic rash
      • nausea
      • dyspnea, dry cough
      • teratogenic
      • in vitro interactions with other nucleosides
        • increases DDI
        • decreases AZT, D4T
    • Management
      • dose reduction or epoetin alfa
      • antihistamines, topicals
      • take with food
      • effective birth control
      • careful monitoring for lactic acidosis and HIV viral breakthrough
  • Ribavirin Drug Interactions
    • Anti-HIV synergy with DDI
      • Increases intracellular levels
      • Case reports of fatal pancreatitis and lactic acidosis. FDA issued warning
    • Care with overlapping toxicities
      • Anemia with ZDV
      • Weight loss/lipoatrophy with D4T
    • Data from CROI 2008
      • Higher rates of SVR with TDF
        • compared to ABC and ZDV
    CROI 2008 Salmon-Céron. Lancet. 2001;357:1803. Hoggard . AAC. 1995;39(6):1376 .
  • HCV: Prevention and Care
    • PREVENTION
      • Universal precautions
      • Safer sex/Harm reduction
      • No vaccine available
    • CARE
      • Vaccination against Hepatitis A and B
      • Avoid ETOH
      • Care with hepatotoxic medications
      • Screen for HCC if cirrhotic
  • PEP
  • Hepatitis B MMWR, June 29, 2001
  • Hepatitis C
    • No evidence of efficacy of immune globulin
    • No CDC recommendations
    • Evidence of improved SVR for those starting interferon based treatment early after infection early
  • HIV PEP: Considerations
    • Risk level of exposure
    • Concomitant conditions
    • Drug-drug interactions
    • Resistance
    • Tolerability
    • Start as soon as possible
    • Continue for 4 weeks
  • HIV: Mucus Membrane Exposure MMWR, Sept 30, 2005
  • HIV: Needlestick Exposure MMWR, Sept 30, 2005
  • Post-exposure Prophylaxis
    • National Clinician’s Consultation Line
      • http://www.nccc.ucsf.edu/
    • Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis
    • http://www.cdc.gov/MMWR/preview/MMWRhtml/rr5011a1.htm
    • Updated US Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis
    • http://www.cdc.gov/mmwR/preview/mmwrhtml/rr5409a1.htm
  • Helpful Resources
    • www.HIVandHepatitis.com
    • Hepatitis Info 1-800-223-0179
    • http://www.hivdent.org/
  •