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Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
Hepatitis C Co-infections: A Review and a Look at Critical Issues
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Hepatitis C Co-infections: A Review and a Look at Critical Issues

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  • New virus, new messages Beyond needle-sharing = beyond syringe access
  • 2 million adults in prison Cal - 42%, Conn-32%, MD 38%, NY 17%, Tex-28% RI: Of HCV patients eligibility for treatment 60% have <15 month 30% refuse 9% have drug alcohol or other medical problems This leaves 1%
  • Transcript

    • 1. Hepatitis C Co-infection: A Review and a Look at Critical Issues Sharon Stancliff, MD AIDS Institute New York State Department of Health & Harm Reduction Coalition November 2005
    • 2. Hepatitis C
      • RNA virus isolated in 1988 but still not cultured in the laboratory
      • There are still many questions about:
        • Transmission
        • Who will progress to severe liver disease
        • Who to treat
        • And we need better treatment options
    • 3. Hepatitis C in the USA &NYS
      • USA: Estimated New infections/year: 30,000
      • USA: Persons with chronic infection: 2.7 million
      • USA: Deaths from chronic disease/year:8,000-10,000
      • Based on these numbers
      • NYS: Persons with chronic infection: 237,500
      • CDC
    • 4. Epidemiology
    • 5. Injecting Drug Use and HCV Transmission
      • The most common risk factor - high rates of conversion early in injection career
      • One NYC MMTP: 60% of patients are chronically infected
      • Incidence among IDUs decreasing but prevalence is high
    • 6. HCV Transmission: It’s All About the Blood HarHar Harm Reduction Coalition Hepatitis C Harm Reduction Project
    • 7. Bloodborne viral infections among injection drug users B altimore 1983–1988 Seroprevalence (%) Duration of Injecting (months) HCV HBV HIV Garfein RS. Am J Public Health. 1996;86:655. 0 6 12 18 24 30 36 42 48 54 60 66 72 0 20 40 60 80 100
    • 8. Impact of Syringe Access and Education: Prevention works NYC 1990: 54% of IDUs HIV positive; 71% of all new (<5yrs) IDUs Hepatitis C positive NYC 2002: 13% of IDUs HIV positive; 39% of all new IDUs Hepatitis C positive Des Jarlais 2005 AJPH, AIDS 2005
    • 9. Sexual Transmission
      • Associated with:
        • Infected partner, multiple partners, early sex, non-use of condoms, other STDs, sex with trauma
        • But:
        • MSM no higher risk than heterosexuals
        • Low prevalence (1.5%) among long-term partners
        • Terrault 2002
    • 10. Other risk factors
      • Perinatal
        • About 5%, up to 17% if co-infected with HIV
        • Infants probably do well
      • Nosocomial: hemodialysis,
      • At least 10% of cases have no known risk factor
      • Uncertain role of tattooing, piercing, intranasal drug use
    • 11. Corrections
      • HCV +: 16-41%
      • Chronic infection: 12-35%
      • Entrants into NYS prison: Men- 13% Women- 23%
      • Incidence while incarcerated: Estimated to be 1.1/ 100 person yrs
        • MMWR 2003
    • 12. Sentinel Counties Study of Acute Viral Hepatitis Reported Risk Factors for Acute Hepatitis C, 1991 – 1998 *None since 1994 **6% Low SES
    • 13. Clinical Aspects
    • 14. Clinical Features
      • Incubation: 6-7 weeks
      • Clinical illness: 20-40%
        • Malaise, jaundice, abdominal pain
      • Long term outcome: possible cirrhosis, liver failure after 20-40 years
        • coagulopathy, encephalopathy, ascites
      • Hepatocellular carcinoma
      • Leading indication for liver transplant
    • 15. Progression
    • 16. Risk factors for progression
      • Heavy use of alcohol
      • HIV positive- lower CD4 counts in particular
      • Older age at infection
      • Male
      • Progression very hard to predict
    • 17. HCV/HIV Co-infection
      • HIV both accelerates and increases risk of HCV progression
      • Liver disease is increasing as a cause of death in HIV+ persons
      • Impact of HCV on HIV continues to be investigated- impact may be greater in post- HAART era
      • Sulkowski 2002, Anderson 2004
    • 18. Treatment
      • Weekly pegylated interferon with daily oral Ribavirin for 24-48 weeks;
      • Side effects: often very debilitating
        • Flu-like syndrome, hair-loss, thyroid dysfunction
        • Depression and other psychiatric disorders
        • Anemia, retinal bleeding
    • 19. Effectiveness of Treatment
      • In clinical trials: 30-50% have sustained viral response (SVR), in some genotypes 2 and 3 up to 80%
      • May also slow progress and reduce risk of liver cancer regardless of SVR
      • Much lower response in the community especially with advanced disease, older, male, African American and heavy alcohol users
    • 20. Who Should be Treated?
        • Goal: Find and treat those for whom the illness is worse than the treatment
        • D. Thomas
        • Current NIH standard includes presence of progression of illness on liver biopsy
    • 21. HIV and HCV Treatment
      • HIV+ patients with relatively intact immune systems can respond to treatment
      • Sustained viral response in clinical trials for co-infected people
        • Overall: 27% to 40%
        • Genotype 1: 10-15% higher in some studies
        • Genotypes 2 & 3: up to 73%
        • Torriani 2004, Chung 2004
    • 22. HCV and HIV treatment
      • HCV+ patients may be less likely to receive HAART
      • While HAART increases the risk of hepatotoxicity most HCV+ patients can tolerate it
      • HAART therapy may protect the liver by maintaining higher CD4 counts
      • Anderson 2004, Mehta, 2005
    • 23. Treating HCV in the co-infected
      • Recent recommendations
      • Defer treatment if liver biopsy has minimal damage
      • Optimize CD4 prior to treatment
      • Kontorinis, 2005
    • 24. Liver transplant in HIV
      • HIV+ persons are receiving transplants in various centers and are showing good survival rates
      • In 2003 NIH initiated a multi-center trial to evaluate strategies and outcomes of solid organ transplants in HIV+ individuals
      • Neef 2004
    • 25. Challenges
      • Successful treatment rates much lower in community than in clinical trials
      • Relative contraindications common particularly among co-infected patients-
        • Psychiatric illness
        • Substance use
      • African Americans respond poorly to current treatment
    • 26. (Injection) Drug Users
      • NIH Consensus Statement
        • 1997: defer treatment of drug users until a period of abstinence
        • 2002: individualized decisions regarding treatment of active drug users
      • A review of 7 clinical trials found that drug users were similar to controls or comparable groups in adherence and response
      • Schaefer 2004, Mehta 2005
    • 27. African Americans
      • Higher incidence of HCV- particularly Genotype 1
      • Possibly less likely to progress
      • Much less likely to respond to treatment
        • Independent of genotype, alcohol and adherence
      • Muir 2004
    • 28. A Look at New York
      • ADAP users of interferon and/or interferon :
        • 2003- 91
        • 3/04- 3/05- 189
    • 29. Challenge: Treating the typical co-infected patient
      • 104 co-infected patients referred to GI for evaluation of HCV, at least 72% had IDU as risk factor
      • 21 had a liver biopsy
      • 16 received treatment
      • Restrepo, 2005
    • 30. Reasons for non-treatment
      • Non-adherent to appointments: 40%
      • Active substance users: 15%
      • Active psychiatric conditions: 8%
      • Medical contraindications: 37%
      • Conclusion: “A majority of non-candidates had potentially modifiable psychosocial factors leading to non-treatment”
      • Restrepo, 2005
    • 31. Co-infection Clinic: Oakland
      • Chart review: of 228 co-infected patients found poor performance on vaccines and alcohol counseling and only 2 treated for HCV
      • Established co-infection clinic:
        • Educate- journal clubs, mini-residencies case conference
        • Full time nurse specialist
        • Increase availability of biopsy
      • Clannon CID 2005
    • 32. Progress to date
      • 15 patients initiated treatment
        • 6 discontinued- one achieved SVR
        • 7 all achieved SVR
      • Pearls:
        • Aggressive management of side effects: epoitin and SSRIs
        • Lot’s of water for systemic symptoms
        • CD4 counts dropped a lot and cause distress
        • Clannon, 2005
    • 33. Co-infection Clinic: Providence
      • Co-infection clinic 2x/month: HIV/HCV specialist, hepatologist, coinfection nurse and coordinator in collaboration with a community mental health and addiction treatment provider
      • Requirements: adherence to appointments and cooperating with psychiatric plan
      • No exclusion based on addiction- stability is a goal which may be harm reduction
      • Taylor CID 2005
    • 34. Progress to date
      • 146 referred, 92 seen once, 69 have had liver biopsies 97% history of addiction, 43% current users 85% with psychiatric disorder
      • 17 in pretreatment, 17 treated
        • 7 completed 1 SVR
        • 5 in treatment
        • 5 dropped out- none because of drug use
        • Taylor, 2005
    • 35. NYS Clinical Guidelines
      • Co-infection guidelines- first in country, updated September 2004
      • Mono-infection: for primary care providers October 2005
      • Focus areas
        • Risk assessment
        • Diagnosis
        • Treatment
        • Medical management
        • Prevention and counseling
    • 36. Hepatitis C Conference
      • Two locations
        • Buffalo – November 1, 2005
        • NYC - November 15, 2005
      • Agenda
        • HCV in corrections
        • HCV Transmission in the healthcare setting
        • Consumer panel
        • Ethnic disparities
          • African Americans and HCV
          • Cross cultural care
    • 37. The Hepatitis C Project
      • Focus on hepatitis C in IDUs
      • Training, technical assistance, and policy development for NYC needle exchange programs
      • Posters, brochures, website: www.hepcproject.org
      • Current initiatives on new models for HCV prevention, networks of HCV care and treatment for IDUs
      • Harm Reduction Coalition
    • 38. Tasks
      • Patient and clinician education
      • Research and guidelines on management of current drug users
      • Research and guidelines on management of psychiatric disorders in HCV treatment
      • Research on the impact of alcohol on treatment
      • Research on resistance to treatment: focus on African-Americans- initiated by NIH
    • 39. For more HIV-related resources, please visit www.hivguidelines.org

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