Lesson 2: Secondary Prevention of Viral Hepatitis Core Competency 2: Primary and Secondary Prevention of HCV among PLWH Lesson 2: Secondary Prevention of Viral Hepatitis PLWH = People Living with HIV July 2017

Lesson Objective Identify secondary prevention interventions for people with HCV infection

HAV and HBV Screening Evaluation for other conditions that affect the liver, including HAV and HBV1 HAV IgM anti-HAV2, IgG anti-HAV Indicates past infection or vaccine-related immunity (IgG), acute infection (IgM), susceptibility3 HBV HBsAg, anti-HBs, anti-HBc, IgM anti-HBc Indicates resolved infection, acute infection, chronic infection, vaccine-related immunity, susceptibility4,5 Evaluation for other liver infections Determination of susceptibility to other liver infections HAV (fecal to oral): generally determining between immunity (past infection) and susceptibility (no past infection or vaccine). Acute infection is short. HBV (bloodborne, sexually transmitted): several scenarios that can indicate immunity, infection, or susceptibility. If person is actively infected with HBV, assess for treatment need. HAV = hepatitis A virus HBV = hepatitis B virus HBsAg = hepatitis B surface antigen IgG = immunoglobulin G IgM = immunoglobulin M HBc =  hepatitis B core antigen Anti-HBs = hepatitis B surface antibody Anti-HAV = hepatitis A virus antibody

HAV and HBV Vaccination Recommended for all susceptible persons with HIV/HCV co-infection1 HAV/HBV combination vaccines: 3-4 doses HAV: 2 doses6 HBV: 2-3 doses IM Post-vaccination testing for serologic response 1-2 months after last dose7 Vaccination against other viral hepatitides. If susceptible to both viruses, consider a combination vaccine and choose the appropriate schedule Because of HIV infection, serologic testing after 1-2 months to assess whether immunity was acquired. IM = Intramuscular injection

Risk Reduction for HAV Vaccination Precautions when traveling in endemic regions Bottled or boiled water (including for brushing teeth), peel and wash fruit and vegetables, avoid undercooked meat and fish Good hygiene Washing hands often -- diaper changes, preparing food, eating8 Barrier methods during anilingus9 HAV – fecal to oral transmission. Best prevention is vaccination If not immune be aware (in particular in endemic regions) when: Eating Drinking Hygiene (including tooth brushing) Mouth to anus sexual activity

Risk Reduction for HBV Vaccination Partner testing and disclosure Use of condoms Safe use of injection equipment Precautions with piercing and tattooing Precautions when traveling to endemic regions10 HBV – sexual and blood borne Best prevention is vaccination. Serodiscordant couples should avoid sharing injection equipment or having unprotected sex Beware of anything pointy used to break the skin.

Harm Reduction for Liver Disease Alcohol abstinence Physician or pharmacist review of all medications, including: Prescription, over the counter, supplements, herbals, hormones11 Safe food practices Healthy behaviors Diet and exercise for a healthy weight Control blood sugar, cholesterol, blood fats Reduce stress, increase emotional support12 Potential pre-existing challenges for HIV/HCV co-infected: Existing liver damage due to HCV Inflammation due to HIV Liver affects of medications Be kind to your liver – it doesn’t complain. Avoid behaviors that challenge the liver further: Drinking alcohol taking certain medications Eating/preparing food without proper precautions and appropriate cooking Engage in behaviors that maintain health Eat healthy Exercise Appropriately manage other indicators of health Seek emotional balance, reduce stress, engage

References American Association for the Study of Liver Diseases, International Antiviral Society -- USA. HCV Guidelines. Recommendations for Testing, Managing, and Treating Hepatitis C. Available at: http://hcvguidelines.org/sites/default/files/HCV-Guidance_October_2016_a.pdf. Updated July 6, 2016. Accessed June 15, 2017.  Centers for Disease Control and Prevention. The ABCs of Hepatitis. Available at: https://www.cdc.gov/hepatitis/resources/professionals/pdfs/abctable.pdf. Updated 2016. Accessed June 15, 2017 Mayo Clinic. Interpretive Handbook Test 32110. Available at: http://www.mayomedicallaboratories.com/interpretive-guide/?alpha=H&unit_code=32110. Accessed June 15, 2017. Centers for Disease Control and Prevention. Recommendations for Identification and Public Health Management of Persons with Chronic Hepatitis B Virus Infection. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5708a1.htm. Published September 19, 2008. Accessed June 15, 2017. Centers for Disease Control and Prevention. Interpretation of Hepatitis B Serologic Test Results. Available at: https://www.cdc.gov/hepatitis/hbv/pdfs/serologicchartv8.pdf. Accessed June 15, 2017 Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices. Hepatitis A ACIP Vaccine Recommendations. Available at: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hepa.html. Updated December 22, 2014. Accessed June 15, 2017. Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices. Hepatitis B ACIP Vaccine Recommendations. Available at: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hepb.html. Updated September 14, 2015. Accessed June 15, 2017. Mayo Clinic. Hepatitis A Prevention. Available at: http://www.mayoclinic.org/diseases-conditions/hepatitis-a/basics/prevention/con-20022163. Accessed June 15, 2017. Mayo Clinic. Hepatitis A Risk Factors. Available at: http://www.mayoclinic.org/diseases-conditions/hepatitis-a/basics/risk-factors/con-20022163. Accessed June 15, 2017. Mayo Clinic. Hepatitis B Prevention. Available at: http://www.mayoclinic.org/diseases-conditions/hepatitis-b/basics/prevention/con-20022210. Accessed June 15, 2017 Centers for Disease Control and Prevention. Hepatitis C FAQ for Health Professionals. Available at: https://www.cdc.gov/hepatitis/hcv/hcvfaq.htm. Accessed June 15, 2017. U.S. Department of Veterans Affairs. Viral Hepatitis Keeping Your Liver Healthy. Available at: https://www.hepatitis.va.gov/patient/basics/keeping-liver-healthy.asp. Accessed June 15, 2017. American Association for the Study of Liver Diseases, International Antiviral Society -- USA. HCV Guidelines. Recommendations for Testing, Managing, and Treating Hepatitis C. Available at: http://hcvguidelines.org/sites/default/files/HCV-Guidance_October_2016_a.pdf. Updated July 6, 2016. Accessed June 15, 2017.  Centers for Disease Control and Prevention. The ABCs of Hepatitis. Available at: https://www.cdc.gov/hepatitis/resources/professionals/pdfs/abctable.pdf. Updated 2016. Accessed June 15, 2017 Mayo Clinic. Interpretive Handbook Test 32110. Available at: http://www.mayomedicallaboratories.com/interpretive-guide/?alpha=H&unit_code=32110. Accessed June 15, 2017. Centers for Disease Control and Prevention. Recommendations for Identification and Public Health Management of Persons with Chronic Hepatitis B Virus Infection. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5708a1.htm. Published September 19, 2008. Accessed June 15, 2017. Centers for Disease Control and Prevention. Interpretation of Hepatitis B Serologic Test Results. Available at: https://www.cdc.gov/hepatitis/hbv/pdfs/serologicchartv8.pdf. Accessed June 15, 2017 Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices. Hepatitis A ACIP Vaccine Recommendations. Available at: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hepa.html. Updated December 22, 2014. Accessed June 15, 2017. Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices. Hepatitis B ACIP Vaccine Recommendations. Available at: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hepb.html. Updated September 14, 2015. Accessed June 15, 2017. Mayo Clinic. Hepatitis A Prevention. Available at: http://www.mayoclinic.org/diseases-conditions/hepatitis-a/basics/prevention/con-20022163. Accessed June 15, 2017. Mayo Clinic. Hepatitis A Risk Factors. Available at: http://www.mayoclinic.org/diseases-conditions/hepatitis-a/basics/risk-factors/con-20022163. Accessed June 15, 2017. Mayo Clinic. Hepatitis B Prevention. Available at: http://www.mayoclinic.org/diseases-conditions/hepatitis-b/basics/prevention/con-20022210. Accessed June 15, 2017 Centers for Disease Control and Prevention. Hepatitis C FAQ for Health Professionals. Available at: https://www.cdc.gov/hepatitis/hcv/hcvfaq.htm. Accessed June 15, 2017. U.S. Department of Veterans Affairs. Viral Hepatitis Keeping Your Liver Healthy. Available at: https://www.hepatitis.va.gov/patient/basics/keeping-liver-healthy.asp. Accessed June 15, 2017.

Authors and Funders This presentation was prepared by Leigh Guarinello, MPH (MidAtlantic AETC) and John Nelson, PhD, CPNP (AETC National Coordinating Resource Center) for the AETC National Coordinating Resource Center in July 2017. This presentation is part of a curriculum developed by the AETC Program for the project: Jurisdictional Approach to Curing Hepatitis C among HIV/HCV Co-infected People of Color (HRSA 16-189), funded by the Secretary's Minority AIDS Initiative through the Health Resources and Services Administration HIV/AIDS Bureau.

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