Lesson 4: Preventing HCV Reinfection Core Competency 2: Primary and Secondary Prevention of HCV among PLWH Lesson 4: Preventing HCV Reinfection PLWH = People Living with HIV July 2017

Lesson Objectives This lesson will focus on addressing HCV reinfection prevention among HIV/HCV co-infected persons who have been successfully treated for HCV in the past Differentiating relapse and reinfection Education on risk of HCV reinfection after HCV treatment has been successfully completed Education on risk reduction NEXT

Relapse1,2 RELAPSE HCV relapse = return of HCV viremia (detectable HCV RNA) within 24 weeks of end of treatment NEXT Blackard, J Infect Dis. 2007

Reinfection1,2 REINFECTION NEXT Reinfection = infection with HCV during or after HCV treatment, resulting in HCV viremia at 6 months post end of treatment Blackard, J Infect Dis. 2007

Mixed Infection1,2 Mixed infection = simultaneous infection with two or more HCV strains NEXT Blackard, J Infect Dis. 2007

Superinfection1,2 Superinfection = presence of new and different viral strains in a person with chronic HCV infection as a result of reinfection NEXT Blackard, J Infect Dis. 2007

Relapse vs. Reinfection1 In persons with ongoing risk behaviors for HCV infection, completed HCV treatment, and a resurgence of HCV RNA, the answer may be: Incomplete treatment of a mixed infection (one strain completely suppressed, but one strain not) Reinfection Relapse Depends on viral genome sequencing and behavioral history NEXT

Reinfection Among persons successfully treated for HCV, reinfection incidence rates are low1 Despite clearance of primary HCV infection with the use of DAAs, PLWH are at greater risk of HCV reinfection than are similar people without HIV infection3 PWID are also significantly more likely to be reinfected than are those who acquired HCV infection by other means,3 and post-treatment PWID in particular4 DAA = Direct Acting Antiviral PLWH = People Living with HIV PWID = People Who Inject Drugs

Reinfection Risks NEXT Among PLWH successfully treated for HCV in Canada, those who had the highest rates of reinfection (7% of 257) were5: High-frequency IDU MSM with high-risk sexual activity Low-frequency IDU PLWH = People Living with HIV IDU = Injecting Drug User MSM = Men who have Sex with Men

Other Therapies Opioid substitution therapy, along with HCV treatment, results in significantly lower rates of HCV reinfection among PWID3 Those receiving mental health services (outside of opioid substitution therapy) along with DAA are significantly less likely to be HCV reinfected3 Access for PWID to sterile injection equipment along with substance use and mental health services6 DAA = Direct Acting Antiviral PWID = People Who Inject Drugs NEXT

Recommendations Provider fear or concern of reinfection should not prevent treatment of HCV1 Mental health services for persons getting or ending treatment for HCV3 Opioid substitution therapy for PWID who are completing or have completed HCV treatment3 Harm reduction counseling should be provided to all persons during and at end-of-treatment for HCV reinfection prevention4 (see Lesson 2.1) PWID = People Who Inject Drugs NEXT

References Grady BP, Schinkel J, Thomas XV, Dalgard O. Hepatitis C virus reinfection following treatment among people who use drugs. Clin Infect Dis. 2013 Aug;57 Suppl 2:S105-10. Blackard JT, Sherman KE. Hepatitis C virus coinfection and superinfection. J Infect Dis. 2007 Feb 15;195(4):519-24. Islam N, Krajden M, Shoveller J, et al; British Columbia Hepatitis Testers Cohort (BC-HTC) team. Incidence, risk factors, and prevention of hepatitis C reinfection: a population-based cohort study. Lancet Gastroenterol Hepatol. 2017 Mar;2(3):200-210. Martinello M, Grebely J, Petoumenos K, et al. HCV reinfection incidence among individuals treated for recent infection. J Viral Hepat. 2017 May;24(5):359-370. Young J, Rossi C, Gill J, et al; Canadian Co-infection Cohort Investigators. Risk factors for hepatitis C virus reinfection after sustained virologic response in patients coinfected with HIV. Clin Infect Dis. 2017 May 1;64(9):1154-1162. Des Jarlais DC, Nugent A, Solberg A, Feelemyer J, Mermin J, Holtzman D. Syringe service programs for persons who inject drugs in urban, suburban, and rural areas -- United States, 2013. MMWR Morb Mortal Wkly Rep. 2015 Dec 11;64(48):1337-41. NEXT

Authors and Funders This presentation was prepared by 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.

Disclaimer and Permissions Users are cautioned that because of the rapidly changing medical field, information could become out of date quickly. You may use or present this slide set and other material in its entirely or incorporate into another presentation if you credit the author and/or source of the materials. The complete HIV/HCV Co-infection: An AETC National Curriculum is available at: https://aidsetc.org/hivhcv