Lesson 2: Special Considerations When Treating HIV/HCV Co-infection Core Competency 4: HCV Treatment Lesson 2: Special Considerations When Treating HIV/HCV Co-infection July 2017 Updated: December 2018

Lesson Objectives At the end of this lesson, participants will be able to: Describe the major health impacts of HIV/HCV co-infection Identify key medication interactions and sources for current interactions information Build further knowledge via online training tools

HIV/HCV Co-Infection The primary impact is accelerated HCV-related fibrosis in persons with poorly controlled HIV infection The effects of HIV on HCV and vice-versa are covered in Lesson 1.3 Patients with well-controlled HIV do not have notably different HCV-related fibrosis progression as do those with advanced HIV disease.

HIV/HCV Co-infection Studies1 PLWH respond just as well to current DAA-based treatment as HIV-uninfected patients Unlike prior IFN-based regimens where PLWH had half the response rates as HIV-uninfected persons DAA regimen recommendations are no different for PLWH aside from medication interaction considerations* * Exception: abbreviated 8-week course of sofosbuvir/ledipasvir, which is recommended for HIV-uninfected, treatment-naïve, non-cirrhotic, non-African American genotype 1a/b patients with VL <6 million, and is not recommended in PLWH Multiple studies have shown equivalent excellent DAA treatment response rates in HIV/HCV co-infected patients (ALLY-2, C-EDGE, ERADICATE, TURQUOISE-1, COSMOS, ASTRAL-5). The only exception is that HIV patients should not undergo the abbreviated 8wk course of treatment allowed for treatment-naïve, non-cirrhotic, non-African American genotype 1a/b patients with VL<6 million.

Medication Interactions Important HIV-HCV DAA medication interactions exist for every HIV and HCV medication class Look up drug-to-drug every time – even experienced practitioners do this! In general, integrase strand transfer inhibitors (INSTIs) tend to have fewer drug interactions with HCV medications Become facile with a drug interaction resource – see following slides for examples Do not interrupt HIV antiretroviral therapy (ART) during HCV therapy If no suitable HCV regimen can be constructed, consult the patient’s HIV medication prescriber regarding a possible ART switch

Reference AASLD-IDSA. Unique Patient Populations: Patients with HIV/HCV co-infection. Recommendations for testing, managing, and treating hepatitis C. http://www.hcvguidelines.org/full-report/unique-patient-populations-patients-hivhcv-coinfection Accessed December 31, 2018.

Tools and General References AASLD-IDSA. Unique Patient Populations: Patients with HIV/HCV Coinfection. http://www.hcvguidelines.org/full-report/unique-patient-populations-patients-hivhcv-co-infection DHHS Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. Considerations for Antiretroviral Use in Patients with Coinfections, HCV/HIV Coinfection. https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv- guidelines/26/hcv-hiv Table 12 provides a useful reference to bookmark for clinical care University of Liverpool. HEP Drug Interactions. www.hep-druginteractions.org UCSF HIV InSite. Database of Antiretroviral Drug Interactions. http://hivinsite.ucsf.edu/interactions Northeast/Caribbean AETC. Antiretroviral Guides. http://necaaetc.org/node/149 The definitive guideline for testing, evaluation, and treatment of Hepatitis C in the US is published on-line by the American Association for the Study of Liver Diseases and the Infectious Disease Society of America (AASLD/IDSA) AASLD-IDSA and DHHS both provide information in narrative and tabular formats. HEP Drug Interactions and HIV InSite information is primarily tabular.

Online Resources Hepatitis C Online: Module 6. Treatment of Special Populations and Special Situations. Lesson 2. Treatment of Hepatitis C in Patients with HIV Coinfection. http://www.hepatitisc.uw.edu/go/special-populations-situations/treatment-hiv-coinfection/core-concept/all Slide presentation http://www.hepatitisc.uw.edu/go/special-populations-situations/treatment- hiv-coinfection/treatment-hiv-coinfection Live support: National Clinician Consultation Center http://nccc.ucsf.edu/ (844) HEP‐INFO or (844) 437-4636 Monday – Friday, 9 a.m. – 8 p.m. ET

Authors and Funders This presentation was prepared by Philip J. Bolduc, MD (New England AETC) for the AETC National Coordinating Resource Center in July 2017 and updated December 2018. 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