Hepatitis B & Hepatitis C in HIV Dr K.Bujji Babu,MD Consultant HIV Physician Dr.Bujjibabu HIV Clinic.

HIV Hepatitis B 40 million worldwide 1 million in the US RNA retrovirus Integrates in genome 1y target CD4 cells Reverse Transcriptase Nucleoside Analogues Mutations=Resistance 400 million worldwide 1.25 million in the US DNA hepadna virus Integrates into genome 1y target hepatocytes Reverse Transcriptase Nucleoside Analogues Mutations=Resistance

HIV HBV Co-infection About 10% of HIV+ patients are HBSAg+ (Rustgi VK, Ann Int Med 1984) HIV+ pts 3-6x more likely to develop chronic HBV than HIV- (Bodsworth JID 1991) HIV/HBV is associated with more cirrhosis than HBV alone (Colin JF Hepatology 1999 )

HBV & HIV – Rx Guide lines HBV DNA > 105 copies/ml ALT consistently >2-fold above N bioptic detection of liver fibrosis Healthy carriers don’t require treatment

HBV & HIV – Rx Guide lines Lamivudine and Tenofovir are primarily indicated for HIV treatment, the status of HIV infection must be considered (e.g. necessity for treatment, prior therapies, resistance). An individual decision must be reached.

HIV & HBV – Rx guide lines Adefovir can be given as mono Lamivudine or Tenofovir –no monotherapy On HAART - lamivudine (possibly plus tenofovir) as a component of HAART Resistance with Lam, Tenofovir can be used as an alternative component of HAART. Treatment to continue till seroconversion or until there is loss of efficacy (renewed increase of transaminases and viral load)

Lamivudine in Pts Co- infected with HBV and HIV 122 co-infected patients treated with lamivudine and antiretroviral therapy in CAESAR study Safety data comparable across treatment arms French study of 40 HIV/HBV co-infected patients (Benhamou, et al., Ann. Int. Med., Nov. 1996)

Conclusions HBV infection has worse outcomes in HIV Lamivudine resistance is becoming increasinly common Newer drugs that have activity against LAM resistant HBV are coming soon Treating HBV in HIV patients is getting more challenging daily

Prevention Vaccine less effective due to immunosuppression - 30 % (2.5 %) Vaccination repeated - double dose in four steps (months 0,1,6 and12) Post Exposure Prophylaxis as in normal individuals

Worldwide Prevalence of Hepatitis C HCV Prevalence <1 1-2.49 2.5-4.99 5-10 >10 No data

HIV and HCV 30 % of HIV pts can have HCV infection Less likely to clear HCV in co-infected Higher HCV RNA viral load Rapid progression of liver disease - CD4 <100; 10 yrs vs 20 yrs for Cirrhosis In Haemophiliacs – higher mortality in co-infected

HCV and HIV More rapid deterioration of HIV disease CD4 count may not rise much blunted immune response - HAART

HCV co infection & HAART Drug induced heaptotoxicity more in co infected – protease inhibitors & ATT 88% co infected pts tolerated HAART well without hepatotoxicity Antiretrovirals safe in Chronic hepatitis C Stop Rx – if symptomatic or Liver enzymes > 5 x normal

HIV & HCV Screen by ELISA – Confirm by RNA PCR If CD4 count < 100 – Anti HCV may be low or undetectable HCV RNA should be done if suspeected

HIV – HCV : Management Avoid Alcohol Vaccinate against HAV & HBV Look for Chronic Liver disease SGPT, HCV RNA – Limited usefulness Liver Biopsy for disease activity Liver biopsy safe in HIV infected persons

HIV HCV - Treatment HCV to be treated before HIV Peg Interferons with Ribavarin ideal Limited data on its safety in co infected Significant side effects for Peg IFN and Ribavarin reported Drug interactions – Ribavarin vs HIV drugs

CD4 count & HAART If > 350 , IFN and HAART 200 – 350, individual case < 200 IFN relative contra indication might deteriorate Didanosine contraindicated - Pancreatitis, mitochondrial toxicity,liver decompensation Zidovudine avoid - additive toxicities anemia and leukopenia Stavudine - due to mitochondrial toxicity

Guide lines for therapy-HIV HCV Review HIV – CD4 counts HCV RNA, SGPT, Liver Biopsy Exclude co morbid conditions During therapy Blood counts, SGPT, HCV RNA – Adjust HCV RNA at 24 wks – If detected – stop Birth control during & 6 months after Rx

HCV anti bodies negative Positive HCV RNA negative negative elevated SGPT, Genotype elevated normal Peg IFN Liver Bx Positive negative

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