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

2. 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

3. 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 )

6. 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

7. 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.

8. 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)

9. 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 )

17. 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

18. 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

19. Worldwide Prevalence of Hepatitis C
HCV Prevalence
<1
1-2.49
5-10
>10
No data

20. 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; yrs vs 20 yrs for Cirrhosis
In Haemophiliacs – higher mortality in co-infected

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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

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

29. thank you