Hepatitis C and HIV Coinfection
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1 Hepatitis C and HIV Coinfection Chia Wang, MD, MS Virginia Mason Medical Center Sections of Gastroenterology and Infectious Diseases
2 Life expectancy of HIV-infected individuals Which of the following statements is true? A. HIV is now just a chronic disease that does not reduce an individuals life expectancy B. HIV causes an average decrease in life expectancy of 5-10 years C. HIV causes an average decrease in life expectancy of years D. HIV continues to reduce life expectancy by more than 20 years; infected individuals cannot get life insurance
3 Life Expectancy of patients with HIV Nakagawa et al. AIDS 2012;26:
4 Mathematical modeling of HIV mortality Predict the life expectancy for a 30 year old MSM infected with drug-sensitive virus in 2010 Assuming a 40% chance of being a smoker and no hepatitis co-infection Estimated life expectancy = 75 years General population = 82 years Thus, 7 years lost attributable to HIV Smoking reduces life expectancy by 7 years Diabetes reduces life expectancy by 5 years
5 HIV infection is now just another chronic disease "New medicines have transformed HIV from a death sentence into a chronic disease that has a very, very small impact on your life expectancy if you start treatment early and do not smoke, drink or have diabetes, "HIV has a much lower impact on survival and life expectancy than cancer, severe diabetes or nasty high blood pressure." Charles Gilks, UNAIDS country coordinator for India, December 2011
6 Hepatitis C has a tremendous negative impact on individuals with HIV infection
7 Clin Infect Dis Apr;58(8):
8 Epidemiology of Hepatitis C and HIV Co-infection in the US ~240,000 (30%) HIV-HCV coinfected 1 75% 10% 15% ~800,000 HIV infected individuals in the United States IDU M-F Sex M-M Sex 1 Sulkowski et al, Clin Infect Dis 2000,supplement 1, 77-84
9 Natural History of HIV and Hepatitis C Acute HIV AIDS Opportunistic Infections Death Acute hepatitis C 85% Chronic hepatitis C 70% Chronic hepatitis (abnormal liver biopsy) 20% Cirrhosis 1% Hepatocellular CA 20 years
10 HIV is an accelerant for Hepatitis C Acute HIV AIDS Opportunistic Infections Death Acute hepatitis C 20% Cirrhosis? years
11 Successful treatment of HCV reduces adverse outcomes of coinfection CROI 2015, on February 26, :00 AM-12:00 PM, presented by Cindy Zahnd
12 Delaying HCV treatment increases the likelihood of liver related deaths CROI 2015, on February 26, :00 AM-12:00 PM, presented by Cindy Zahnd
13 Hepatitis C treatment in patients with HIV
14 Hepatitis C: Treatment Landscape % % 45-47% % % 10 6% 0 IFN 24 Wks IFN 48 wks IFN/RBV 24 wks IFN/RBV 48 wks 1998 IFN/RBV 48 wks 2001 PegIFN/RBV 48 wks
15 Hep C: Mono-infected versus coinfected % % PegIFN/RBV 48 wks MONOINFECTED PegIFN/RBV 48 wks COINFECTED
16 Available regimens for the treatment of hepatitis C Ledipisvir Sofosbuvir (Harvoni) ION-4 trial Paritaprevir/r/Ombitasvir & Dasabuvir+RBV Turquoise-1 trial Daclatasvir - Sofosbuvir ALLY-2 trial
17 Ledipasvir-Sofosbuvir from CROI 2015 on February 26, :00 AM-12:00 PM, presented by Susanna Naggie
18 Ledipasvir-Sofosbuvir (ION-4 Trial) from CROI 2015 on February 26, :00 AM-12:00 PM, presented by Susanna Naggie
19 Ledipasvir-Sofosbuvir (ION-4 Trial) from CROI 2015 on February 26, :00 AM-12:00 PM, presented by Susanna Naggie
20 Ledipasvir-Sofosbuvir (ION-4 Trial) from CROI 2015 on February 26, :00 AM-12:00 PM, presented by Susanna Naggie
21
22 Viekira Pak (Turquoise 1)
23 TURQUOISE-I: safety and efficacy of ABT-450/r/Ombitasvir, Dasabuvir, and Ribavirin in patients co-infected with hepatitis C and HIV-1 from CROI 2015 on February 26, :00 AM-12:00 PM, presented by David Wyles
24 TURQUOISE-I: safety and efficacy of ABT-450/r/Ombitasvir, Dasabuvir, and Ribavirin in patients co-infected with hepatitis C and HIV-1 from CROI 2015 on February 26, :00 AM-12:00 PM, presented by David Wyles
25 Virginia Mason!
26 ALLY-2 Trial
27 Daclatasvir-Ledipasvir (ALLY-2) from CROI 2015 on February 26, :00 AM-12:00 PM, presented by David Wyles
28 Daclatasvir-Ledipasvir (ALLY-2) from CROI 2015 on February 26, :00 AM-12:00 PM, presented by David Wyles
29 Daclatasvir-Ledipasvir (ALLY-2) from CROI 2015 on February 26, :00 AM-12:00 PM, presented by David Wyles
30 Daclatasvir-Ledipasvir (ALLY-2) from CROI 2015 on February 26, :00 AM-12:00 PM, presented by David Wyles
31 Conclusions from Coinfection Trials All-Oral Regimens for Coinfected patients are highly effective with response rates >90% Regimens are safe and well-tolerated and there is no loss of control of HIV infection Response rates are similar to that of monoinfected patients There are some drug-drug interactions to consider with regards to Hiv therapy
32 Not It s the immune system, stupid
33 Hep C: Mono-infected versus coinfected % % PegIFN/RBV 48 wks MONOINFECTED PegIFN/RBV 48 wks COINFECTED
34 Hep C: Mono-infected versus coinfected 90-98% 90-98% DAAs 12 weeks MONOINFECTED DAAs 12 weeks COINFECTED
35 HIV treatment (HAART)
36 HIV treatment in a nutshell We always use at least 3 drugs Most popular backbone is Truvada (tenofovir + emtricitabine) 3 rd drug is often Efavirenz (non-nucleoside analogue) Other popular 3 rd drug option is Atazanavir/R (protease inhibitor, causes hyperbilirubinemia) Raltegravir is an integrase inhibitor that is being used more frequently due to potency and lack of side effects
37 CROI 2015: Study of HAART Compatibility with HCV treatment (Poster 651) CROI 2015, Poster 651
38 Need to switch with other regimens CROI 2015, Poster 651
39 CONCLUSIONS Hepatitis C substantially reduces the life expectancy of individuals with HIV infection Don t delay treatment of Hep C in HIV coinfected patients Treatment is short (12 weeks), highly effective (>90%), and safe Most patients will need an anti-retroviral treatment switch before starting treatment for Hep C
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