Chair: Silvia Petretti, UKC
Facilitators: Robert Fieldhouse, UKC, Henry Grahame-Smith, CD4 professionals
Rapporteur: Andrew Little, UKC
The chair opened this workshop, attended by 25 participants, by asking everyone to indicate their present understanding of HIV and hepatitis C (HCV) treatment, care and prevention on a scale of 1-10. This self-evaluation indicated fairly low levels of awareness around co-infection issues. After this the group spent a few minutes thinking about the following:
Mixed messages being given out about treatment
How terrible is terrible? (relating to treatment of HCV)
What is the impact of HCV treatment on CD4 count? (during and after)
Screening (how often?)
Transmission issues – how?
Pressure from doctors to start treatment (informed choice)
Are you automatically screened?
What access is there to screening pre/post test counselling?
Impact of interferon containing therapy
What do you do if treatment fails?
Support and Knowledge
The results of this formed the basis of the direction of the session. The following topics were raised and then addressed:
1. Transmission; the role of sex involving blood and drug use other than injecting. UKC campaign to raise awareness.
2. Prevention; safer sex, safer drug use
3. Diagnosis; monitoring genotype tests, viral load, liver biopsy
4. Treatment; (the apricot study) 40% cure rate in co-infected patients (the largest study ever completed in HIV/HCV), cure higher among those with genotypes 2 & 3
5. Managing treatment; side effects, using complementary therapies. Sticking with treatment
HCV was first isolated in 1989. World wide 40 million have HIV but 170 million have HCV. HCV increases the potential for sexual transmission of HIV and mother to child risk of HIV transmission is increased. Transmission occurs blood to blood.
What are the chances of transmission from a needle stick?
1 in 3 hepatitis B (HBV)
1 in 30 HCV
1 in 300 HIV
HCV is NOT spread in semen BUT it is spread via blood, but it doesn’t take much – it is VERY easily spread.
Dried blood can pass on HCV
HCV affects the liver and can lead to cirrhosis which is the scarring of the liver that causes the problem. HIV speeds up the progression of HCV.
What action can HCV have on HIV? It can mean there is increased toxicity of HIV medication. This may result in the need to change HIV drugs. You may end up with more of the HIV drugs in your system because the liver isn’t flushing the drugs out as efficiently. Interactions can occur in Saquinavir, Ritonovir, Tenofavir, Atanzanavir, Efavirenz. For example, Ritonovir boosts Saquinavir and Efavirenz reduces Tenofivir, but then the liver effect impacts on this. Therefore drug levels may need to be tested regularly.
HCV (Hepatitis C)
Because HCV is transmitted blood to blood some advice includes the following:
Avoid sharing sex ‘toys’
Sharing notes, bullets or nose straws is not advisable because of the risk of blood droplets in the nasal passages.
Avoid sharing hair clippers (because of cuts or nicks)
HBV (Hepatitis B)
People living with HIV can be vaccinated against HBV, however a number of people do not respond very well to the vaccine and this is not necessarily to do with HIV status.
HAV (Hepatitis A)
There is also a vaccine against HAV and which people living with HIV may want to consider, especially if already co-infected with HCV
Is HCV present? There are two types of tests. The first is qualitative, this means it is to find out whether someone is HCV+. The second test is quantitative, which means it measures how much HCV is in the blood.
Other tests can be done to look at how effectively the liver is working in the body. These include liver function, ALT, AST and a liver biopsy (to check for cirrhosis).
Like HIV, there are different types of HCV called genotypes. There are six major types and the most common in Europe is 1.
The initial phase of infection is called ‘acute’ and treatment can be given during this time (3-6 months) and the success rate amongst people with HCV only is around 15-20%. The body can also clear hepatitis naturally but this won’t happen more than 6 months after being infected and the condition is then considered chronic.
In people with chronic HCV but not HIV there is about a 50% success rate across all genotypes. The APRICOT study of people co-infected with HIV and HCV showed that the success rate was around 40% for all genotypes. If you are only infected once, you are more likely to clear HCV. If you are infected repeatedly, clearance is reduced to 15-20% (you can be re-infected after clearing HCV once).
The treatment for HCV is with pegylated interferon (a weekly injection) and ribavirin (tablets).
How do you know if the HCV treatment is working? The aim is to have an undetectable HCV viral load after 12 weeks. If this is not achieved, you and your doctor may discuss stopping the treatment, however there have been some people who took longer to reach an undetectable result and they were recommended to continue for 18 months.
When should you treat HCV? There is a need to treat the HCV while the HIV is under control. A biopsy can also be used to prioritise access to treatment by assessing how badly damaged the liver may be.
If treatment is not an option or does not work a liver transplant can be considered if you are likely to be alive for the next five years, therefore people with HCV and HIV do qualify.
Possible side effects of HCV treatment include:
Diarrhoea/ constipation
Hair loss
Hair straightening
Flu like symptoms
Change in taste buds
Behavioural changes (mania/obsessive/emotional)
Depression
Needle phobia
Needle site reactions
Post treatment depression
Vivid dreams
Management of treatment through diet, gentle exercise and stretching can be a big help.
There were fairly low levels of awareness around co-infection issues
HAV and HBV are preventable by vaccination
HCV can be cured
People living with HIV can be referred for a liver transplant
This workshop was evaluated by 20 people. The youngest participant was 27 and the oldest was 47. The average age was 40.
Gender
14 male, 5 female, 1 not stated
Ethnicity
12 white, 4 black African, 3 not stated, 1 other non-white
Sexuality
12 gay, 6 heterosexual, 1 not stated
Co-infection
4 HCV, 1 HBV & HCV, 1 HBV
Usefulness
Very useful |
Useful |
Not useful |
75%(15) |
25% (5) |
0% (0) |
NOBODY said not useful
9 people set themselves action points:
Seriously consider starting treatment for HCV
Protect myself and others
Get more info
Learn a lot
Update knowledge on subject
More confident in approaching treatment
New information will affect my life
Encourage testing
Safer sex practices
Move on to Xpress Yourself