In February 2004, people living with HIV, and professionals providing services to them had the opportunity to quiz two of the country's leading experts on HIV-hepatitis coinfection at an awareness raising event hosted by the UKC as part of its Knowledge is Power Project.

Dr Mark Nelson from Chelsea and Westminster Hospital and Dr Sanjay Bhagani, answer questions. A copy of presentations given on the evening will be available on this website soon, along with commentary for each slide.

What does the APRICOT study tell us about treatment for people with cirrhosis?

MN Being such a large study, it would be interesting to be able to make cuts in the data. This has not been done yet.

What is the prevalence of HIV-hepatitis C coinfection in the UK?

SB There are only data from individual clinics, there has been no national effort to identify how many people are co-infected.

MN At the Chelsea and Westminster Hospital about one and a half per cent of the clinic population have caught hepatitis C in the last year and a half. The chronic figure is about ten or twelve percent. I am sure there are people at both clinics who have been missed.

How do you identify recent hepatitis C infections?

MN We do the same as the Royal Free, when an abnormal liver function test occurs, patients will be offered hepatitis C screening. Additionally patients will be offered hepatitis C screening on an annual basis. Some doctors at the Chelsea and Westminster have a lot of patients who are co-infected, others don't, and maybe it is because they are not testing for it. This has to be patient driven- you have to ask what is going on if my liver function test is elevated. Our nurse led clinic is also having a positive impact on getting patients tested. Essentially, though, if patients ask, they get!

If you are only infected with hepatitis C, what is the chance of responding to pegylated interferon if you have failed it before?

MN It does occur but it occurs very rarely.

SB It seems unlikely.

What kind of time period are we looking at until new drugs are available for hepatitis C treatment?

MN It depends really what Boehringer Ingelheim do with their hepatitis C protease inhibitor development. The timespan is going to be 3, 4 or 5 years I guess.

What are the main side-effects associated with interferon and ribavirin treatment?

SB Interferon and ribavirin are well known to cause numerous side-effects. Ribavirin can cause anaemia as it gets directly into red cells and breaks them down. We know of ways around it now, so that we can support the patient through treatment without reducing the ribavirin dose, such as the use of EPO.

If patients have a low white cell count we are quite happy to support them with treatment with GM-CSF to encourage white cell production.

There is a new kind of ribavirin which is known as viramadine and it is coming into phase III study; it appears not to cause anaemia to such a large degree.

Is there any information about response to treatment in women co-infected with HIV?

MN Around twenty percent of the participants in APRICOT were women, so it may be possible to do a cut in the data and get some information from this trial.

How long does it take for antibodies to hepatitis C to develop?

Within the first 4-6 weeks you will begin to see hepatitis C virus in the blood, but it can take up to 24 weeks for antibodies to be produced in the blood.

Is it possible to be infected with hepatitis C with more than one genotype?

SB Yes, certainly in our haemophiliac population we have seen patients with multiple genotypes. There is very little data on treatment in people with multiple genotypes, but recently there has been a study from Hong Kong, and it seems much more difficult to treat.

Is it true that people with mild disease on a biopsy will not be offered treatment? Is the motivation purely financial?

MN There is a queuing system. But new drugs are coming and you may be better off waiting for the new drugs; it depends how you feel, you may be desperate to try with the current drugs. In patients only infected with hepatitis C, it does come down to money, clearly there is only a certain amount of money there and that money needs to go to those who need the treatment most. The opposite side of the coin is that those with milder disease may actually be easier to treat and respond to therapy better. There is a finite amount of money. People with cirrhosis tend to do worse, but the cirrhotics are also more likely to die.

What about dental practices? If you have bleeding gums, do you need to tell your dentist?

SB Dentists should be well aware of this and should be using universal precautions.

MN As Sanjay said, the dentist should be using precautions so you telling him should make no difference at all.

Do you think there is an ongoing epidemic among HIV negative gay men in London that just isn't being picked up?

MN As Sanjay said we are picking up the majority of these acute hepatitis C cases because they have had abnormal liver function tests, not because they are sick and they have had unsafe sex. The question is if there is this epidemic going on and it is being picked up by liver function tests, should we not be performing liver function tests on all gay men attending GUM clinics? That is something I have suggested, but in the end it comes down to money.

SB We are about to start a pilot project of that nature at the Royal Free, looking at the gay men who come to our GUM clinic and giving them liver function tests. Though liver enzymes are not a very sensitive marker, the test is a very cost-effective one.

MN We actually did it five years ago, when we tested people at the GUM clinic for hepatitis C. At that time we found that 2-3% of heterosexuals and homosexuals had hepatitis C without any risk factors.

How is the Health Protection Agency involved in tracking this evolving epidemic and what are most hospitals doing to track it?

SB I would hope that most hospitals are at least doing the annual test for hepatitis C.

MN The data is well known in the UK, including the Health Protection Agency, but you need to ask them what they are doing about it, I have had no contact with them at all.

Can you say something about GP's awareness of hepatitis C?

There is a document now from the Department of Health called the Hepatitis C Strategy. One of the areas that it highlights is primary care and awareness among GPs.

Is there a postcode lottery with hepatitis C treatment in this country?

MN There should not be because there has been NICE guidance about hepatitis C treatment since January. Obviously some areas have more money than others. Being HIV positive means that your hepatitis C treatment comes out of the HIV budget so there is no waiting time.

Can you be re-infected with hepatitis C?

MN Yes. You can cure it with pegylated interferon and then catch it again.

If someone has a liver transplant what is the chance of the hepatitis C virus coming back again?

MN 100%.

What are the advantages of pegylated interferon over normal interferon?

Fewer people have to discontinue pegylated interferon therapy rather than conventional interferon, so it is an advance.