Article ContentsUMDNJ Resources | Update on HIV and Hepatitis C Virus Co-InfectionHIV and Hepatitis C Case Discussion Contributed by Shobha Swaminathan, MD The Infectious Diseases Practice at the University Hospital of UMDNJ, Newark serves about 1,200 patients infected with HIV. Of these, about 40% are coinfected with HCV, at least 70% of whom have genotype 1. In order to effectively manage this coinfection, the clinic team developed an integrated team model that includes:
All the above personnel are located on-site in the clinic making it more accessible for patients. Patients with HIV-HCV are referred by their primary physician to the hepatologist to determine eligibility for treatment. The mental health counselor and the nutritionist then evaluate all eligible candidates. This is critical to the success of treatment because depression, at times with suicidal ideation, has been reported in patients undergoing treatment for HCV. Based on the mental health counselor’s evaluation, patients with elevated risk for depression are referred to a psychiatrist for assessment and treatment, which may include anti-depressant medication and/ or ongoing therapy. The final decision to initiate HCV treatment is made by the team. The nurse clinician works closely with the patient, the HIV physician and the hepatologist and helps to coordinate their care. The nurse is not only responsible for education about the disease, medications, and injection techniques but also functions as an adherence counselor throughout the course of treatment. The team follows patients very closely to ensure that toxicities of treatment, if any, are identified and managed early on. 1) A 39 year old male with HIV, with HCV Genotype 1 has CD4 426, VL <50 on Combivir® and lopinavir and ritonavir. He was started on therapy with pegylated interferon weekly and 1200 mg of ribavirin daily. His baseline labs revealed a hemoglobin of 11.0g/dl, AST-63 U/dl and ALT-72. He came in to the clinic 6 weeks later with severe fatigue and inability to function. He was found to be severely anemic with a Hb 6.0 g/dl. What would you do next? a) Transfuse with packed red cells and discontinue HCV therapy. Answer: a. This patient already had some baseline anemia to begin with, which may have been as a result of chronic HIV infection or as a result of being on zidovudine. The addition of ribavirin to the regimen probably caused hemolysis thereby worsening his anemia. As an outpatient his HAART regimen was initially changed to Epzicom TM (abacavir sulfate and lamivudine) and Kaletra® (lopinavir/ritonavir), and his hemoglobin remained at 11.5 g/dl with all other work up for anemia being negative. The patient was however very motivated, and wanted to restart his HCV treatment; hence he was started on weekly pegylated interferon with a slightly lower dose of ribavirin of 1000 mg. He was closely monitored with weekly CBC and was also started concurrently on erythropoietin weekly injections. He continues to do well and is at 12 weeks now. By giving erythropoietin we were able to maintain his HCV treatment with ribavirin on board thus improving his chance for effective HCV viral load suppression. 2) A 47-year-old Black male with HIV/HCV, CD4 202, and VL 150,000 came in asking why he was not being treated for HCV. He only occasionally has a drink, and has a history of depression which seems to be currently controlled. His baseline labs show HCV PCR- > 7,700,000 IU/mL and HCV genotype 1b. He is taking Epzicom, Viread® (tenofovir disoproxil fumarate), Reyetaz® (atazanavir sulfate) and Norvir® (ritonavir). You will: a) Discuss the need to get his HIV under control first. Answer: d. This patient had several relative contraindications to treatment. His HIV was poorly controlled with a relatively low CD4 count and he continues to drink alcohol. All of these may indicate a relatively non compliant patient who would run a higher risk of complications with HCV therapy. In addition, he would benefit from close psychiatric follow up to ensure that his depression stays well controlled. 3) A 36 year old white man with HIV and HCV has an HIV VL<50, CD4 of 424. His HCV VL is >1 million copies/ml with genotype 1b. His current medications include Videx® (didanosine, or ddI), Epivir® (lamivudine or 3TC), and Kaletra, and his liver biopsy reveals some areas of fibrosis. What will you do next? a) Start him on interferon and ribavirin. Answer: b. There are many drug interactions between HIV medications and HCV treatment. Videx is contraindicated in patients undergoing HCV treatment due to the risk of severe hepatotoxicity. Hence these patients must always be managed by a team of professionals who understand the intricacies of this patient population. The patient’s regimen was changed to Truvada and Kaletra, and the patient did well. 4) 51 year old Black male with HIV, CD4 556, VL 431 on Combivir, Viread, Reyataz and Norvir, has an HCV PCR > 3,000,000, and HCV Genotype 1. Labs reveal a serum albumin- 2.3, bilirubin- 3.0, ascites-+, encephalopathy +, INR- 1.3, platelet count of 35,000/ml. What do you do next? a) Tell the patient that he needs to be started urgently on HCV treatment because of his advanced liver disease. Answer: b. This type of presentation is becoming increasingly prevalent in the HIV clinic. This patient clinically has evidence of advanced liver cirrhosis with evidence of liver failure. He would have a very high rate of complication with treatment using standard pegylated interferon and ribavirin. The clinician should inform him of the risks, and if he chooses to receive treatment, he should be referred to a tertiary center for evaluation by a specialist.
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