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Updated New York State Guidelines on HCV-HIV Coinfection: annual screening recommended for HIV+ At-Risk Individuals
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"Consider obtaining a liver biopsy every 3 to 5 years to assess for disease progression"
LINK:
UPDATE: Hepatitis C Virus in HIV-Infected Patients
http://www.hivguidelines.org/clinical-guidelines/adults/hepatitis-c-virus/
"Clinicians should screen all HIV-infected patients for anti-HCV antibodies at baseline....The high rate of HIV/HCV co-infection and the similar routes of transmission of both viruses underscore the importance of screening all HIV-infected patients for anti-HCV antibodies at baseline. HIV-infected patients with continued high-risk behaviors who are seronegative for HCV at baseline should receive annual testing thereafter."
"The acute phase is defined as the first 6 months of HCV infection (from Jules - for all those with new HIV diagnosis should include HCV screening)....During this time, serum alanine aminotransferase (ALT) levels frequently rise, fluctuate, and fall again, which indicates recovery from the acute phase......Treatment of acute HCV infection in HIV-infected adults is supported by a 60% to 70% sustained virologic response rate"
"Patients with acute HCV who remain positive for HCV RNA 12 weeks after infection should be treated with combination pegylated interferon and ribavirin."
"Clinicians should obtain an alcohol and substance use history for HIV/HCV co-infected patients. Patients with alcohol abuse or dependence should be referred for alcohol-dependency treatment"
"The rate of depression in untreated HCV-infected patients may be as high as 25%,35 demonstrating that HCV itself may also be a risk factor for depression. HCV commonly presents with symptoms of fatigue and malaise, which may mimic depression and complicate its diagnosis"
Clinicians should perform the following:
* Mental health screening in all HIV/HCV co-infected patients at baseline and at least annually according to standard guidelines for all HIV-infected patients (see the Mental Health Guidelines)
* Depression screening at initiation of anti-HCV treatment and at least every 4 weeks thereafter during treatment (see Section XII. Treatment Monitoring of HIV/HCV Co-infected Patients)
For patients in whom anti-HCV treatment is deferred, clinicians should:
* Obtain serial ALT and AST levels every 6 months
* Consider obtaining a liver biopsy every 3 to 5 years to assess for disease progression (BIII)
* Perform ongoing patient education, including education regarding the hepatotoxic effects of alcohol and other substances (see Section V. G. Assessment for Alcohol and Substance Use) and prevention of HCV transmission (see Section XV. Prevention of HCV Transmission and Re-infection)
"evidence suggests that biannual AFP coupled with annual ultrasonography may be cost-effective in HCV-infected patients with cirrhosis.34 If AFP is elevated, then a screening examination is no longer appropriate, and a diagnostic test is indicated. Both triple-phase CT scans and liver MRI offer greater sensitivity in finding and distinguishing among liver abnormalities."
"Key Point: Up to 30% of patients with either HCV mono-infection or HIV/HCV co-infection may have persistently normal liver chemistries but still have significant liver disease"
"SEXUAL TRANSMISSION: The efficiency of sexual transmission of HCV is much lower than HIV or other sexually transmitted viruses. However, isolated outbreaks of permucosal HCV transmission have been reported among HIV-infected men who have sex with men (MSM).18-23 In the setting of the following risk factors, HCV transmission was increased among HIV-infected MSM compared with non-HIV-infected MSM: sharing drugs via anal or intranasal routes; unprotected anal intercourse and anal/oral ("rimming") or anal/hand contact ("fisting"); and the presence of other sexually transmitted infections (STIs)."
Significant revisions include the following:
Assessment for anti-HCV therapy is now recommended for HIV-infected patients with acute HCV infection (see Section VI. B. Assessment for Treatment of Acute HCV Infection)
* An annual HCV antibody test is now recommended for HIV-infected patients who have continued high-risk behaviors but are seronegative for HCV; such individuals include:
· Injection drug users
· Men who have sex with men without barrier protection
· Anyone with multiple sexual partners
* Quantitative HCV RNA viral load testing is now recommended for HIV-infected patients:
· To confirm a reactive HCV ELISA antibody screen
· To exclude HCV infection in those who are seronegative for HCV but have risk factors for HCV exposure and unexplained liver disease, including increased serum liver enzymes
* A table has been added that lists the tests for measuring HCV RNA (see Table 1)
* Sections on assessment of mental health disorders and alcohol and substance use have been added (see Sections V. F. Assessment of Mental Health Disorders and G. Assessment of Alcohol and Substance Use)
* A new section has been added on ongoing evaluation of patients when anti-HCV therapy is deferred (see Section VII)
* A new section has been added that outlines baseline assessments and counseling at initiation of therapy (see Section VIII)
* Consultation with a psychiatrist is now recommended when prescribing anti-HCV therapy for HIV-infected patients with mental health disorders
* Figure 2. Initial Anti-HCV Therapy for HIV/HCV Co-infected Patients has been updated and now recommends determining whether or not to continue anti-HCV treatment after week 12 by assessing for virologic response according to quantitative HCV RNA
* A table has been added that outlines strategies for managing side effects of anti-HCV therapy (see Table 7)
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