Update on Hepatitis C SSHA Conference 2015 - PowerPoint Presentation

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Update on Hepatitis CSSHA Conference 2015

Daniel Bradshaw

Locum Consultant

GUM/HIV

Brighton and Sussex University Hospitals NHS Trust

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OverviewEpidemiologyNatural history of HCVAcute HCV in HIV-positive MSMDiagnostic tests for HCVTreatments – old and newTreatment as prevention

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Global anti-HCV prevalence

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Easterbrook et al IAS 2015

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Natural history of HCV20 % spontaneous clearance80 % chronic infection

20% develop cirrhosis after 20

yr

1-4% per year risk of hepatocellular cancer

HCV acquisition

Freeman et al

Hepatol

. 2001

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Transmission of HCV infection

Route of Exposure

HCV

HIV

HCV transmission compared to HIV

Parenteral

(

needlestick

)

1.5-3%

0.3%

> x10

Permucosal

(sexual)

0.1-0.3%

1-5%

< x10

Vertical

2-5%

20-30%

< x6-10

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Study

Type of study

Study population

N

Duration

follow-up

Incidence /1000 person years (cases)

Kao 2000

Prospective

Taiwanese

112

46 m

0.23 (1)

Vandelli

2004

Prospective

Italian

776

120 m

0.37 (3)

Tahan

2005

Prospective

Turkish

216

36 m

None

Terrault

2013

Cross-sectional

American

500180 m0.72 (3)

HCV transmission: HIV-negative, HCV-discordant heterosexual couples



1 transmission per 190,000 episodes of sex

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Risk group

Anti-HCV

Associated factors

FSWs

6%

Number of partners, other STIs, sex with trauma, non-use of condoms

STI clinic

4%

Risk for IDU > sexual factors.

In non IDU : number of partners, high-risk sexual contacts, HIV+

MSM

4%

Risk for IDU > sexual factors.

In non IDU : HIV+, number of partners, sexual practices

HCV

seroprevalence

in high–risk STI groups suggests sexual risk is present

Terrault

Hepatology

2002

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Characteristics of the study population, by hepatitis C virus (HCV)

serostatus

in EUROSIDA cohort

Rockstroh

et al

2005

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Acute HCV in HIV-positive MSM

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Acute HCV in the Swiss HIV Cohort Study

Wandeler

et al

CID

2012

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Sun 2012

Wandeler

2012

Vogel 2005

Gotz

2005

Browne 2004

Gambotti

2005

Matthews 2007

Luetkemeyer

2006

Nishijima

2013

Sanchez 2013

Orsetti

2013

EHSSS 2009

Countries reporting acute HCV in HIV+ MSM

Chan 2015

Apers

2015

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Behavioural1. Serosorting12. Mucosal trauma2,3,43. Mucosally

-administered recreational drugs

2,3,4

Biological

1.

HIV

5,6

2

. STIs

2,3,4,7

Potential factors for increasing

permucosal

transmission in HIV+ MSM

Lattimore et al 2011

Danta

et al 2007

Schmidt et al 2011

MMWR

Morb

Mortal

Wkly

2011

Briat

et al 2005

Sherman et al 2005

Van de

Laar

et al 2007

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Detection of HCV in semenBradshaw et al JID 2015

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Serosorting behaviour amongst MSM

Lattimore

et al

STD 2011

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Changing patterns of drug use in MSM 20052012Crystal meth

0%

40%

GBL/GHB

3.2%

27%

Mephedrone

0%

18%

Ref via GUM/A&E/statutory drugs services

8%

63%

David Stuart 2013

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Mechanism of sexual transmission of HCV in HIV-infected MSM

Group Sex

Sexual

practices

Drug

practices

High-risk practices

Internet

Shared implements

‘Club drugs’

STI

Permucosal

NOT

parenteral

transmission

Sexual transmission

of HCV

HIV

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Martin AIDS 2013Martin

et al

AIDS

2013

HCV reinfection in HIV-infected MSM

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2

Vanhommerig

et al, JAIDS,

2014

Incidence of HCV in HIV-positive MSM in Amsterdam

HCV IR by age in 2008

HCV IR among 761 HIV+MSM (observed and fitted)

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Acute HCV in HIV-negative MSMMcFaul et al

J Viral Hep 2015

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Diagnostic tests for HCV infectionAnti-HCV antibody HCV antigenHCV RNA

Fibroscan

assessment of liver fibrosis

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When to test for HCV in HIV-positive MSM? 1) After very high risk (high risk sex with HCV+ partner) OR if liver enzymes abnormal 

HCV Ab and PCR



Repeat PCR at 4 weeks.

2) After high risk (but normal liver enzymes)



HCV Ab



Repeat Ab at 12 weeks.

3) Repeat testing (Ab and PCR) at 3-6 monthly intervals if ongoing high risk

4) Annual HCV Ab testing if not high risk

BHIVA Guidelines on Viral Hepatitis 2013

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HCV treatments

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TransmissionStigma

More

rapid progression

of

liver disease

Increase in

HIV

related comorbidities

Increase in HAART toxicity

Reasons for treatment of HCV in HIV-infected individuals

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Multiple organ dysfunction in HCV/HIV coinfection

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“An 'elephant in the room'?”Stigma and hepatitis C transmission among HIV-positive 'serosorting' gay men

Owen G

Cult Health Sex

2008

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New anti-HCV therapies

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Figure 1

The Lancet

 2015 385, 1124-1135DOI: (10.1016/S0140-6736(14)62401-6)

Webster

et al

Lancet 2015

HCV SVR rates between 1990 - 2014

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MODELLING PROJECTIONS: EDINBURGH

Martin NK, et al.

Hepatology

2013

Slide32

Salazar-Vizcaya et al CROI 2015

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Two-mode social network diagrams ofHIV+ MSM with acute HCV and venues used for sourcing sexual partners

Bradshaw

et al

AASLD

2013

Sydney

Melbourne

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SummaryEpidemic of acute HCV in HIV+ MSM with mostly sexual acquisitionHigh levels of reinfection in this cohort

New HCV therapies equally effective in both HIV+ and

HIV-

individuals

In the UK, new HCV therapies are currently only available to cirrhotic patients

Reducing the epidemic will require increases in levels of testing, treatment and effective behavioural interventions

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AcknowledgementsProfessor Mark Nelson

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THANK YOU