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I need your Advice/Hepatitis B and HIV
Sep 20, 2000

Dear Doctors:

I really would like you advise.

In 1986 I contacted hepatitis B, and have never converted. I was diagnosed with HIV in May of 1988. At that time my CD4 count was 722. and my sgot and sgt count where in the 100-120 range.

From 1988 to 1994 my cd4 count ranged from 722 - 1108 with elevated liver counts.

About 2 years ago my cd4 count was appx 455 with a V/L of appx 17,339. I had my cd4 count retested a month later and it 735.

In 10/99 my cd4 was 934 and V/L was 76,something. Recently in 7/2000 my V/l is now 134,something, my sgot and sgt levels are still around the 100-125 level which has been the same for several years.Because the lab I have been going to for the last several years drew the incorrect tube for the cd4 count I have not yet gotten the current results.

I really need your advise, as I am unsure what is best given my hepatitis and liver count history, should I consider starting medication solely based on the V/L even though my CD4 count for the past years have been stable between 700 -900.

Also, if you believe I should consider medications now, what would you recommend if view of the hepatitis and years of elevated liver counts.

I sincerely would appreciate you response as I am note sure what I should consider since I have remained in fairly good health except for hypertension for which I am currently taking medication for.

Thank for any insight you can provide.

Response from Dr. Stryker

I am assuming that you mean that you have chronic hepatitis B infection, probably for about 14 years. About 12 years ago, you tested positive for HIV, and have never had treatment for either viral infection.

This is not an uncommon situation, as co-infection with HIV and Hepatitis B is a story we hear often. About 10% of patients who acquire hepatitis B (usually sexually or through needle-sharing) never fully eliminate the virus, and are said to be chronically infected. [The other 90%, by the way, are immune for life and should have no further problems after the initial infection clears. But it is a very serious infection, and can be life-threatening.] A subset of these patients may go on to develop serious complications. Mildly elevated sgot and sgpt (liver tests, also called ast and alt) can be a tip-off that someone may have chronic hepatitis B, but not always. All gay men, and IVDU's, should be tested for hepatitis B, and vaccinated if they are not already immune. Same is true for hepatitis A, by the way. Chronic hepatitis B is a completely preventable serious illness, and not enough of us are getting checked and vaccinated!

In your case, a few pointers are in order. One, you should be checked for hepatitis A and C, and if not immune to A, you should be vaccinated. There is no vaccine for hepatitis C at this point, only prevention.

Two, you should see a liver specialist, who may want to do a liver biopsy to see how advanced your hepatitis is at this point. The procedure is simple, so don't be scared off by the possibility. Also, a simple viral load blood test for hepatitis B will help to decide if treatment is indicated. This person can also talk with you about possible treatment options for chronic hepatitis, which can include interferon, lamivudine, or more experimental agents.

Three, an HIV specialist can talk with you about possible treatment options that can cover both HIV and Hepatitis B at the same time, if needed. Lamivudine, also called 3TC, is active against both, and would probably figure into the treatment plan. As to whether now is the time to start HIV treatment, that is a tough question, one that you need to discuss in detail with a specialist. In general, it sounds as though your CD4+ is pretty stable and relatively high, so you may be able to safely defer treatment for a while more. But your viral load sounds like it is increasing, and this may be an indication for you to act sooner. Most patients with chronic hepatitis can be safely treated with HIV meds, though more careful monitoring of liver tests may be smart. There is no single best combination of drugs for someone in your situation, except that 3TC should almost certainly be a component.

Hope this helps as a start, and good luck. RAS

Rick Stryker, M.D., M.P.H.

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