Judging by the heavy turnout at the June Community Forum on hepatitis and HIV, people are concerned about liver health. At the Forum, Dr. Borcich and Mr. Marco updated the audience on both hepatitis disease management and liver toxicity associated with antiretroviral medications for HIV infection. They offered practical advice and reassurance that it is possible to maintain good health in the face of hepatitis/HIV coinfection.
Hepatitis B is an infection caused by a virus that can cause inflammation of the liver and may lead to permanent liver damage. People who are infected with hepatitis B virus (HBV) may have no symptoms at all or may exhibit symptoms such as nausea, fever, vomiting, jaundice, dark urine and pale stools. The symptoms typically resolve in a few weeks. Most people (90%) who are infected with HBV have an acute case with the symptoms above, then recover and are protected against the disease in the future. The remaining 10% become chronically infected with HBV, which may lead to cirrhosis (liver scarring), liver cancer or liver failure later in life.
The mode of transmission for hepatitis B is the same for HIV: it is passed through infected blood, semen, vaginal fluids or breast milk. Infection can be prevented with the hepatitis B vaccine, administered in three shots over a six-month period. In addition, a treatment called hepatitis B immune globulin can be administered within a few weeks of an HBV exposure to help prevent infection.
Dr. Anthony Borcich, a New York City hepatologist, began his presentation with a discussion of treatment for hepatitis B. HBV infection is currently treated with interferon or lamivudine (Epivir, 3TC). Other antiviral medications for HBV are in development. HBV treatment research has been going on for over 50 years, and the first significant advance came 10 years ago with the use of interferon. Interferon is a protein that is released into the blood during a viral infection. Interferon causes non-infected cells to produce disease-fighting enzymes. When used as a treatment for HBV, it is given as a daily injection for a 16-week treatment course. The side effects of interferon include flu-like symptoms such as fever, fatigue, headache, weakness and nausea/vomiting. Dr. Borcich explained that the side effects can be so severe that they may cause treatment discontinuation. A new formulation of interferon called pegylated interferon recently became available. Pegylated interferon lasts longer in the blood stream then standard interferon, so a shot can be given once a week instead of daily. The side effects of pegylated interferon are similar to those of standard interferon, however.
Dr. Borcich described some of the limitations of interferon treatment: it may not be effective in lowering the hepatitis B viral load and there may be relapses after treatment is completed. He stated that the goal of treating HBV is not eradication of the virus but to prevent manifestations of the viral illness; that is, to prevent severe liver disease in the short- and long-term. So who should be treated for HBV? Only patients who have had HBV for at least 6 months (chronic carriers) who have elevated AST and ALT values (two liver function tests) should be treated. Patients with high AST and ALT values and a low hepatitis B viral load will respond best to treatment.
Lamivudine for HBV works in the same way that it works against HIV: by preventing the virus from making copies of itself that can infect new cells. Dr. Borcich explained that one possible limitation of lamivudine therapy is that resistance develops easily, whether lamivudine is being used alone or in a combination regimen.
In cases of severe liver damage from HBV disease, transplantation may be considered. Transplantation may not be an option for all HIV-infected individuals, however, because preparation for transplantation requires the use of immunosuppressive drugs to keep the immune system from rejecting the transplanted organ. Some people with HIV may not be able to take drugs that will further weaken the immune system. In addition, HBV may recur after a transplant, so a transplant may not be beneficial. It is believed that treatment with lamivudine and/or hepatitis B immune globulin can reduce the chance of HBV recurrence.
Dr. Borcich encouraged audience members to ask their doctors whether or not they have antibodies to HBV. A simple blood test is all that's required to get the answer. If you do not have the antibodies, which would make you immune to HBV, it is strongly recommended that you get vaccinated. Finally, Dr. Borcich informed the audience that coinfection with HIV and HBV does not appear to cause either disease to progress more rapidly.
Dr. Borcich briefly reviewed liver toxicity in HIV therapy. Liver toxicity has been associated with antiretroviral medications as well as cholesterol-lowering agents and several antibiotics (Biaxin, Bactrim) that people with HIV often use. Liver toxicity stems from mitochondrial damage, which is damage to the part of cells involved in energy production. Symptoms of liver toxicity are similar to symptoms of HBV disease: dark urine, fatigue and jaundice. It may be necessary to modify or discontinue certain therapies due to liver toxicity.
Michael Marco spoke next on hepatitis C and HIV coinfection, explaining the epidemiology and natural history of hepatitis C (HCV) disease and different options for treatment.
About 2% of the American population (four million people) are infected with HCV, and the rates of HCV/HIV coinfection are high, especially in urban centers with large populations of IV drug users. HCV is transmitted through blood-to-blood contact (shared syringes, blood transfusions or blood products before 1992, needlesticks, and possibly, though rarely, sexual activity. Infection with HCV can lead to cirrhosis (liver scarring), end-stage liver disease or liver cancer.
Mr. Marco explained the natural history of HCV infection, using a sample of one hundred infected people.
|If 100 people are infected with HCV,
Of the 85 chronically infected,
There are several factors that put individuals at higher risk for liver disease resulting from HCV infection. The major risk factors are:
Mr. Marco then reviewed several studies of HIV/HCV coinfection. As described in the natural history of HCV infection above, the time for progression to cirrhosis in chronic HCV carriers can be anywhere from 15-60 years. That's quite a range! Here's how it pans out: In a 1999 study, HIV-infected subjects with less than 200 CD4 cells who had more than 5 alcoholic drinks per day progressed to cirrhosis in 15 years (average). For HIV-infected subjects with more than 200 CD4 cells and less than 5 alcoholic beverages consumed per day, the estimated time to disease progression is approximately 36 years, which is roughly the same as those who are not HIV-infected and with minimal alcohol intake.
So who needs to be treated for HCV infection, and what do doctors use to treat their patients? People with HCV should be followed closely. If liver function tests become abnormal, a liver biopsy (removal of a tiny sample of liver tissue) may be needed. The biopsy can show the degree of liver inflammation and whether or not there is liver fibrosis (the formation of fibrous tissue as a result of liver damage) or cirrhosis. The current treatment for HCV is interferon, usually in combination with another drug called ribavirin, for six months to a year. Six months after the end of treatment, if there is an undetectable hepatitis C viral load, it is approximately 97% certain that the hepatitis C virus has been eradicated. The side effects of interferon often make it difficult to complete treatment, however.
Currently, it is recommended to treat HIV infection before tackling HCV infection. Boosting the immune system with HIV medications helps the body fight HCV more effectively. Also, HCV treatment is not recommended until there is at least minimal fibrosis, and there are many HIV/HCV coinfected patients whose HCV infection will never progress.
This forum cleared up many misconceptions about hepatitis infection. The condition is not usually fatal, and with close monitoring and treatment if necessary, people with hepatitis and HIV can expect relatively good health. Both presenters stressed preventive measures, such as lowering alcohol consumption and taking HIV meds to support the immune system, that can help keep hepatitis in check. Work with your doctor to keep your liver healthy!