HCV

HIV

Kees Brinkmanafd Interne Geneeskunde

Virale Hepatitis ( = geelzucht)

leverontsteking veroorzaakt door virus

“5” soorten:– hepatitis A via “ poep”– hepatitis B via bloed / naalden / M-K / sex– hepatitis C via bloed / naalden / (M-K)

niet per se via sex!

– hepatitis D alleen samen met HBV– hepatitis E via “poep” (Azië)

Virale Hepatitis

genezing? – hepatitis A spontaan 99,9 %– hepatitis B spontaan 95%

5% chronisch

– hepatitis C spontaan 20-30% 70 - 80% chronisch

– hepatitis E spontaan 99,9 %chronische hepatitis B/C: besmettelijk voor anderen

Chronische Hepatitis

→ cirrose

• duur: 15 – 60 jaar • alcohol !!• therapie: levertransplantatie• extra risico: leverkanker

HCV & HIV

• bekende associatie– chronische HIV & chronische HCV– risicogroepen:

• (ex) IVDU• bloedtransfusies• hemofilie e.d.

NB geen duidelijke sexuele overdracht bekend

Prevalence of HCV and HBV Co-infection in persons living with HIV

EuroSIDA cohort

• Among 9803 subjects in the EuroSIDA Cohort:

– of 5883 HBsAgtest available attime of enrollment

• 530 (9%) positive

– of 5957 HCVAb test available

• 1960 (33%) positive

HBV:9.7%HBV:9.7%

HBV 9.2%HBV 9.2%

HBV+ 9.1%HBV+ 9.1%

HBV 6%HBV 6%

ArgentinaArgentina

HBV+: 7.8%HBV+: 7.8%

Konopnicki D et al.; AIDS. 2005.

Rockstroh J et al.; JID 2005South: HCV+ 44,9 %

North: HCV+ 24,5 %

Central: HCV+22,9 %East: HCV+ 47,7 %

SHM 2005: • 9088 patienten• 839 HCV positief (10,6%)

– IVDU: 94,4% – heterosex: 5,1 %– MSM: 3,0%

HCV bij HIVin Nederland

Natural history of HCV infection in HIV+:

HCV infection

Resolved 10%Chronic Infection 90%

Normal ALT55%

Mild disease

Elevated ALT45%

Cirrhosis

25%

Liver failure

HIV

HIV

HIV

Liver Related MortalityHIV

HCC

Incidence of HCV-related cirrhosis in HIV-infected patients

Ten-Year Incidence of Cirrhosis

2.6

14.9

0

5

10

15

20

HCV HIV/HCV

Fre

qu

ency

(%

)

P<0.01

Mean Time to Cirrhosis

23.2

6.9

0

5

10

15

20

25

HCV HIV/HCV

Tim

e (y

ears

)

P<0.001

Soto et al. J Hepatol 1997;26:1-5

The effect of HIV coinfection on the risk of cirrhosis and HCC in US veterans with HCV

26,641 patients with HCV only and 4761 with HCV/HIV coinfection

An increased risk of cirrhosis and HCC in patients with coinfection was only found during the pre-HAART-era (before 10/1996) (hazard ratio 1.48, 1.06-2.07, p=0.02) but not among patients who entered the cohort during the HAART era

Kramer JR et al., Am J Gastroenterol 2005

11

Impact of ART on Overall Liver MortalityImpact of ART on Overall Liver Mortalityin HIV/HCV-Coinfected Patientsin HIV/HCV-Coinfected Patients

• Bonn cohort (1990-2002)Bonn cohort (1990-2002)

- 285 HIV/HCV coinfected 285 HIV/HCV coinfected patientspatients

• Liver-related mortality rates Liver-related mortality rates per 100 person-yearsper 100 person-years

- HAART: 0.45HAART: 0.45

- ART: 0.69ART: 0.69

- No therapy: 1.70No therapy: 1.70

• Predictors for liver-related Predictors for liver-related mortalitymortality

- No HAARTNo HAART

- Low CD4 cell countLow CD4 cell count

- Increasing ageIncreasing ageQurishi N, et al. Lancet. 2003:362:1708-1713.

0,2

0,4

0,6

0,8

1

DaysDays

Overall MortalityOverall Mortality

Cu

mu

lati

ve S

urv

ival

Cu

mu

lati

ve S

urv

ival

0 1000 2000 3000 4000 5000 60000 1000 2000 3000 4000 5000 6000

ARTART

HAART*HAART*

0,2

0,4

0,6

0,8

1

DaysDays

Liver-Related MortalityLiver-Related Mortality

Cu

mu

lati

ve S

urv

ival

Cu

mu

lati

ve S

urv

ival

0 1000 2000 3000 4000 5000 60000 1000 2000 3000 4000 5000 6000

HAART*HAART*

No therapyNo therapy

ARTART

No therapyNo therapy

**PP=0.018=0.018

**PP<0.001<0.001

acute HCV bij HIV

hoe ontdekt:- bij alle HIV patiënten: controle leverwaarden- bij stijging: onderzoek naar hepatitis

NB: weinig kennis over acute HCV !