Index - 68 - 69/70/71 - 72/73 - 74/75 - 76/77 - 78 - 79 - 80
GENERAL RECOMMENDATIONS FOR COUNSELLING IN PATIENTS WITH HIV AND HEPATITIS CO-INFECTION
SCREENING
  1. All HIV-infected patients should be screened for hepatitis C at diagnosis and then on an annual basis. Screening for HCV in HIV infected patients should be done using anti-HCV antibody test. A positive result should be followed by evaluation for the presence of HCV-RNA and the genotype should be determined. Patients with risk factors (ongoing IVDU, mucosal traumatic sex; ongoing unprotected anal intercourse, recent sexually transmitted infection) with unexplained increase in hepatic transaminases and a negative HCV antibody test should be offered an HCV-RNA test for early detection of a recent infection.
  2. HIV-infected patients should be screened for hepatitis A and B. Patients from high prevalence countries for HBV, in particular those with elevated liver transaminases should be screened for HBV-DNA in addition to HBs Ag to rule out occult HBV infection.
  3. Hepatitis delta antibodies should be screened for in all HBsAg+ patients.
  4. Patients with liver cirrhosis should be screened at 6-monthly intervals with serum alpha-fetoprotein and hepatic ultrasound for the occurrence of hepatocellular carcinoma. Routine screening is also advised for oesophageal varices at the time of diagnosis and at 1 – 2 year intervals thereafter.
VACCINATION
  5. Patients lacking anti-HAV IgG antibodies or anti-HBs antibodies should be offered vaccination for the respective virus to prevent infection regardless of their CD4-count. The response to the HBV vaccine is influenced by the CD4-count and level of HIV-RNA. In patients with low CD4-counts (<200/μl) and ongoing HIV replication, HAART should be initiated first prior to respective vaccination. Patients anti-HBc positive and anti-HBs negative should be tested for anti-HBs response 2 – 4 weeks after a first HBV vaccination and may skip remaining vaccinations in case of sufficient anti-HBs response (anti-HBs > 10 IU/l).
In case of insufficient response (anti-HBs < 10 IU/l) revaccination should be considered. Double dose revaccination (40μg) at 3-4 vaccination time points (months 0, 1, 6 and 12) may help to improve response rates to HBV vaccination. Patients who fail to seroconvert after hepatitis B vaccination and remain at risk for HBV-infection should have annual serological tests for evidence of HBV infection.
HAART:
  6. Hepatitis B and/or C co-infected patients benefit from early HAART because liver fibrosis progression is reduced with immune reconstitution and suppression of HIV-RNA. Stopping HAART has been associated with enhanced risk for AIDS and non-AIDS related events in the SMART study and this risk was enhanced for patients with hepatitis co-infection. Particular prudence is warranted in HIV/HBV co-infected patients who stop anti-HBV containing HAART.
END STAGE LIVER DISEASE (ESLD):
  7. HIV-positive patients require the same measures for the treatment of oesophageal varices, hepatorenal syndrome, hepatic encephalopathy or ascites as HIV-negative patients.
  8. HIV-coinfected patients who suffer from ESLD warrant particular attention in the management of liver insufficiency. Apart from considerations of treatment of HBV or HCV, antiretrovirals metabolized via the liver may need to be dose adjusted and in individual cases therapeutic drug monitoring of the respective drug is advisable.
  9. Creatinine clearance using Cockcroft Gault estimation in the setting of advanced or decompensated liver cirrhosis overestimates the true glomerular filtration rate and use of the arithmetic mean urea and creatinine clearance or inulin clearance is recommended.
  10. Patients with a MELD-score > 15, CD4-cell count > 100/µl and options for efficacious and durable HAART should be evaluated for liver transplantation (OLTX). OLTX outcomes in HIV/HBV coinfected patients are particularly promising, whereas post-transplant survival in HIV/HCV co-infected patients has been somewhat lower than in HCV-monoinfected patients mainly due to the complicated course of HCV re-infection after transplantation.
PREVENTION/SUPPORT
  11. Psychiatric, psychological, social and medical support should be made available to patients with a high alcohol intake to stop drinking or to limit alcohol consumption.
  12. Substitution therapy (opioid replacement therapy) in patients with active drug abuse as a step towards cessation of active drug use should be considered; help provided (e.g. through needle- and syringe-exchange programs) reduces the risk of re-infection including parenteral viral transmission (harm reduction strategy).
  13. Since HBV and HIV and occasionally HCV are transmitted sexually, adequate counselling including the use of condoms is advisable. Information on the risk of HCV transmission due to mucosal traumatic sexual practices associated with a high likelihood of blood contact should be provided and risk reduction should be discussed.