HIV/HCV co-infection in Taiwan

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HIV/HCV co-infection in Taiwan

• Nai-Ying Ko RN. PhD., Hsin-Chun Lee MD,
  Shainn-Wei Wang PhD., Wen-Chien Ko MD,
• National Cheng Kung University Hospital
• Taiwan

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Topics

• Molecular epidemiology of HIV/HCV coinfection in
  Taiwan
• Treatment and care for patient with HIV/HCV
  coinfection in Taiwan
• Challenges of management of HIV/HCV coinfection
  in Taiwan

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Annual Numbers of Newly Reported HIV Cases by
Mode of Transmission, 1984-2007 Cumulative number
of reported HIV cases 15,866 (June 30, 2008)
Harm reduction
Free HAART
2462
1813
629
713
Year
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HIV/AIDS Reported Case Number and Fatality Rates
in Taiwan, 1984 2006
AIDS-related deaths / AIDS case number
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Anti-HCV prevalence in Taiwan
Population 157,720 adults Period
1996-2005 Anti-HCV seropositivity 4.4 HCV
genotype distribution 1b 5881.1 2a 7.412
2b 3.44.9 Chen CH at al., J Formos Med
Assoc. 2007106(2)148-55 Yu ML et al, J. Med.
Virol. 20016558-65
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Extremely high prevalence of HCV infection among
HIV-infected IDUs in Taiwan
Liu JY, et al. , Clinical Infectious Diseases
2008 4617618
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The proposed route of HIV/HCV transmission from
China and Southeast Asia to Taiwan
Liu JY, et al. , Clinical Infectious Diseases
2008 4617618
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Co-Infections among HIV-Infected Adults
J Formos Med Assoc 2008107(5)404411
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Serological characteristics and types of HBV and
HCV of 146 HIV-1-infected adults categorized by
HIV risky groups in NCKUH
, n/N , n/N , n/N , n/N
Total MSM Hetero IDU p value
HBs Ag () 16.8, 23/137 20.0, 13/65 20.0, 7/35 8.1, 3/37 0.255
HBs Ab () 59.6, 84/141 57.6, 38/66 53.8, 21/39 69.4, 25/36 0.35
HBc Ab () 79.7, 102/128 79.4, 50/63 75.7, 28/37 85.7, 24/28 0.606
Isolated HBc Ab () 14.1, 19/135 15.6, 10/64 10.5, 4/38 15.2, 5/33 0.747
HCV Ab () 32.6, 46/141 7.2, 5/69 11.4, 4/35 100, 37/37 lt 0.001
HBs Ag () HCV Ab () 3.5, 5/142 1.4, 1/69 2.8, 1/36 8.1, 3/37 0.238
HBc Ab () HCV Ab () 24.8, 33/133 7.2, 5/69 11.1, 4/36 85.7, 24/28 lt0.001
No. of cases with positive HCV-RNA/No. of cases being tested 37/141 5/64 3/39 29/38
Types of HCV
1a 12 0 0 12
1b 6 1 2 3
2a 4 1 1 2
2b 2 0 0 2
3a 7 0 0 7
6a 4 1 0 3
6g 1 1 0 0
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HCV infection is significantly associated with
HIV infection among gay bathhouse attendees in
Taiwan, 2004-2007

Odds ratio 7.1 95 CI 2.3-22.1
NY Ko, at al. (2008) unpublished data
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Topics

• Molecular epidemiology of HIV/HCV coinfection in
  Taiwan
• Treatment and care for paitents with HIV/HCV
  conifection in Taiwan
• Challenges of management of HIV/HCV coinfection
  in Taiwan

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HBV/HCV Treatment in Taiwan

• 1980s Department of Health
• Hepatitis Prevention Act
• 2003 Bureau of National Health Insurance
• program for strengthening treatment for chronic
  hepatitis B and C
• 2007 National Health Research Institute
• National Forum on screening, treatment and
  long-term follow-up of patients with hepatitis B
  virus- or hepatitis C virus-related liver
  diseases

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Treatment of Chronic Hepatitis C (National
Health Insurance, Taiwan)

• Criteria
• Anti-HCV () ,
• ALT ? 2X, 3 M apart, within 6 M
• Fibrosis ? F2
• ( F1, since August, 2004 )
• PEG-IFN or IFN RBV for 24 weeks

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Screening for HIV/HCV coinfection in Taiwan

• Test of anti-HCV for all patients with HIV
• Test of HCV RNA for patients with HIV
• Anti-HCV() and progression to chronic hepatitis
• Anti-HCV(-), rapid progression with abnormal
  liver function tests, and patients with low CD4
  cell counts (lt 200 cells/mm3)
• Anti-HCV(-), suspect acute HCV infection

(NHRI National Hepatitis BC Forum, 2008)
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Preparation for HIV/HCV coinfection treatment in
Taiwan

• Before treatment
• Liver function tests (AST, ALT), HCV RNA, HCV
  genotype, liver biopsy
• HIV RNA, CD4 cell counts
• Optimized HAART treatment
• When considering treatment
• CD4 gt350 cells/mm3, treat HCV first
• If CD4 201-350 cells/mm3, treat HIV first then
  HCV
• CD4 lt 200 cells/mm3, treat HIV

(NHRI National Hepatitis BC Forum, 2008)
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Treatment for HIV/HCV coinfection in Taiwan

• Standard of care in coinfected patients is
  pegylated interferon plus ribavirin
• Optimal dosing of pegylated interferon and
  ribavirin
• HCV genotype 1, ribavirin (1000 mg/day if lt 75 kg
  and 1200 mg/day if gt 75 kg)
• HCV genotype 2 3, ribavirin (800 mg/day)
• F/U HCV RNA at 12, 24, 48 wks, and 6 months
• F/U HIV RNA every 3-4 months

(NHRI National Hepatitis BC Forum, 2008)
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Topics

• Molecular epidemiology of HIV/HCV coinfection in
  Taiwan
• Treatment and care for patient with HIV/HCV
  coinfection in Taiwan
• Challenges of management of HIV/HCV coinfection
  in Taiwan

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Needle-Syringe Programming

• Pilot stage (Nov. 2005 )
• (76 NSP stations)
• Expanding stage (Jul. 2006 )
• (427 NSP stations)
• Present stage (Jan. 2008)
• (1103 NSP stations)

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Drug Substitution Treatment
Pilot stage (Feb. 2006 ) (6 hospitals) Expanding
stage (Aug. 2006 ) (33 hospitals
clinics) Present stage (Jan. 2008 ) (68
hospitals clinics)
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Health seeking behaviors among patients with HIV
categorized by route of transmission
CH Yang (2006) HIV-related Medical Expenditure
Analysis in Taiwan
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Challenges of management of HIV/HCV coinfection
in Taiwan

• Harm reduction policy was implemented since 2006
• HCV treatments founded by NHI were performed by
  hepatologists, oncologists, and hematologists
• Current standards include presence of progression
  based on liver biopsy
• Some hepatologists still withhold treatment from
  patietns with HIV or IDUs
• Cost of test for HCV RNA and genotype

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Conclusions

• HCV infection is highly prevalent in HIV-infected
  IDUs and exhibit great genetic diversity.
• HIV-1 CRF07_BC, HCV genotype-1a, 3 and 6 have
  been transmitted from China into Taiwan through
  drug trafficking route.
• Pegylated interferon plus ribavirin is available.
  
• Some hepatologists still withhold treatment from
  patients with HIV or IDUs.
• Poor access to care and fewer clinical visits
  among HIV infected IDUs.

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Acknowledgements

• Taiwan CDC Dr. CH Yang
• EDH Dr. HH Lin
• NTUH Dr. CC Hung, Dr. WH Sheng
• KMUH Dr. ML Yu
• NHRI Dr. IJ Su, Dr. FC Tseng

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Thanks your attention