Dr. Rodwick, HIV AIDS, transgender, hepatitis C, Clearwater, FL, AAHIVM, WPATH, testosterone, Sculptra

Hepatitis C

There are 3 common types of Hepatitis:

Hepatitis A – nearly 100% full recovery.

Hepatitis B – about 60% full recovery, and about 40% become “chronic” where there is continued persistence of infection and liver damage.

Hepatitis C – about 85-90% persist and do not resolve.  This MAY lead to cirrhosis and liver failure or liver cancer.  Generally, this takes about 20 years (in patients without HIV). 

Hepatitis C and HIV – Hepatitis C generally does not affect HIV infection.  However, if someone has both HIV and Hep C, the Hepatitis C usually will be more aggressive and it is expected to lead to liver problems a lot faster.  With current HIV treatments, about 50% of patients with both infections who die, die from complications from the Hepatitis C and not from HIV problems.

Hepatitis C evaluation –
Additional tests include:  Genotype (“strain”) – classified as 1, 2, 3, 4 often with a letter (1a, 3b etc,), and viral load (like in HIV), but Hepatitis C viral loads are generally much higher (thousands to millions).  Right now, the difference is only divided by:  “undetectable” – likely resolved, under 2,000,000 (better), over 2,000,000 (worse).  Liver function tests are routinely followed in everyone, but they do not generally predict how much liver damage has been done until the damage is very advanced.

Liver biopsy –
The only sure way to know how much liver damage has been done over the years.

There are usually two scores (0=best, 4=worst) – the Grade is “how active” the hepatitis is, and the Stage is how much damage and scarring has already occurred.  The test is done as an outpatient in the X-ray department – after some sedation, a needle is used just under the right ribs – mostly there is only a little soreness for a day or two after the biopsy.

There is a blood test (FibroSure) that tries to give the same findings as a biopsy, but it is not clear how accurate it is.

Two radiologic tests may assess liver damage:  FibroScan uses ultrasound, and the other test uses a technique like an MRI scan – both measure how elastic (or stiff) the liver is – but are not as accurate as biopsy and can underestimate the amount of scarring.

Treatment –
Recent treatment was a combination of two drugs that stimulate the immune system to clear the hepatitis C virus:

PEG-interferon (PEG-Intron or Pegasys) – a shot given once a week.  Side effects are often feelings of having the flu – fever, tiredness, aching joints and muscles, nausea.  Generally these last not more than 1-2 days, and go away until the next shot.  They also improve some over the first few weeks as the patient adjusts to the medication.

Ribavirin – pills that make the PEG-interferon much more effective.  The dose depends on the person’s weight – generally 5-8 pills a day.  Anemia (low red blood cell counts) is common, so often blood tests will be done every couple of weeks for the first 2 months to monitor for this. 

And sometimes Procrit – if anemia develops, Procrit is given as a shot once a week to treat the anemia, and therefore the full dose of ribavirin can be continued.

Weight loss (average about 20 pounds) is not unusual.  Depression may develop and usually responds well to medication – sometimes the anti-depressant medication is started when the Hepatitis C treatment starts to try to prevent it.

How long someone would stay on treatment depends on the Genotype:
Genotypes 1 and 4 – 12 months of treatment, and about 35% of patients can have a “sustained response” (may be like a cure).
Genotypes 2 and 3 – 6 months of treatment, and about 80-85% have a “sustained response”.

Direct-acting antivirals –
In May 2011, two new medications were approved for treatment of hepatitis C, but approved only for genotype 1 – they directly stop the virus from reproducing (therefore “direct-acting antiviral” or DAA) rather than affect the immune system.  They are both taken in addition to interferon and ribavirin.  They are both protease inhibitors, similar to protease inhibitors used for HIV infection.  Resistance also may develop to the drugs. Patients with HIV co-infection may need a longer treatment duration.

Incivek – (telaprevir) – given as 2 pills 3 times a day with food for the first 3 months.  If the viral load is undetectable at both 4 and 12 weeks of treatment, the interferon and ribavirin can be stopped after a total of 24 weeks of treatment.  In patients previously treated with interferon and ribavirin who did NOT respond completely or at all, the interferon and ribavirin should be continued for a total of 48 weeks.  The most common side effect is a rash (50-55%), but only 4-5% have the rash severe enough to require that the medication be stopped.  Anemia happens a little more frequently, also.  There are many drug interactions with other medications that need to be addressed.  The HIV medications that can be used are Sustiva and Reyataz+Norvir, and probably Isentress, along with nucleosides.  The rate of a sustained response is increased to about 80% (92% if undetectable at weeks 4 and 12, 60% if still detectable at either week 4 or 12).

Victrelis – (boceprevir) – given as 4 capsules 3 times a day with food beginning after the first 4 weeks of interferon and ribavirin. If the viral load is undetectable at weeks 8, 12, and 24, all medications are stopped at week 28.  If the viral load is detectable at week 8 but undetectable at weeks 12, and 24, Victrelis is continued through week 36 and interferon and ribavirin is continued for an additional 12 weeks to complete a total of 48 weeks.  Anemia and lowering of the white blood cell count occur more often.  Rash is an infrequent problem.  Drug interactions are also a concern.

Several new medications are in development, and the expectation is that in the next 1-2 years there will be all-oral regimens (and no need for interferon). Drug interactions with HIV medications will continue to be a concern.

Hepatitis Links

www.liverfoundation.org  American Liver Foundation (ALF) - Hepatitis resources

www.atdn.org   AIDS Treatment Data Network - The Access Project – resources for state residents

www.hbvadvocate.org  Hepatitis B Advocate - Community and support, resource library

www.hcvadvocate.org   Hepatitis C Advocate - Fact sheets, education, advocacy

www.hepb.org Hepatitis B Foundation - Research, education, and advocacy

www.hepbinitiative.org  Hepatitis B Initiative - Materials, screening, statistics

www.hepatitis-central.com  Hepatitis C Central - HCV news and support

www.hepc-connection.org Hepatitis C Connection - Education and support network

www.hepfi.org Hepatitis Foundation International - Living with hepatitis, online learning center

www.hepatitismag.com Hepatitis Magazine - National magazine dedicated to patients of hepatitis B and C

www.hepprograms.org Hepatitis Prevention - Hepatitis A and B information, support programs

www.natap.org/hbv.htm  National AIDS Treatment Advocacy Project - Hepatitis B
www.natap.org/hcv.htm  National AIDS Treatment Advocacy Project - Hepatitis C   

www.lola-national.org   Latino Organization for Liver Awareness - Bilingual

An example of our schedule of blood tests to monitor effectiveness and toxicity can be found here. Co-infection with Hepatitis C and HIV InfoNet Fact Sheet can be found here.
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