Clinic’s Reused Needles May Have Exposed 40000 To Hepatitis Hiv
Nearly 40,000 people learned this week that a trip to the doctor might have made them sick.
In a type of scandal more often associated with developing countries, a Las Vegas clinic was found to be reusing syringes and vials of medication for nearly four years. The shoddy practices may have led to an outbreak of the potentially fatal hepatitis C virus and exposed patients to HIV, too.
The discovery led to the biggest public health notification operation in U.S. history, brought demands for investigations and caused scores of lawyers to seek out patients at risk for infections.
Thousands of patients are being urged to be tested for the viruses. Six acute cases of hepatitis C have been confirmed. The surgical center and five affiliated clinics have been closed.
“I find it baffling, frankly, that in this day and age, anyone would think it was safe to reuse a syringe,” said Michael Bell, associate director for infection control at the national Centers for Disease Control and Prevention.
One of the infected patients is retired airplane mechanic Michael Washington, 67, who was the first to report his infection. On the advice of his doctor, he received a routine colon exam in July at the Endoscopy Center of Southern Nevada.
In September, he started to get sick. He was losing weight fast. His urine turned dark. His stomach hurt. By January, it was clear what had happened.
When Should You Start Treatment For Hepatitis C
With the new antiviral drugs for hepatitis C, it’s now recommended that everyone with hepatitis C shouldn’t wait to be treated, regardless of liver disease severity.
The aim of this treatment is a cure sometimes described as a sustained virologic response. This means that no hepatitis C virus is detectable in your blood six months after youve finished treatment.
Preventing Hepatitis C Infection
Here’s how you can protect yourself against hepatitis C:
- Do not share needles, syringes or any other equipment to inject drugs.
- Use latex gloves for fisting, with a new glove with each partner.
- Do not share pots of lubricant.
- Do not share sex toys, or put a new condom on the sex toy each time you use it.
- Properly used condoms provide excellent protection against the transmission of HIV, hepatitis C and other sexually transmitted infections.
- A caesarean delivery can reduce the risk of mother-to-child transmission of the virus.
Theres no vaccine for hepatitis C. Unlike hepatitis A and B, having hepatitis C once doesnt mean youre then immune from getting it again. Its possible to be reinfected with the hepatitis C virus.
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Interpreting Hcv Rna Test Results
It is essential that the provider understands how to interpret HCV RNA test results, especially during the course of HCV treatment.
|Result of HCV RNA Test
|A quantified viral load — any exact number
|Ongoing HCV infection
|The HCV RNA is detectable but the number of international units is so low that it cannot be quantified accurately. This indicates extremely low level of virus is present.
|“< 12 IU/mL” or “< 15 IU/mL” or “< 25 IU/mL” All of these are “less than the LLOQ”
|HCV RNA is undetectable. No virus is detected at all in the patient’s serum specimen.
Treating Hepatitis C In People With Hiv Co
DAAs have good outcomes for people previously considered hard-to-treat. This includes people with HIV co-infection. The outcomes of treatment in people with co-infection are comparable to those in people with hepatitis C alone – rates of sustained virological response are over 95%, even in individuals who have not responded to previous treatment and people with cirrhosis.38There is no longer a need to consider HIV/HCV- co-infected patients as a special, difficult-to treat patient population, WHO states in its 2016 guidance.39
The key issue that remains, WHO emphasises, is the potential for drug-drug interactions between medications for HIV and hepatitis C. When these may occur, the regimens for either infection may need to be altered.40 However, modern HIV medications rarely have the harmful effects on the liver that characterised some older drugs. Hepatitis C treatment is generally provided to people who are already taking HIV treatment.41
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What If You Find Out You Have Hep C Or Hiv
If youve been diagnosed with Hep C or HIV, you may feel fear, anger, sadness and other emotions. It is very normal to feel this way. Getting support can help. If you feel comfortable, talk to a family member or friend about what youre going through. A lot of prisoners who have Hep C or used to have Hep C are open to sharing their experiences and supporting other prisoners with Hep C. You can also call PASAN or another community agency.
Its important to know that you can live well with Hep C and HIV. There is Hep C and HIV treatment available inside and outside of federal prisons. Treatment has a high chance of curing Hep C, and HIV treatment cant cure you but it can help you stay healthy for a long time.
Managing Hepatitis C And Hiv
Having both hepatitis C and HIV, called a coinfection, can increase your risk for liver damage if not properly diagnosed and managed.
According to the Centers for Disease Control and Prevention , 21 percent of HIV-positive people across the country have also tested positive for a past or current hepatitis C infection, although the danger varies greatly depending on your personal risk factors. If you have both conditions, that alone places you at increased risk for liver damage compared with those who have hepatitis C only.
Coinfection with hepatitis C and HIV usually represents an intersection of risk factors for each virus, says Kenneth E. Sherman, MD, PhD, a hepatologist who is the director of the division of digestive diseases and Gould Professor of Medicine at the University of Cincinnati College of Medicine.
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Sexual Transmission And Viral Hepatitis
Certain adults who are sexually active should be vaccinated against hepatitis B.
CDC and the Advisory Committee on Immunization Practices recommend hepatitis B vaccination for
- sexually active people with more than one sex partner during the previous 6 months
- people seeking evaluation or treatment for a sexually transmitted disease
- sex partners of people with hepatitis B and
- men who have sex with men .
Hepatitis C And Hiv Coinfection
Human Immunodeficiency Virus and Hepatitis C Virus co-infection is a multi-faceted, chronic condition that significantly impacts public health. According to the World Health Organization , 2 to 15% of those infected with HIV are also affected by HCV, increasing their risk of morbidity and mortality due to accelerated liver disease. The burden of co-infection is especially high in certain high-risk groups, such as intravenous drug users and men who have sex with men. These individuals who are HIV-positive are commonly co-infected with HCV due to shared routes of transmission including, but not limited to, exposure to HIV-positive blood, sexual intercourse, and passage of the Hepatitis C virus from mother to infant during childbirth.
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Treatment For People With Hiv And Hepatitis C Co
In the UK, standards for HIV treatment and care are set and monitored by the British HIV Association , the professional association for HIV doctors and other healthcare professionals. The most recent guidelines on HIV and hepatitis co-infection were produced in 2017 . Experts now agree that treatment recommendations for people with HIV and hepatitis C should be the same as for everyone else with hepatitis C, so your treatment will follow national guidelines for hepatitis C treatment.
Like everyone else living with HIV, people with HIV and hepatitis C co-infection are advised to start antiretroviral treatment soon after being diagnosed with HIV. People with co-infection may particularly benefit from early treatment because having well-controlled HIV and restored immune function reduces the risk of liver disease progression.
Current guidelines recommend that everyone with HIV and HCV co-infection should start hepatitis C treatment with DAAs. Treatment is especially urgent if you have moderate or worse liver fibrosis . But everyone with HIV and hepatitis C co-infection can benefit from early hepatitis C treatment because their liver disease may progress faster than it would in an HIV-negative person. Where there is a waiting list for treatment, people with HIV and hepatitis C co-infection are likely to be prioritised, especially if you have moderate or severe fibrosis.
- raltegravir .
Treatment Of Hepatitis C
Unlike hepatitis A and B, there is no vaccine available for hepatitis C. Fortunately, both acute and chronic hepatitis C infections are curable.
Current hepatitis C treatments involve taking two or more medications known as direct antiviral agents, or DAAs. This combination of medications prevents HCV from replicating until the virus is no longer present in the body. Treatment usually takes 6 to 24 weeks but can take longer.
However, people who have both HIV and HCV need individualized treatments because the medications used to treat HCV infections can interact with HIV treatments.
A doctor will recommend a treatment plan based on the individualâs:
- hepatitis C genotype
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Sexual Transmission And Hepatitis A
Transmission of hepatitis A virus can occur from any sexual activity with an infected person and is not limited to fecal-oral contact. People who are sexually active are considered at risk for hepatitis A if they are MSM, live with or are having sex with an infected person, or inject drugs. Vaccination is the most effective means of preventing hepatitis A transmission among people at risk for infection. CDC has published recommendations for prevention of hepatitis A that identify all groups recommended for vaccination, including hepatitis A vaccination for MSM.
Clinical Trial Pharmacokinetic And Drug Interaction Data
Extensive recommendations for ART use are available at .
Antiretroviral drug switches may be performed to allow compatibility with DAAs with the goal of maintaining HIV suppression without compromising future options. Considerations include prior treatment history, response to ART, resistance profiles, and drug tolerance . Treatment interruption in HIV/HCV-coinfected individuals is not recommended as it is associated with increased cardiovascular events and increased rates of fibrosis progression and liver-related events . The availability of multiple effective HCV DAA and HIV antiretroviral regimens makes it possible for all HIV/HCV-coinfected patients to safely and successfully receive HCV treatment. Switching an optimized antiretroviral regimen carries risks, including adverse effects and HIV viral breakthrough . HIV viral breakthrough is of particular concern for those with substantial antiretroviral experience or known resistance to antiretroviral drugs. If necessary, ART changes should be undertaken in close collaboration with the treating HIV provider prior to HCV treatment initiation.
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Hepatitis C Treatment Guidelines
Guidelines issued by WHO in April 2016 recommend four preferred regimens, each including the drug sofosbuvir, in order to simplify treatment decisions for hepatitis C.36 Depending on the regimen, treatment may last 12 or 24 weeks.
When these guidelines were issued, the choice of drug regimen was dependent on which of the six genotypes the patient had. Different genotypes, each with its own genetic composition of the virus, are more common in different parts of the world. Each patient therefore required genotype testing before treatment could be provided.
In July 2018, WHO updated these treatment guidelines to reflect certain key developments. It recommended that the use of DAA regimens for all people with chronic hepatitis C infection, rather than reserving DAA treatment for people with more advanced disease as had previously been done. In part, this is linked to the continued substantial reduction in , which has enabled treatment to be rolled out rapidly in a number of low- and middle-income countries. In addition, as several new pangenotypic DAA medicines have now been approved, the need for genotyping to guide treatment decisions has been reduced.37
Hcv Treatment Data In Persons With Hiv Coinfection
Multiple HCV treatment studies using direct-acting antiviral -based therapy have demonstrated sustained virologic response rates in individuals with HIV-HCV coinfection that are comparable to those with HCV monoinfection , providing convincing evidence that persons with HIV-HCV coinfection should no longer be considered as a treatment-refractory population. In these trials, most participants did not have cirrhosis and most had CD4 counts well above 200 cells/mm3. Subsequently, however, a variety of observational cohort studies with heterogeneous cohorts of persons with HIV-HCV coinfection, including those with more advanced liver disease and lower CD4 cell counts, showed comparable HCV SVR rates in persons with HIV-HCV coinfection compared with those who have HCV monoinfection. The following provides a summary of key clinical trials involving DAA treatment of HCV infection in persons with HIV coinfection.
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Regimens Not Recommended For Patients With Hiv/hcv Coinfection
NOT RECOMMENDED Antiretroviral treatment interruption to allow HCV therapy is not recommended. III, A Elbasvir/grazoprevir should not be used with cobicistat, efavirenz, etravirine, nevirapine, or any HIV protease inhibitor. III, B Glecaprevir/pibrentasvir should not be used with atazanavir, efavirenz, etravirine, nevirapine, or ritonavir-containing antiretroviral regimens. III, B Sofosbuvir/velpatasvir should not be used with efavirenz, etravirine, or nevirapine. III, B Sofosbuvir/velpatasvir/voxilaprevir should not be used with efavirenz, etravirine, nevirapine, ritonavir-boosted atazanavir, or ritonavir-boosted lopinavir. III, B Sofosbuvir-based regimens should not be used with tipranavir. III, B Ribavirin should not be used with didanosine, stavudine, or zidovudine. III, B
Indirect Effect Of Hiv On Liver Disease Progression
The principal mechanism through which HIV indirectly accelerates liver disease progression is increased microbial translocation. HIV infection induces severe depletion of the gastrointestinal lymphoid tissue, impairing the gastrointenstinal tract epithelial integrity and allowing bacterial LPS to translocate from the gut to the systemic circulation and through the liver . LPS binds to TLR4 on the surface of quiescent HSCs, leading to upregulated chemokine secretion and chemotaxis of Kupffer cells. Concurrently, this interaction induces downregulation of the TGF- pseudoreceptor Bambi to sensitize HSCs to TGF–induced signals from Kupffer cells . Activation of HSCs is further aggravated by HIV-mediated depletion of Kupffer cells that are responsible for LPS phagocytosis .
Elevated levels of microbial translocation markers were reported in HCV-infected subjects upon HIV acquisition and compared to HIV uninfected subjects . In addition, decreased levels of endotoxin-core antibodies and increased levels of IgG, specific for a heterophilic epitope, which has previously been associated with stage of liver disease , were observed in HIV-infected compared to uninfected subjects . All these measures were strongly associated with HCV-related liver disease progression to cirrhosis .
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Liver Disease In Hcv/hiv Coinfected Individuals
HCV/HIV co-infected individuals are at a higher risk of progressive liver disease, with accelerated progression to liver cirrhosis and higher rates of HCC, even when HIV is controlled by ART . HIV coinfection accelerates HCV-mediated fibrosis through both direct and indirect mechanisms that will be discussed in this section and are summarized in Figure 1.
High Rates Of Hepatitis C And Hiv Coinfection Among Key Populations
26 April 2021
Viral hepatitis infection is a major global public health problem causing approximately 1.4 milli
Viral hepatitis infection is a major global public health problem causing approximately 1.4 million deaths per yearmore than the annual number of AIDS-related deaths. Ninety-six per cent of these deaths are from cirrhosis and hepatocellular carcinoma due to hepatitis B and C viruses, which are transmitted via blood and body fluids.
People living with HIV and hepatitis B or hepatitis C coinfection have a more rapid progression to cirrhosis. Liver disease has emerged as an important cause of death among people living with HIV coinfected with either hepatitis B or hepatitis C.
Hepatitis C coinfection with HIV is reported across all key populations at higher risk of HIV, especially among people who inject drugs. This is due to the ease with which both viruses are spread through the sharing of non-sterile drug preparation and injecting equipment.
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Hiv And Hepatitis B And Hepatitis C Coinfection
Hepatitis B and hepatitis C are liver infections caused by a virus. Because these infections can be spread in the same ways as HIV, people with HIV in the United States are often also affected by chronic viral hepatitis.
Viral hepatitis progresses faster and causes more liver-related health problems among people with HIV than among those who do not have HIV. Liver disease, much of which is related to HBV or HCV, is a major cause of non-AIDS-related deaths among people with HIV.
Given the risks of hepatitis B or hepatitis C coinfection to the health of people living with HIV, it is important to understand these risks, take steps to prevent infection, know your status, and, if necessary, get medical care from someone who is experienced in treating people who are coinfected with HIV and HBV, or HIV and HCV.
A Tale Of Two Viruses: Immunological Insights Into Hcv/hiv Coinfection
- 1Centre de Recherche du Centre hospitalier de lUniversité de Montréal , Montréal, QC, Canada
- 2Département de microbiologie, infectiologie et immunologie, Faculté de Médecine, Université de Montréal, Montréal, QC, Canada
- 3Department of Medical Microbiology and Immunology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
- 4Département de médecine, Faculté de médecine, Université de Montréal, Montréal, QC, Canada
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