Objectives

To understand the epidemiology of the current HIV epidemic in the Philippines

To discuss the interactions between HIV and Hepatitis B

HIV Human Immunodeficiency Virus Causative agent of Acquired Immune

Deficiency Syndrome RNA virus – retrovirus, uses reverse

transcriptase enzyme Target Cell is T-helper (CD4 positive

cell) Causes unregulated immune activation

leading to collapse

Natural history

Acute HIV infection is characterized by a flu-like illness with lymphadenopathy, fever and malaise

Self-limited and patient usually recovers Takes 8 to 10 years to develop AIDS

From Fauci AS, Pantaleo G, Stanley S, Weissman D. Immunopathogenic mechanisms of HIV infection. Ann Intern Med. 1996 Apr 1;124(7):654-63.

AIDS Defined either by laboratory parameters in

an asymptomatic patient, or by an AIDS-defining illness, usually an opportunistic infection

CD4 < 200 is AIDS Opportunistic infections: PCP, MAC,

Cryptococcus meningitis, Kaposi’s sarcoma, CNS lymphoma, esophageal thrush etc. = AIDS at ANY CD4 count

Epidemiology 33.4 million people worldwide are

currently infected with HIV 28 million deaths so far 2.5 million new cases in 2009 2 million deaths reported number of new cases has declined by

19% since 2001 number of deaths has decreased by

10% since 2001

January 2013: 380 cases/ 31 days 12 new cases/day in 2013 Contrast: 1 new case every 2 days

in 2003 24-fold increase in the last decade 12,082 confirmed cases since 1984 Nearly 2/3 newly diagnosed in the

last three years

New Cases From 2001-2011

20% 1250%

WORLD PHILIPPINES

Why now?

92.5% circumcision rate in Filipinos Increased local transmission Increased MSM transmission ?new strains ?better testing Lowest condom use in Asia: 30%

Is this MSM driven?

Data looks that way, a lot like San Francisco and less like Africa, BUT…

More awareness in MSM community Likelier to test WE DO NOT KNOW, only 6% MARPs

tested

Source: A. Nakamura, California AIDS Registry, California State Office of AIDS

From death sentence to chronic disease After an unprecedented global effort in

research and aid, effective medication was discovered

Turning point came with discovery of protease inhibitors, and use of HAART

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USE OF HAART

Mortality and Highly Active Antiretroviral Therapy (HAART)

Palella et al. CROI; 2002

Why get tested?

Earlier diagnosis means better response to medication and longer life

Treatment being covered by Philhealth Being on treatment reduces risk of

transmission by 96% You do not put your loved-ones at

further risk

Liver disease highest non-HIV cause of mortality in HIV patients

D:A:D Study Group. AIDS. 2010;24(10):1537–1548.

HBV coinfection

No clear evidence that HBV co-infection negatively impacts HIV infection and progression to AIDS

HIV infection negatively impacts course of HBV infections

8x higher rate of liver-related death compared to HIV mono-infection

22x higher rate of liver-related death compared to HBV mono-infection

Thio et al., Lancet 2002; Konopnicki et al., AIDS 2005

Epidemiology of co-infection

Variable data worldwide US: 6% (MACS) UK: 7% (UK CHIC) Europe: 9% (EuroSIDA) Philippine data: 10% co-infection as part

of TREAT ASIA cohort

http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/hepatitis-b.htm

SAGIP (PGH) Cohort (Salvana et al., submitted IDWeek 2013)

HBV co-infection (HbSAg+): 14% HBEAg +: 57% Out of 175 HBSAg negative patients,

59% were anti-HBS reactive, 37% were anti-HBc reactive,

No significant difference in AST, ALT levels, but higher trend in co-infected patients

No differences in CD4 levels

Genotype differences

Genotype B associated with higher rates of hepatitis flare and increased risk of developing lamivudine resistance compared to Genotype C

Trend toward higher mortality in Genotype B, but not significant

Sheng et al., CID 2012

Treatment Caveats

Some HIV drugs have excellent activity against HBV: tenofovir, emtricitabine and lamivudine

Entecavir can induce cross-resistance to other NRTI’s

Hepatotoxicity of drugs (such as nevirapine) may be increased in HBV coinfection

Vaccinate for HAV if not immune Timing of treatment for either HIV or

HBV or both should be in accordance with guidelines, subject to some caveats

Treatment Caveats

Caveats

If HIV is to be treated, use tenofovir + lamivudine + efavirenz as first line

If HBV alone is to be treated, avoid entecavir, lamivudine, tenofovir, emtricitabine as monotherapy – will induce NRTI resistance in HIV

If HBV must be treated but not HIV, use PEG-interferon alpha

More Caveats

When switching or discontinuing ARV’s, especially lamivudine or tenofovir, watch out for possible flare of HBV activity

If switching NRTI to stavudine + zidovudine regimen, may want to keep either lamivudine or tenofovir EVEN if with documented HIV resistance to suppress HBV

Take Home Points

There is an HIV epidemic in the Philippines

HIV is preventable HIV is treatable The earlier you are diagnosed and

treated, the better the outcome HIV is no longer a death sentence HIV/HBV is challenging