Hepatitis C : Screening and Prevention Strategies

Transcription

1 Hepatitis C : Screening and Prevention Strategies JAMEELA J. YUSUFF, MD MPH FACP MEDICAL DIRECTOR STAR HEALTH CENTER AT SUNY DOWNSTATE MEDICAL CENTER JANUARY 24, 2018

2 Overview Review of Screening Guidelines for HCV: NYS testing law CDC guidelines Review of Prevention Strategies including: Harm reduction strategies Secondary prevention of viral hepatitis Treatment as Prevention Preventing reinfection

3 NYS Hepatitis C Testing Law Effective January 1, 2014, a hepatitis C screening testing must be *offered* to every individual born between 1945 and 1965 receiving health services as an inpatient or primary care services Outpatient department of a hospital Freestanding diagnostic and treatment center Physician, PA, NP providing primary care At least once, unless ongoing risk factors for HCV A patient with a reactive test must be offered follow-up care May refer to another provider (including HCV RNA test) Test offering culturally and linguistically appropriate

4 Notable exceptions to law: Emergency Departments Individual being treated for a life threatening emergency Previously offered or has been subject of a hepatitis C test Individual lacks capacity to consent (may use healthcare proxy or appropriate person ) Does not require insurance companies to pay May do testing at off site lab if that is usual protocol for labs Posters advertising testing do not count as an offer Offer must be direct, in writing or orally The testing does not have to be free Patient may be referred to free testing site if otherwise would refuse

5 Why ? 68.7% and 65.6% of anti-hcvpositive participants in NHANES III and IV, respectively, were born between It is estimated that the babyboomers account for 75% of HCVpositive population

6 CDC Guidelines: HCV Screening Currently injecting drugs Ever injected drugs including one time Clotting factors prior to 1987 Transfusion or organ transplant before July 1992 Transfusion known HCV+ Hemodialysis Abnormal ALT Healthcare workers s/p needlestick or mucosal exp HCV+ blood Children born to HCV+ women HIV (2009) All persons born regardless of HCV risk factor one time (2012)

7 Additional Guidelines: AASLD/IDSA: Inclusive of CDC recs Intranasal illicit drug use Tattoos unregulated setting Incarceration NYC DOHMH Inclusive of CDC recs Invasive medical procedures in countries with high prevalence (Egypt, Pakistan, former Soviet Union) Current sexual partner of person infected with HCV Intranasal drug users or crack users Symptoms of acute or chronic hepatitis C Incarceration

8 CDC: Testing Sequence New testing sequence: Relies on HCV Ab and RNA Eliminates RIBA No longer available Infection in past 6 months? RNA Repeat Ab Immunosuppressed? RNA

9 HCV Assays Rapid Oraquick Fingerstick capillary Venipuncture whole blood Oral swab NOT approved (US) Result 20 mins HCV Ab (EIA) Requires venipuncture Reflex to diagnostic (quantitative HCV RNA) test: Quest, Labcorp, Bioreference HCV RNA Qualitative vs. quantitative

10 Viral Viability: HCV on Surfaces HCV can survive extended period on dry surfaces Evidence after 5 days 6 to 6 weeks 7 depending on volume and environmental factors (temperature, location) HCV is inactivated by: Temperature > C 6 Bleach, ethanol, 7 1-propanol Commercially available disinfectants 6

11 Viral Viability: HCV in Syringes Viability of HCV is related to syringe type/volume and temperature where syringe is maintained; 32 ml tuberculin syringes maintain viral viability longer (up to 63 days) than 1 ml insulin syringes (1-7 days based on temperature) 8 Syringes with more dead space volume (the space in the hub of the needle), often those with detachable needles, allow for longer HCV survival times 9

12 HCV in Injection Equipment: Follow the Blood Focus on components of the injection experience where the needle/syringe can be contaminated with HCV: shared water filters water containers 10,11

13 Biomedical Prevention Biomedical prevention can significantly reduce HIV transmission PrEP PEP There is no equivalent of PrEP or PEP for HCV, so other harm-reducing practices need to be reinforced with those at risk

14 Harm Reduction for HIV/HCV Co-infected PWID Get treatment for drug use Avoid sharing syringes, needles, filters, water, and water containers Use sterile needles, syringes, and water Clean unsterile needles and syringes with bleach Clean skin before injecting Avoid sex while high, and if blood exposure will occur Use condoms with all sex partners Get tested for STIs Encourage PrEP for HIV-negative contacts 12

15 SAPs/SSPs Increase availability and distribution of sterile syringes, needles, injection equipment See Resources for national SAP/SSP directory Resources/referrals Safe disposal of used needles and syringes Pharmacies, CBOs mobile or fixed, provider prescription 13 Distributing low dead-space syringes 14

16 Minimizing Morbidity and Mortality for Coinfected PWID Linkage to appropriate resources Limiting likelihood of overdose Providing safe injection spaces

17 Intranasal Drug Use Evidence that HCV can be transmitted through non-injection drug use Stronger association among PLWH 15 Injectors may transition to intranasal use 16 Counsel to avoid sharing of intranasal equipment (straws) 15 Counsel on PrEP for HIV prevention for HIV-uninfected sexual and drug equipment-sharing contacts

18 HIV/HCV in Those Obtaining Body Art Tattoos and piercing have been studied: increased risk of HCV in unregulated parlors and by unlicensed artists Higher risk if done in prisons or by friends Education/awareness among inmates and youth to reduce use of non-sterile tools and ink 17

19 HIV/HCV Sexual Risk Behaviors Receptive anal sex confers the highest sexual risk for acquiring HIV and HCV Insertive anal sex confers highest risk for transmitting HIV 18 Evidence of increase in HCV among MSM and sex workers, particularly in the presence of HIV Counsel on safer sex practices, including consistent condom use Counsel on PrEP for HIV prevention among HIV-uninfected contacts

20 Transgender Persons Transgender PLWH may be at risk of HCV infection through injection and sexual practices Counsel on need for silicone injections to be administered by licensed care provider Use clean needles/syringes for hormone injections 22 Practice safer sex: Acts that are NOT physically traumatic to the mucous membranes More lubrication Decreased frequency of encounters Decreased number of partners Use of barriers such as condoms Counsel on PrEP for HIV prevention among HIV-uninfected contacts

21 HAV and HBV Screening Evaluation for other conditions that affect the liver, including HAV and HBV 1 HAV IgM anti-hav 2, IgG anti-hav Indicates past infection or vaccine-related immunity (IgG), acute infection (IgM), susceptibility 3 HBV HBsAg, anti-hbs, anti-hbc, IgM anti-hbc Indicates resolved infection, acute infection, chronic infection, vaccine-related immunity, susceptibility 4,5

22 HAV and HBV Vaccination Recommended for all susceptible persons with HIV/HCV co-infection 1 HAV/HBV combination vaccines: 3-4 doses HAV: 2 doses 6 HBV: 2-3 doses IM Post-vaccination testing for serologic response 1-2 months after last dose 7

23 Risk Reduction for HAV Vaccination Precautions when traveling in endemic regions Bottled or boiled water (including for brushing teeth), peel and wash fruit and vegetables, avoid undercooked meat and fish Good hygiene Washing hands often -- diaper changes, preparing food, eating 8 Barrier methods during anilingus 9

24 Risk Reduction for HBV Vaccination Partner testing and disclosure Use of condoms Safe use of injection equipment Precautions with piercing and tattooing Precautions when traveling to endemic regions 10

25 Harm Reduction for Liver disease Alcohol abstinence Physician or pharmacist review of all medications, including: Prescription, over the counter, supplements, herbals, hormones 11 Safe food practices Healthy behaviors Diet and exercise for a healthy weight Control blood sugar, cholesterol, blood fats Reduce stress, increase emotional support 12

26 Definition of Treatment as Prevention What is treatment as prevention? HIV providers saw that PLWH with undetectable HIV VL were less likely to transmit the virus to uninfected sex partners The HIV Prevention Trials Network 052 (HPTN 052) study 1 showed that, among heterosexual serodiscordant couples, reducing the HIV VL in the partner living with HIV significantly reduced HIV transmission by that person These findings, first published in 2011, galvanized the concept of treatment as prevention 2 and led to test and treat initiatives as a means of lowering the community HIV VL globally

27 Viral Treatment Goals Treatment of HIV with ART reduces the risk of HIV transmission significantly Treatment of HCV with DAAs is done to cure the chronically infected person of HCV, making transmission impossible as long as this person doesn t become reinfected

28 Ask, Screen.. Ask all patients about sexual behaviors, including genital, anorectal, and oral sex Screen for STIs: genital anorectal oropharyngeal blood

29 ..and intervene Ulcerative lesions (eg, primary syphilis, chancroid, HSV lesions) may facilitate the transmission of HCV and/or HIV 6 Treat and counsel on harm reduction of reinfection

30 Screen for Mental Health Disorders Depression Drugs and Alcohol Use Anxiety Disorders Trauma

31 Substance Use/Mental Health Disorders Substance Use Disorder and other Mental Health Disorder treatment must be included to reduce the risks of: Further liver damage (primarily from alcohol) HCV reinfection or superinfection Transmission behaviors associated with substance use 3,7-9

32 Partners Partner notification counseling should be provided about HIV/HCV testing of past and present sex partners and drug equipment-sharing partners Harm-reduction counseling should be provided for partners who test negative for HIV and/or HCV Linkage to care should be provided for those identified to have HIV and/or HCV infection(s)

33 Relapse

34 Reinfection

35 Mixed Infection

36 Superinfection

37 Relapse vs. Reinfection In persons with ongoing risk behaviors for HCV infection, completed HCV treatment, and a resurgence of HCV RNA, the answer may be: Incomplete treatment of a mixed infection (one strain completely suppressed, but one strain not) Reinfection Relapse Depends on viral genome sequencing and behavioral history

38 Reinfection Among persons successfully treated for HCV, reinfection incidence rates are low 1 Despite clearance of primary HCV infection with the use of DAAs, PLWH are at greater risk of HCV reinfection than are similar people without HIV infection 3 PWID are also significantly more likely to be reinfected than are those who acquired HCV infection by other means, 3 and post-treatment PWID in particular 4

39 Reinfection Risks Among PLWH successfully treated for HCV in Canada, those who had the highest rates of reinfection (7% of 257) were 5 : 1. High-frequency IDU 2. MSM with high-risk sexual activity 3. Low-frequency IDU

40 Other therapies Opioid substitution therapy, along with HCV treatment, results in significantly lower rates of HCV reinfection among PWID 3 Those receiving mental health services (outside of opioid substitution therapy) along with DAA are significantly less likely to be HCV reinfected 3 Access for PWID to sterile injection equipment along with substance use and mental health services 6

41 Key Points Decrease incidence and risk of new infection or reinfection in a community through: Screening all individuals at risk, particularly baby boomers Harm-reduction education and resources Testing, diagnosis, and cure of all persons with chronic HCV infection as early as possible Providing needed substance use disorder treatment and other mental health services

42 Recommendations Provider fear or concern of reinfection should not prevent treatment of HCV 1 Mental health services for persons getting or ending treatment for HCV 3 Opioid substitution therapy for PWID who are completing or have completed HCV treatment 3 Harm reduction counseling should be provided to all persons during and at endof-treatment for HCV reinfection prevention 4