HIV/Hepatitis co-infection situation in Czech and Slovak Republics

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2nd Central and Eastern European Meeting on Viral Hepatitis and Co-Infection with HIV HIV/Hepatitis co-infection situation in Czech and Slovak Republics Viktor

1 2nd Central and Eastern European Meeting on Viral Hepatitis and Co-Infection with HIV HIV/Hepatitis co-infection situation in Czech and Slovak Republics Viktor ASTER, MD, PhD Department of Infectious and Tropical Diseases, Hospital Bulovka, First Faculty of Medicine, Charles University in Prague, District Hospital Liberec.

2 2nd Central and Eastern European Meeting on Viral Hepatitis and Co-Infection with HIV Disclosure: I have no disclosure : Central and Eastern Europe?

3 HIV, HBV and HCV in The Czech Republic Prevalence Annual Incidence Comments HIV 0,026% 1) 2480 p. living with HIV 266 cases (y.2015) 1) 25,2/ inhabitants HBV 0,14% HBsAg+ 3) 89 cases of acute VHB (y.2015)1) 3,2% anti-hbc IgG+ 3) 8,5/ inhabitants increasing trend decreasing Trend HCV 1,67% anti-hcv+ 2) 0,93% HCV RNA+ 956 cases (y.2015) 1) 91/ inhabitants increasing trend (originally till 2014: 0,37% anti-hcv+) 3) Coinfected HIV/HBV Coinfected HIV/HCV 2,1% HBsAg+, unknown 37,5% anti-hbc IgG+ 4) 10,9% anti-hcv+ 4) unknown 1) National institute of Health, ) Chlibek R, University of Defence, ) Chlibek R, University of Defence, ) Aster V, Polakova A, Nemecek V, Maly M, September 2013, Snopkova S, June 2015

4 2nd Central and Eastern European Meeting on Viral Hepatitis and Co-Infection with HIV HIV subtypes Prevalence of Different Subtype/Genotype in Czech Republic HIV Subtype Distribution: A = 11,4%, B = 74,8%, Other = 13,8% HIV-1 SUBTYPE A B C D F G CRF01_AE CRF02_AG CRF03_AB CRF06_cp x other Total n % 11,4% 74,8% 3,0% 0,4% 0,4% 0,8% 3,5% 1,4% 0,0% 0,5% 3,7% 100,0% Maly M, Nemecek V, National institute of Health, 2016

5 HCV Genotype and Subtype and Q80K mutation distribution in Czech R. HCV Genotype Distribution: (common population) 1a = 25%, 1b = 25%, 3 = 46.4%, other = 3,6% 1) HCV GT distribution in common population. Chlibek R, 2016: 3 centers: Hradec Kralove, Brno, Ceske Budejovice, n=3000 HCV GT distribution in HIV+ Aster V, Patients treated for VHC since 2003 till AIDS-Center Prague. n=46 1a: 25% 1b: 25% 3: 46,40% GT 1a; 29% GT 1b; 14% GT 3; 25% other: 3,60% GT 1a/b; 16% GT 4; 16% Q80K positive: 20% n=60 80% 20% Detection of Q80K mutation in HCV NS3 protease gene in Hradec Kralove initial experience Pliskova L1, Kutova R1, Plisek S2, Stepanova V3 1 Inst. Clin. Biochemistry and Diagnostics - Dept. Mol. Biol., 2 Clinic of Infectious Diseases, 3 Inst. Clin. Microbiology Virology Dept., University Hospital and Fakulty of Medicine, Charles University, Hradec Kralove, Czech Republic. Poster, Lisabon 2016 Comment: growing prevalence of GT 3, (originally GT 1b 80%), growing prevalence of subtype 1a, GT 4 still rare exept HIV+ MSM

HIV+) exact data not not available Main Risk factors for HIV Transmission in The Czech Republic IDU; 105; 4%

6 Main Risk factors for Transmission HIV MSM = 65%, Hetero = 24% IVDU = 4% HBV HCV Sexual (till 1989 nosocomial) exact data not available IVDU (common population), sexual (in MSM, esp. HIV+) exact data not not available Main Risk factors for HIV Transmission in The Czech Republic IDU; 105; 4% IDU+HOM+HET; 60; 2% HEM; 17; 1% NOS; TRF; 14; 1% VER; 9; 0% UNK; 80; 3% 5; 0% HET; 689; 24% HOM; 1857; 65% HOM HET IDU UNK IDU+HOM+HET HEM TRF VER NOS

in June 2016 n=186 1) 2) 92,50% 25,20% 35,80% 23,10% 38,50% 62,60% 53,50% 4,10% NRTI NNRTI INSTI PI Inh CCR5 2015 2016 3,30% 1,60% Fus Inh 1) Snopkova S, AIDS Center Brno.

7 Antiretroviral Treatment Currently available HIV First line regimens: % NNRTI, % PI/r, % INI complete exact data not available Trend in The Czech R.: decreasing use of PI, increasig use of InSTI 100,00% 90,00% 80,00% 70,00% 60,00% 50,00% 40,00% 30,00% 20,00% 10,00% 0,00% 86,20% ARV drugs used in pt s from AIDS-Center Brno in July 2015 n=123 and in June 2016 n=186 1) 2) 92,50% 25,20% 35,80% 23,10% 38,50% 62,60% 53,50% 4,10% NRTI NNRTI INSTI PI Inh CCR ,30% 1,60% Fus Inh 1) Snopkova S, AIDS Center Brno. Protrombotic state in HIV+ persons, using ARV drugs. Institutional support Ministry of Health ) Snopkova S, AIDS Center Brno, % Most common ARV combinations in Czech R. DRV/RTV/FTC/TDF DRV/COBI/FTC/TDF LPV/RTV/FTC/TDF RPV/FTC/TDF EVG/FTC/TDF RAL/FTC/TDF DTG/FTC/TDF RAL/ABC/3TC DTG/ABC/3TC DTG/ABC/3TC Drugs available in Czech R. TDF FTC/TDF FTC/ TDF /EVG/COBI FTC/ TAF /EVG/COBI FTC/ TDF /RPV ABC/3TC 3TC/ZDV RAL DRV LPV/RTV ATV EFV ETV RPV RTV DTG DTG/ABC/3TC DRV/COBI ATV/COBI

Anti-VHC/VHB Treatment Currently available HBV All drugs well available, TBV not registered HCV Still limited access to IFN-free regimens ETV, TDF 3TC (exeptionally in pt s with poor prognosis and in

8 Anti-VHC/VHB Treatment Currently available HBV All drugs well available, TBV not registered HCV Still limited access to IFN-free regimens ETV, TDF 3TC (exeptionally in pt s with poor prognosis and in pt s with serious courses of acute VHB) Peg-IFN (decreasing trend of usage) Temporary prophylaxis in immunocompromised persons: 3TC still more common than TDF DAA available: LDV/SOF, 3D, SOF, DCV, ASV, SMV. specific program with ASV/DCV, window between approval and reimbursement Guidelines derived from EASL guidelines % of interferon use: unknown, but still most pt s treated by IFN containing regimens (F0-F2) INF-free regimens: for F3 and F4 pt s, available in 15 centers in C.R. IFN-free VHC treatment in Hepatologic Center Hospital Bulovka, Prague Aster V, September 2016 waiting non HIV started IFN-free died (not started) HIV+ Number of patients

Patients on HAART, supressed pt s and number of dying Percent of Patients on HAART Percent of patient suppressed (<20) Number Dying in Stage AIDS HIV Czech R.

till Aug 2016 n=2836 3) 2480; 87% 356; 13% living dying number dying patients 25 20 15 10 5 0 Number of Dying HIV+ pt s in Czech R.

9 Patients on HAART, supressed pt s and number of dying Percent of Patients on HAART Percent of patient suppressed (<20) Number Dying in Stage AIDS HIV Czech R. unknown unknown 250 (70%) (out of 356 HIV+ dying) 3) AIDS Center Brno 97,4% 82,1% (186 out of 191 pt s) 1) (n=123, 65% with CD4>500) 2) Living and Dying HIV+ pt s in Czech R. till Aug 2016 n=2836 3) 2480; 87% 356; 13% living dying number dying patients Number of Dying HIV+ pt s in Czech R. till Aug ) non-aids AIDS 1) Snopkova S, AIDS Center Brno, June ) Snopkova S, AIDS Center Brno. Protrombotic state in HIV+ persons, using ARV drugs. Institutional support Ministry of Health, Dec ) Nemecek V, Maly M, National institute of Health, Aug 2016

HBV-infection in The Czech Republic Percent of Patients on Therapy Of Those Treated Percent of Patients Suppressed HBV unknown presuption:hbv DNA negative>(95%) Number Dying of Cirrhosis/ Hepatoma

10 HBV-infection in The Czech Republic Percent of Patients on Therapy Of Those Treated Percent of Patients Suppressed HBV unknown presuption:hbv DNA negative>(95%) Number Dying of Cirrhosis/ Hepatoma Unknown/ presumption: 20 pt dying of hepatoma LTx. for HBV infection IKEM 1995-April2015. N=1187 LTx in 1122 recipients 1) 3,80% HBV other Dg. 1) Trunecka P, et all. Twenty years programme of liver transplatation in IKEM-indications and results. XLIII. May Hepatologic Days Oral presentation.

HCV infection in The Czech Republic Frankova S.

Patients Received Therapy HCV 40-50% (presumption in diagnosed cases) Of Those Treated Percent of Patients Cured

for HCV infection, IKEM 1995-Sept. 2016. n=1371 2) 186 LTx. 16% Number of LTx.

2016 LTx for HCV 1996-2013 25 48 12 101 HCV other Dg.

11 HCV infection in The Czech Republic Frankova S., IKEM Presumption in diagnosed cases: 500 living HCV infected pt s in cirrhosis stage (2016) 1) Percent of Patients Received Therapy HCV 40-50% (presumption in diagnosed cases) Of Those Treated Percent of Patients Cured unknown Number Dying of Cirrhosis/ Hepatoma unknown/dying of Hepatoma:20 ptś /y (presumption) Percentage of LTx. for HCV infection, IKEM 1995-Sept n=1371 2) 186 LTx. 16% Number of LTx. for HCV infection, IKEM: increased incidence of HCC in LTx. For HCV 3) LTx for HCV 2013-Sept.2016 LTx for HCV HCV other Dg HCC Yes without HCC Time to Tx on waiting list in The Czech R.: 84 days on average 2) 1) Urbanek P ) Trunecka P et all, IKEM (Institute of Clinical and Experimetnal Medicine, Prague) ) Frankova S, IKEM (Institute of Clinical and Experimetnal Medicine, Prague) 2016

HIV, HBV and HCV in The Slovak Republic Prevalence Annual Incidence Co-infection HIV 0,015% 1) 796 p.

2015)1) 14,6/1000 000 inhabitants 1) HBV 2,8% HBsAg+ 2,3) 15,9% anti-hbc IgG+ 2),3) 1,80% HBV DNA+ 2)3)

HIV/HCV coinfection 4) (HCV RNA+) Number of dying HIV+ persons in Slovakia n=857, June 2016 14; 2% 47; 5%

n=857 0,1 2,2 23,6 9,2 64,9 HO HET IVDU TRF unknown 1) Stanekova, 2015 2) Jarcusca P.

12 HIV, HBV and HCV in The Slovak Republic Prevalence Annual Incidence Co-infection HIV 0,015% 1) 796 p. living with HIV 1) 86 cases (y.2015)1) 14,6/ inhabitants 1) HBV 2,8% HBsAg+ 2,3) 15,9% anti-hbc IgG+ 2),3) 1,80% HBV DNA+ 2)3) HCV 1,52% anti-hcv+ 2) 0,67% HCV RNA+ (new study in process) 5% HIV/HBV coinfection 4) (HBsAg+) 5% HIV/HCV coinfection 4) (HCV RNA+) Number of dying HIV+ persons in Slovakia n=857, June ; 2% 47; 5% 796; 93% living dying non AIDS dying AIDS HIV infection according mode of acquisition in Slovakia in % n=857 0,1 2,2 23,6 9,2 64,9 HO HET IVDU TRF unknown 1) Stanekova, ) Jarcusca P. HepaMeta Study ) Veseliny E, et al. High Hepatitis B and Low Hepatitis C Prevalence in Roma Population in Eastern Slovakia.Central European Journal of Public Health 2014, suppl 1, 1. 4) Jarcucka P,June 2014

13 Conclusions Prevalence of HIV infection in The Czech Rebulic is still low, but is apparently growing, predominatly in MSM Relatively growing use of InSTI Prevalence of HCV infection in Czech R. is higher than was originally supposed The use of IFN containing regimens is still common in VHC treatment and access to IFN-free regimens is still not satisfactory (even for F3 and F4 pt s) No VHC treatment special budget for HIV co-infected population in C.R. HCV GT4 is rare, but not in HIV+MSM Relatively growing prevalence of HCV GT3 and GT 1a growth of residents from other countries (Ukraine) growth of new HCV infections from I.V. drug abuse population relatively short time to Tx on waiting list in The Czech Republic Increased incidence of HCC in LTx. for HCV Slovakia versus Czech R.: 2x lower prevalence of HIV infection, 20x higher prevalence of HBV infection similiar prevalence of HCV infection

Acknowledgement SNOPKOVA Svatava, Clinic of Infectious Diseases, Faculty of Medicine, Masaryk University, Brno, Czech Republic FRANKOVA Sona, Institute of Clinical and Experimental

Republic CHLIBEK Roman, 4Department of Epidemiology, Faculty of Military Health Sciences, University of Defence, Hradec Králové, Czech Republic MALY Marek, National Reference Laboratory

National Institute of Health, Prague, Czech Republic SHUNNAR Azzaden, Faculty of Medicine, Comenius University in Bratislava, Slovakia JARCUSKA Peter, 1st Department of Internal Medicine,

14 Acknowledgement SNOPKOVA Svatava, Clinic of Infectious Diseases, Faculty of Medicine, Masaryk University, Brno, Czech Republic FRANKOVA Sona, Institute of Clinical and Experimental Medicine, Prague, Czech Republic URBANEK Petr, Clinic of Internal Diseases, Central Military University Hospital Prague, First Faculty of Medicine, Charles University in Prague, Czech Republic CHLIBEK Roman, 4Department of Epidemiology, Faculty of Military Health Sciences, University of Defence, Hradec Králové, Czech Republic MALY Marek, National Reference Laboratory for HIV/AIDS, National Institute of Health, Prague, Czech Republic NEMECEK Vratislav, National Reference Laboratory for HIV/AIDS, National Reference Laboratory for Viral Hepatitis, National Institute of Health, Prague, Czech Republic SHUNNAR Azzaden, Faculty of Medicine, Comenius University in Bratislava, Slovakia JARCUSKA Peter, 1st Department of Internal Medicine, P. J. Safarik University in Kosice, Faculty of Medicine and L. Pasteur University Hospital, Kosice, Slovakia All colleageous from AIDS-Center Prague Vaclav Cervenka, Green Gate architect GREEN GATE BUCHAREST

HCV reinfection in HCV/HIV coinfected patients treated for VHC in AIDS Center Prague

HCV reinfection in HCV/HIV coinfected patients treated for VHC in AIDS Center Prague Viktor ASTER, MD, PhD Department of Infectious and Tropical Diseases, Hospital Bulovka, First Faculty of Medicine, Charles