Challenges in management

of HIV/HCV infection
Dr Kyaw Swar Lin
Senior Consultant Physician
Specialist Hospital Mingaladon

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 Experience of HCV Tm program at SHM

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SHM started routine screening in Jan 2017

Current status (End of January 2018)

Total active HIV cohort 8500

Already screened 6595 (77.7%)

HIV/HCV Coinfection 318 (4.8%)

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 316 SD Bioline positive patients

RNA Detected 269 (84.6%) Treatment

RNA <10 , But detected 5 (1.4%) Recheck RNA

RNA not detected 44 (14%) Naturally Cured

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 As of February 2018, 260 patients were treated

Not on ART (all on antiTB) 6

EFV regimen 249
PI/r 5
DAA was
DAC 60 11 purchased for
DAC 90 249 estimated
nonCOL : COL
12 W 231 of 2:3
Initially to
24 W 29 (11%) treat 180 pts,
but can treat
Cause of Death 4 (1.5%)
260 pts
(3 liver; 1 meningitis
SVR 12 results available 66
Cured 59 (89%)
Tm failure 7 (11%)
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Manpower
• OPD sister
• One TN Recruitment , arrange ivt, give appointments

• One of the OPD MO’s ---- check & sign ivt forms

• Data assistant from CHAI ---- enter in open MRS

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Recruitment
• Daily selection ---- anybody who has tested HCV ab positive in the
past is given appointment date to test HCV RNA
• All patients with HIV ---- eligible for treatment
• Any ART program (NAP, NGO, INGO) ; those taking own ART

ရက်သတ်သတ်မတ
ှ ်မှတ် ---

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Not eligible
• Treatment experienced
• Pregnancy
• eGFR < 30 ml/min

• ? TB ---- HCV treatment delayed after completion of antiTB

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Investigations
• On the appointed date of investigations ( every Monday, 10+ people)
• All ivt are done on the same day
• CP, AST, Cr and USG (abd)
• HCV ab by SD Bioline test kit done immediately ---- if negative ??
--- VL sent to NHL if previous HCV ab positive result OR COL+
• All HCV ab positive samples are sent to NHL the same day
• Turnaround time of HCV RNA from NHL ---- assumed as 2 weeks
• Next appointment --- 8 days ( Tuesday)

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Cirrhosis or selection of 24 week regimen

Hierarchy
1. Clinical
2. USG
3. APRI ≥ 1.5

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ေဆဵေောင်ဵော
• ၁၂ ပေ်လာဵ ၂၄ ပေ်လာဵ အချိုဵကို အကကမ်ဵဖျင်ဵ သိဖို့လေ
ို ယ်။

• Usually 10 – 15%

• Mono-infection နဲ့ မေူောက DAC 30 mg ေောင်ဵရလိမဴမ

် ယ်။
• Either 30mg ချည်ဵပဲ ၃ လုဳဵ OR 60+30
• 60 mg ကိုေောဴ ေဝက်ချုိ ဵမေပဵရဘူဵ။

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Dispense
• Every 28 days --- COVID era --- ၃ လစာေပဵသည်။

• ေစ်လေစ်ခါ ေပဵေုန်ဵက ေဆဵလက်ကျန် ေွက်ရခက်သည်။ ေီဘီေဆဵ ေပဵသလို လူနာနာမည်နဲ့ ဗူဵထဲ

မှာ ေဆဵအကုန် ထည်ထ
ဴ ာဵလိုက်ောေကာင်ဵေယ်။

• Different from ART appointment

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 Hepatitis C cascade of care
Hepatitis C cascade of care among the patients initiated on
treatment from June 2018 to current
4500
594
4000

3500

3000
Anti-HCV positivity rate- 24.4 %
No of people

2500

2000 Viremic rate- 88 %

1500

1000 145
159
500 140 SVR12
135 98 rate- 92.891%
0
# screened for Anti-HCV VL tested VL confirmed Treated Tested for Achieved
anti-HCV positive SVR12 SVR12
Hepatitis C cascade of care

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1. LLD , detected but <10 IU/ml
ကုရမှာလား မကုရဘူးလား။
• Cut off points of RNA

• < 10 copies/ml, but detected , What will we do?

• Implications for
• To start Tm ?
သဘာဝ အေလျာက် ြဖည်ဵြဖည်ဵချင်ဵ ေပျာက်ေနောြဖစ်မယ်။ ြပန်စစ်နိုင်ရင် ြပန်စစ် ၊ မစစ်နိုင်ရင် ကုစရာ မလိုပါဘူဵ။

• Decide SVR achieved or not ?

ရှာဵပါေယ်၊ Cured လိ့ပ
ု ဲယူပါေယ်။

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(2) Change of ART
• A PLHIV taking ART for 10 years , stable on AZT/3TC/NVP regimen
since 2008

• Routine HCV test positive in 2017

• HCV RNA PCR 1.6 x 106

• APRI = 1.4
• Alcohol ---social; HBV (-) ; USG --- Fatty liver only; Normal renal
function, not on antiTB
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• Which HCV regimen will you use?

• Considered similar to EFV and use 90 mg DAC ?

• Change NVP to EFV ?

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• မေြပာင်ဵေောဴပါဘူဵ။ NVP နဲ့
EFV အေူေပ ူ ဲ ယူဆပပီဵ DAC
ကို 90 mg ေပဵမှာပါ။

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(3) Change of ART
• A 45 yr old man was known to be HIV/HCV infected 2 years ago

• Baseline CD4 was 335 and asymptomatic and was given Oditec
(TDF/FTC/EFV)
• A year later--- he received Tm for HCV, in the private sector
• GT 3 , HCV RNA 2.4 x 106 ,

• He had normal liver and renal function

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• His family doctor correctly prescribed him

• Dose adjusted DAC90 + SOF for 12 weeks

• Tm failure
• Sent to hepatologist
• Hepatologist plan to give VEL/SOF +/- RIB
• Referred to modify ART

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• What ART will you use?

• HIV Viral load was checked ----- undetectable

• CD4 750

• Changed to TDF/3TC + DTV

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(4)
• A patient with HIV/TB co-infection and CD4 30
• He is an IVDU and baseline ivt showed HCV ab positive
• HCV Register ေောဴ အစကေည်ဵက လုပထ ် ာဵေယ်။ နို့မဟုေ်ရင် pool ထဲမာှ
ေပျာက်ပပီဵ ြပန်ရာှ ရ ခက်လိ့ု ။
• HCV focal nurse က ေီဘီေဆဵ ပပီဵ ၂ ပေ်ြခာဵေလာက်မှာ appointment
ေပဵလိမ်ဴမယ်။

• Start antiTB
• ဘယ်ေလာက်ြခာဵပပီဵ ART စမှာလဲ။ ၂ ပေ် အေွငဵ် ။
• ဘာ Regimen ေပဵမှာလဲ။

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3 ways ြဖစ်နိုင်ပါေယ်။

1. ေီဘီေဆဵ ကာလ ေေလျာက်လုဳဵ TLE ေပဵပပီဵ ေီဘီေဆဵ အပပီဵ ၂ ပေ်အကကာမှာ

TLD ေြပာင်ဵ။ * single drug change , better supported by suppressed viral
load.
2. စကေည်ဵက DTG BD ေပဵ။ ေီဘီေဆဵ ပပီဵရင်ေောဴ DTG OD ြပန်ေလျာဴ။
3. စကေည်ဵကTLE ေပဵ။ ေီဘီေဆဵပပီဵ ၂ ပေ် အကကာမှာ DAC ကို 90mg dose ေပဵ။

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(5) How long to wait to start HCV Tm after ART
• 25 years old man, recently diagnosed to have HIV

• Baseline: CD4 90, TB screening questions negative, normal renal

function, normal CXR, USG ---Chronic hepatitis, APRI 1.8

• ART started: TDF/3TC/EFV

• HCV RNA = 5.5 X 107

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• HCV Tm was started one month after ART : SOF/DAC90 12 week
regimen

• 2 months after ART ( one month after HCV Tm) , pt has fever, cough
and enlarged cervical LN

• CXR --- new fluffy shadows , geneXpert --- MTB positive

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• 2 months to finish HCV Tm

• Prescribe non-rifampicin containing regimen 2(SHZE) + 4 (HE)

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 THANK YOU

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