HIV/AIDS Treatment and Care : Clinical protocols for the European ...

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ManageMent of Hepatitis C and HiV CoinfeCtion Table 1. distribution of genotypes by monoinfection and coinfection, in % Genotype 1 Genotype 2 Genotype 3 Genotype 4 Monoinfected 65 12 19 3 Coinfected 60 5 28 8 Source: Fried et al., Tottiani et al. (33, 34). • Infections with more than one HCV genotype appear to be more often (>5%) in patients coinfected with HCV and HIV, particularly IDUs and haemophiliacs (29, 35). • HCV genotype plays a predominant role as a predictor of SVR in HIV-infected patients, as it has been found in all studies of people without HIV infection. ° For genotypes other than 1 or 4, SVR rates are generally high, ranging from 73% in the ACTG 5071 study (4) to 62% in the APRICOT study (3), 53% in the Barcelona study (5) and 44% in the RIBAVIC study (2). ° For genotype 1, SVR rates range from 29% in APRICOT (3) to 17% in RIBAVIC (2) and 14% in ACTG 507 (4), while Barcelona reported a 38% SVR rate for those with genotype 1 or 4 (5). For more information about laboratory assays for HCV, please see Annex 1. 1.2. Evaluation of HCV disease severity • Evaluation of HCV disease severity should include attempting to define the duration of the infection. The date of infection is usually defined as the first date of risk exposure to HCV infection (first drug injection date, etc.). • For decisions regarding treatment, the focus of the evaluation should be on chronic liver disease, comorbidities and co-conditions. 1.2.1. Clinical evaluation of liver disease Clinical signs of cirrhosis are: • stellar angiomas • dysmorphic liver • digital hippocratism (clubbing of the fingers) • collateral abdominal circulation • signs of hepatic decompensation (ascites, icterus, encephalopathy, etc.). 1.2.2. Biochemical parameters Biochemical tests to be performed are: 2, 3 • transaminases (ALT, AST) • gamma glutamyl transpeptidase (GGT) (may increase in case of cirrhosis) • alcalines phosphatases (to establish another possible cause of hepatic disease) • bilirubine • albumin • prothrombin time. 2 Alanine aminotransferase (ALT) levels do not necessarily reflect the stage of fibrosis, especially in HCV/HIV-coinfected patients. A normal ALT level alone should not be grounds to defer treatment. A biopsy in this situation can help to make a more informed decision. In the RIBAVIC study, baseline ALT >3 times the upper limit of normal was a predictor of higher SVR. 3 Asparate aminotransferase (AST) levels should be controlled when performing the initial complete hepatic evaluation to eliminate other causes of hepatic disease; for example, in cases of alcoholic intoxication there may be an increase in AST and GGT. 235
236 HIV/AIDS TREATMENT AND CARE CLINICAL PROTOCOLS FOR THE WHO EUROPEAN REGION 1.2.3. Child-Pugzh score The Child-Pugh Score, combining clinical symptoms and biological tests (Table 2), is useful for grading the severity of ESLD and should be performed in all patients with cirrhosis (36). Table 2. Child-pugh classification Clinical and biochemical parameters Bilirubin Points 1 2 3 50 µmol/l) Albumin >3.5 g/dl 2.8–3.5 g/dl 60% 40–60% 800 000 IU/ml) Presence of comorbidities: - excessive alcohol consumption - coinfection with HBV and/or hepatitis delta virus - suspicion of medication-associated hepatotoxicity Genotype 2 and 3 Genotype 1 (and probably 4) with low HCV load (≤800 000 IU/ml) Clinical signs of cirrhosis Biopsies must be performed by trained physicians, as significant complications may occur in 1/200 patients. They should be read by specialized anatomopathologists, as subtle differences may change
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HIV/AIDS TREATMENT AND CARE Clinica
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© World Health Organization 2007 A
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iv Acknowledgements The editors wou
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vi Marco Vitoria (WHO headquarters)
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viii CRP C-reactive protein CS caes
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x LFT liver function test LGE linea
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xii TDM therapeutic drug monitoring
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xiv Introduction HIV is a chronic i
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Annex 7. Glossary .................
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HIV/AIDS TREATMENT AND CARE CLINICA
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HIV/AIDS TREATMENT AND CARE CLINICA
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10 HIV/AIDS TREATMENT AND CARE CLIN
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1 HIV/AIDS TREATMENT AND CARE CLINI
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I. Principles management of opportu
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management of opportunistic infecti
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Table 8. pcp second-line treatment
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Table 12. oesophageal and dissemina
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5.9.1.2. Treatment Table 15. treatm
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palliative care for people living w
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III. Initial evaluation palliative
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IV. Treatment palliative care for p
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Fig. 2. who analgesic ladder for ma
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Type of pain or treatment Usual sta
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Table 5. prevalence of symptoms in
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Type Symptoms Possible causes Disea
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Type Symptoms Possible causes Disea
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Table 22. Management of mania and B
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Table 24. Management of cough or di
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V. Special advice for terminal care
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Table 27. common manifestations in
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References palliative care for peop
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VI. Suggested minimum data to be co
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136 HIV/AIDS TREATMENT AND CARE CLI
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Contents I. Policy and principles .
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I. Policy and principles HIV/AIDS T
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HIV/AIDS TREATMENT AND CARE FOR INJ
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° bacterial pneumonia ° endocardi
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Page 195 and 196: HIV/AIDS TREATMENT AND CARE FOR INJ
Page 197 and 198: Social factors are: • homelessnes
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Page 209 and 210: ANNEX 1 ASI6 C © 2004 University o
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Page 235: HIV/AIDS TREATMENT AND CARE FOR INJ
Page 238 and 239: Contents I. Epidemiology and natura
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286 hiv/aids tReatment and caRe cLi
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I. Prevention strategies Prevention
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Prevention of HePatitis a, B, C and
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Prevention of HePatitis a, B, C and
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5. Contraceptive methods for women
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I. Policy issues Prevention of Hiv
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III. Initial evaluation Prevention
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Prevention of Hiv transmission from
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6. Fungal infections...............
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• Disseminated non-tuberculous my
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Annex 3. Rabies vaccines ..........
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442 hIv/aIds tReatment and caRe clI
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Contents I. Policy issues .........
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I. Policy issues post-exposure prop
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post-exposure prophylaxis for hiv i
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° condom use ° presence of STIs (
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Table 3. thre- drug arv regimens Pr
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VI. Suggested minimum data to be co
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History of antiretroviral treatment
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Test results: HBV: HCV: HIV: Post-t
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Infection control standard precauti
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The World Health Organization (WHO)
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