The 6th International Workshop on HIV and Hepatitis co-infection held at the Hilton Hotel Tel Aviv, Israel from the 31st May to June 2nd 2010.  The workshop was organized by Virology Education and sponsored by pharmaceutical companies including GILEAD, Merck Sharp & Dohme (MSD) and Erasmus MC.

The workshop had several eye opening presentations revealing that Hepatitis and HIV co-infection is fast becoming a burden of concern especially in Asia, Africa and the South American continents. Dr. Kenneth E. Sherman from University of Cincinnati in the United States made a presentation on “How to evaluate elevated liver enzymes.” He said that evaluating elevated liver enzymes could help determine liver injury and functional status of the liver. He presented broad liver function tests used to determine Alanine transaminase (ALT) and Aspartate transaminase (AST) levels in presented cases. According to him determining Alanine transaminase (ALT) is more significant to diagnosis of liver disease. He said that test results with ALT levels greater than 30 international units per liter (>30IU/L) for men and ALT levels greater than 19 international units per liter (>19IU/L) for women should be given attention since this figures have been ratified by several medical associations as an indication of liver disease.

Dr. Vincent Soriano Assistant Director of the Department of Infectious Diseases at Hospital Carlos III in Madrid, Spain delivered a lecture on determining and assessing liver fibrosis stage. He presented and explained the four stages of liver fibrosis including Portal track (FI), Periportal (F2), Septal Track (F3) and the Cirrhotic stage (F4). He said the limitations in carrying out fibrosis tests include the need of fragments of up to 2cm, risk of severe complications and cost per patient estimated to be about 1000 Euros. He mentioned and explained the procedure of two fibrosis tests available including imaging tests and serum fibrosis indexes. In his conclusion, he mentioned that no ideal fibrosis staging test exist at the moment.

The management of end stage liver disease (ESLD) was presented by Dr. Massimo Pouti from University of Brescia Italy. He said ESLD could be monitored through fibroscan and biopsy. The management of ESLD tries to change the course of cirrhosis, treat underlying diseases, treat HIV in co-infected patients, reduce portal pressure, and ameliorating systemic hyperdynamic circulatory state using antibiotics and albumin. He reviewed the exceptional cases and noted that HCV and HIV co-infected patients due for transplant have the same indicators, are put on the same waiting list, and have the same donors.

The state of the art management of Hepatitis B & C as presented by Dr. D. Dieterich from Mount Sinai Medical Centre, USA showed that between 15 and 50 new Hepatitis B and C drugs were at various stages of trials. He said the new drugs are termed Direct Action Antivirals (DAA) using protease inhibitors. According to him, a new drug on in phase III trial has achieved a 75% Sustained Viral Response (SVR) after a 24 weeks regimen and a 6.9% -7.7% discontinuation rate after 8 -12 weeks. He said the drug is Telaprevir based treatment and would be ready by the 3rd quarter of 2011. He said that HBV is a growing and insidious threat to world health. Vaccination is key to prevention and the new treatment paradigms are parallel to new HIV treatments.


Another interesting presentation was by Marie-Louise Vachon from the Mount Sinai School of Medicine on “Aging Liver in HIV.” She said that HIV prevalence amongst people over 50 years in the US increases from 17.4% in 2004 to 26% in 2006. She explained that Microbial Translocation leads to systematic immune activation through the depletion of CD4 T-Cells in the abdomen by chronic HIV infection aiding the translocation of microbial products into the mainstream and the liver. She said that the liver is a major target of the aging process in HIV infected patients and this has been attributed to multiple causes. According to her, studies have shown that prolonged exposure to didanosine ARVs can trigger immune activation and lead to non-cirrhotic portal hypertension and severe liver disease.

The Director General of NACA Professor John Idoko was one of the invited speakers and presented a paper titled “Management of Hepatitis C (HCV) and B (HBV) in resource limited settings (RLS).” According to Prof. Idoko, HIV negatively affects the natural history of chronic Hepatitis B. He said that HIV increases the risk of chronic Hepatitis B up to 6 times, reduction of HBV e antigen (HBeAg), increase HBV DNA, and increase Hepatocellular Carcinoma (HCC) with reduced CD4 count. He said in the last five years increased treatment of HIV infected patients have reduced morbidity rates in Nigeria but the paradigm shift is the growing number of AIDS cases due to co-infections with Tuberculosis and liver related complications. The goals of Hepatitis B treatment as presented by the DG include prevention of long term clinical outcomes, primary treatment endpoints (sustained decrease in HBV DNA levels low or undetectable), secondary treatment endpoint in resource limited settings (decrease or normalize serum ALT, improve liver histology, induce HBeAg loss or seroconversion, and induce HBsAg loss or seroconversion). The DG said that out of the over 400 centers treating HIV in Nigeria, only the University of Jos Teaching Hospital has the capacity to carry out HBV DNA tests. This situation has necessitated the reliance on the secondary treatment endpoints in Nigeria.

In the Management of Co-infected patients in resource limited settings, the DG mentioned that there is a need for the modification of recommendations to account for the limited availability of anti-HBV agents and diagnostics. He said that out of the seven agents used for treatment in high income countries, only Lamivudine (3TC) is widely available in resource limited settings. Tenofovir disoproxil fumarate (TDF) and Adefovir have limited availability however TDF is becoming increasingly available due to the expansion of ART sites. Antiretroviral treatment has moved from less than 500, 000 patients to about 4 million in resource limited settings in the last five years and this has led to the increase of TDF. He presented the WHO guideline of 2009 that “everyone with Hepatitis B virus (HBV) co-infection that needs treatment should start treatment with a regimen based on Tenofovir and either 3TC or FTC, regardless of the CD4 T Cell count” and said the same guideline says HIV patients should be treated much earlier. This would put a lot of strain on countries in terms of the number of patients requiring treatment and expansion of facilities to use TDF, carry out screening and address complications.

With regards to HCV/HIV co-infection in resource limited settings, Prof. John Idoko said that there is a dearth of data but it is widely known that HIV accelerates HCV disease, and HCV infection influences HIV in terms of ARV associated hepatoxicity, response to ARV therapy, Natural History of HIV increase, and extrahepatic manifestations.  According to him, the management of HCV/HIV con-infection in resource limited settings are in stages which include diagnosis and clinical evaluation, determining if HCV is active viral infection, monitoring, treatment (Pegylated interferon, Ribavirin, Alcohol, Substance use, psychiatric illness), diagnosis of end stage liver disease, liver transplant (Not Available), and Palliative management (Cirrhosis, HCC).

In his conclusion, Prof. Idoko said that the high prevalence of HIV and HBV co-infection has given rise to a high burden of co-infection;  management of HBV, HCV and co-infection with HIV is handicapped by the availability of drugs and diagnostics; among HIV infected Nigerian individuals, HBV co-infection, especially among those with high volume of HBV replication, was associated with lower CD4+ T Cell count at ART initiation; patients with HBeAg positive status had a lower virological response to ART compared with HBeAg negative patients.