8 WORLD GASTROENTEROLOGY NEWS JANUARY 2015 Editorial | Expert Point of View | Gastro 2015: AGW/WGO | WDHD News | WGO & WGOF News | WGO Global Guidelines | Calendar of Events the risk of fulminant hepatitis. Occult hepatitis B is also more prevalent in HIV infected people and HCC occurs at a younger age and is more aggres-sive 10, 11. HIV/HBV co-infected individuals have higher HBV DNA levels and liver-related mortality from chronic hepatitis B was increased in the pre- HAART era (RR of liver death 17.7 in co-infected compared to mono-infected individuals) 12. Liver-related mortality is twice as high for chronic hepatitis B co-infected as for chronic hepatitis C co-infected individuals. A CD4 count of <200 cells/mm3 is associated with a 16.2 fold increase in risk of liver-re-lated death compared to a CD4 count of >350 cells/mm3 13. Additionally, a potential association with adverse HIV outcomes in HBV co-infected individuals was demonstrated in the SMART study where HIV associated immune deficiency was enhanced by active HBV replication14. Also, an HBeAg positive status has demon-strated an association with a slower virological response to HAART, compared to an HBeAg negative sta-tus 15. However, no long-term effect on clinical HIV outcome has been demonstrated in co-infection. Management of HIV/Hepatitis B and HIV/Hepatitis C co-infection Ideally, all HIV positive patients must be screened for HBsAg and hepatitis C antibody using existing HIV diag-nostic infrastructures. However, there is limited infrastructure for molecular virology in sub-Saharan Africa and screening tests are costly. In order to correctly diagnose and manage HIV co-infections, there is a need for affordable, sensitive and specific point-of-care testing for HIV, HBV and HCV. Here, the need for WHO pre-qualified diagnostic tests to be ap-proved and available is crucial. Advocacy for the screening of mothers for HIV, hepatitis B and hepatitis C with initiation of appro-priate anti-retroviral therapy, mother-to- child prevention therapy together with a birth dose of HBV vaccination, would significantly assist in decreasing the neonatal and infant transmission of HIV and HBV. A meta-analysis of 550 HIV/ HBV co-infected patients confirmed that Tenofovir suppresses HBV to undetectable levels in the majority of HBV/HIV co-infected patients with the proportion fully suppressed continuing to increase with time on treatment. Prior treatment with Lamivudine or Emtricitabine does not alter the efficacy of Tenofovir treat-ment 16. The fixed dose combination once daily therapy of Lamivudine or Emtricitabine, Tenofovir and Efavirenz is easy to administer and benefits adherence, an essential factor for viral suppression. The immune reconstitution syndrome, following the initiation of HAART, can lead to potentially life-threatening flares of hepatitis B, especially in individu-als with low CD4 counts. Cirrhosis risk in HBV co-infected individuals virally suppressed on Tenofovir-based HAART is low 17. Peg-Interferon and Ribavirin treatment can be considered in HIV/ HCV patients with CD4 counts of >500 cells/mm3, however, given the need for intensive monitoring, risk of adverse effects, cost and lack of availability, it is not appropriate for many regions in sub-Saharan Africa. The new era of all oral Direct-Acting Antiviral (DAA) therapy for hepatitis C is the ideal for sub-Saharan Africa. Pan-genotypic combination DAA therapy with high efficacy requir-ing a minimum of diagnostics and monitoring, would allow for simpler management of co-infected patients without the requisite need for com-plex diagnostics. The PHOTON-1 study has demonstrated efficacy for Sofosbuvir, a pan-genotypic NS5B polymerase inhibitor plus Ribavi-rin given for 12-24 weeks to HCV genotype 1-3 co-infected patients, all of whom were on stable HAART ther-apy. Sustained virological response (SVR) rates ranged from 76-94% 18. Improved efficacy approaching 100% SVR rates has been demonstrated with other pan-genotypic DAAs such as the NS5A inhibitor, Daclatasvir in combination with Sofosbuvir. The challenge will be the accessibility and affordability of these therapies. The phenomenal success in upscal-ing HAART in sub-Saharan Africa has provided the model as to how this can be achieved and access to therapies for hepatitis C should follow similar principles. Conclusion Liver disease due to chronic hepa-titis B and C is a significant cause of morbidity and mortality in HIV infected individuals. Early diagnosis of co-infections, initiation of HAART at CD4 counts ≥350 cells/mm3 and the effective treatment of hepatitis C are essential to prevent liver disease. References Matthews GV, Manzini P, Hu Z et al. Impact of lamivudine on HIV and hepatitis B virus-related outcomes in HIV/hepatitis B virus indi-viduals in a randomized clinical trial of antiretroviral therapy in southern Africa. AIDS 2011; 25: 1727–1735. Stabinski L, Reynolds SJ, Ocama P et al. High prevalence of liver fibrosis associated with HIV infection: a study in rural Rakai, Uganda. Antivir Ther 2011; 16: 405–411. Ibrahim A, Shpaner A, Nieto J. Risk factors of accelerated liver fibrosis in HIV-HCV coinfection: a matched analysis. South Afr Gas-troenterol Rev 2004; 2(3): 14–17.
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