BHIVA audit on management of HIV/Hepatitis coinfection
Simon Collins, HIV i-Base
Each year BHIVA audit an aspect of HIV management and the degree to which recommendations included in UK guidelines are being followed in practice. The 2004 audit assessed the impact of last years BHIVA guidelines for management of patients coinfected HIV and hepatitis B (HBV) or hepatitis C (HCV). Preliminary results were presented at the 10th BHIVA Autumn Conference on Friday 8th October by Dr Shamela de Silva from St Mary’s Hospital, London.
The format for the audit is a questionnaire survey of 100 UK clinics, this year conducted from October 2003 – January 2004. Nineteen clinics were in the London NHS region and eight centres were exclusively haemophilia centres.
Eight clinics had >500 patients, 20 centres had 201-500 patients, 101-200 patients and 51-100 patients and 30 centres had less than 50 patients.
Increasing UK caseload
Increasing numbers of new HIV diagnoses bring direct financial pressure and limitations to service providers, as central budgets are not increased proportionally. This is the wider context for any HIV management survey and was clearly highlighted at the start of this presentation.
Over 60% centres had seen their caseload increase by over 15% in the previous year and 25% centres reported an increase of 5-15%. Only 2 centres (other than the six clinics dealing exclusively with haemophilia care) reported no increase in caseload.
BHIVA’s guidelines for both HBV and HCV were published last year and had been used by 87% clinics. Among those who’d read the respective guidelines around half found them “very” useful and a third “quite” useful.
Five centres said that none of their HCV coinfected patients HIV patients had so far required treatment for HCV, and 11 said they would refer HCV coinfected patients elsewhere. 21 centres had referred at least one patient to be assessed for liver transplantation, including five of six exclusive haemophilia centres.
Estimated prevalence of both HBV and HCV coinfection was largely underestimated by the majority of centres. 44 centres estimated HBV prevalence among their HIV patients as 0-3% and 32 estimated 4-6%. Five did not know or did not answer.
HCV prevalence was estimated by 48 centres as 0-3% and by 23 centres as 4-6%. Ten centres estimated 7-9% and 13 estimated >10%, including all 6 exclusively haemophilia centres. Six did not know or did not answer.
Access to viral load testing
Over 15% centres reported restrictions on access to HCV RNA and HBV DNA testing respectively, largely due to local availability and/or financial restrictions. 24 centres weren’t sure or didn’t answer (for HCV RNA).
HBV management was provided by the HIV unit in around 25% centres, and a further 15% in consultation with the HIV unit. 35% patients had HBV treated in a regional or local hepatitis unit. Just under 20% were not sure or didn’t answer.
Only fifteen clinics said they would offer liver biopsy to most HIV/HBV patients, (unless it was contra-indicated). Just over 25% would biopsy those considering HBV therapy, and around 20% only in cases of severe liver disease. More than a quarter of clinics were not sure or did not answer.
Choice of HBV therapy in patients whose HIV does not require treatment also varied considerably:
37 centres would start HAART early and include 3TC/tenofovir; 20 centres would use interferon; 15 centres use adefovir. Of concern, one centre chose lamivudine as their only option, and three centres chose lamivudine but not early ART with a lamivudine/tenofovir combination.
Antiretroviral treatment in patients not requiring HBV treatment showed broad choice of ARVs with HBV activity: half of the clinics in the survey would use dual 3TC/tenofovir. Twelve clinics selected lamivudine as their only choice, not in combination with tenofovir, apparently unconcerned about the long-term risk of HBV resistance. One selected tenofovir as their only choice.
The audit highlighted a range of vaccination schedules currently used in coinfected patients (44% using 0, 1, 6 months inc. 6/7 exclusive haemophilia centres; 23% 0, 1, 2, 12 months; 23% using 0,1, 3 weeks, 12 months). The 0, 1, 3 week, 12 month schedule which is the schedule recommended in DoH and CEG guidelines for GU clinic attendees, has not been tested in people with HIV.
Routine screening for HCV is now widespread although six clinics still do not routinely screen all adult HIV patients for HCV but all screen injecting drug users.
Although HCV genotype testing is recommended in the BHIVA guidelines only 38% clinics routinely genotype patients, and 40% only genotype people who are being assessed for HCV treatment. Genotype is such a major factor in treatment outcome, that it is difficult to understand how treatment could be considered or delayed without this baseline information. This is certainly an important area of patient concern. One centre selected “other” and 21 did not know or did not answer.
Liver biopsy in HCV Co-Infection is offered routinely in 27% centres, unless contra-indicated. A further 41 would offer biopsy to those being considered for HCV therapy. Thirteen selected other options and 19 weren’t sure or didn’t answer.
Restrictions on the availability of HCV treatment for co-infected patients were reported by 20% clinics – 10 for most therapies, 10 for some – relating to funding restrictions (n=16), lack of expertise (n=6) and two mentioned restrictions related to HIV status.
Overall, 40 respondents reported waiting times for HCV therapy for HIV patients of less than 3 months. 23 reported 3-6 months, eight reported 6-12 months, two longer than 12 months. 27 did not answer. Waiting times were longer in centres reporting restrictions on treatment access – of these, six (30%) reported waits of 6-12 months and two (10%) of more than 12 months.
Survey has shown support for BHIVA guidelines and yielded information about current practice regarding HIV/HBV and HIV/HCV co-infection.
The main areas of concern include:
- an underestimation of the prevalence of both HBV and HCV coinfection,
- that a small minority of clinics (six centres) still are not routinely screening for HCV.
- restrictions on access to HBV DNA and HCV RNA tests have a direct impact on the management of coinfection
- HCV therapy at the time of the survey was still not routinely available to all centres.
- Inappropriate choice of drugs are routinely made in some centres for treating patients with HBV coinfection
BHIVA coinfection guidelines are available on the BHIVA website: http://www.bhiva.org
The guidelines for management of coinfection with HBV and/or HCV are currently updated and will be presented in draft format for comment in early 2005. Results from this audit will be available on the BHIVA website and more detailed information of the BHIVA national clinical audit process is available on a website managed by the audit co-ordinator, Dr Hilary Curtis, at: