HIV-positive individuals co-infected with hepatitis B (HBV) or hepatitis C (HCV) are not receiving uniformly optimum care throughout the United Kingdom and Ireland, according to the preliminary results of a confidential audit by the British HIV Association (BHIVA), and presented at BHIVA’s Autumn conference in London earlier this month. Last year, BHIVA published detailed guidelines on the monitoring and treatment of HBV and HCV co-infected patients.
Between October 2003 and January 2004, researchers from BHIVA’s national audit programme sent questionnaires to 100 clinical centres throughout the United Kingdom and Ireland that treat patients co-infected with HIV and either HBV or HCV (or both). Although 87 respondents said they had read both the HBV and HCV guidelines, and one the HCV guidelines only, twelve had read neither the HBV or HCV co-infection guidelines.
The audit found the following causes for concern:
Hepatitis B
- Some centres are treating patients co-infected with HIV and HBV inappropriately
One clinical centre offers 3TC (lamivudine, Zeffix / Epivir) monotherapy as its only treatment option, and a total of three clinical centres offer 3TC alone for HBV therapy in patients whose HIV does not require treatment. The guidelines recommend that 3TC should never be used as HBV monotherapy because HIV can rapidly develop resistance to the drug when used alone.
- There are restrictions on access to HBV DNA testing at 17 centres
Eight centres reported that this was due to lack of local availability; four reported that this was due to financial restrictions; three reported both lack of local availability and financial restrictions; two reported other reasons. HBV DNA testing plays an important part in the assessment and management of HIV / HBV co-infected patients.
Hepatitis C
- There are restrictions on access to HCV therapy
A total of 20 respondents reported restrictions on the availability of HCV treatment for co-infected patients; ten for most therapies; and ten for certain therapies. Sixteen mentioned funding restrictions, including four who are only funded for interferon (IntronA / Roferon-A / Viraferon) rather than pegylated interferon (Pegasys / PegIntron / ViraferonPeg), which, when combined with ribavirin (Copegus / Rebetol / Virazole), is the state-of-the-art in HCV therapy. Six centres responded there are restrictions due to lack of expertise, and two mentioned restrictions related to HIV status.
- There are restrictions on access to HCV viral load testing
Sixty-one respondents confirmed that HCV viral load testing is routinely available at their clinical centres. However, 15 said that it was not routinely available, and 24 were not sure or did not answer. HCV viral load testing (HCV PCR) is a critical part of the assessment and management of hepatitis C.
Due to the confidential nature of the audit, the centres where treatment is less than optimal cannot be named.
The full audit will appear on the website of BHIVA’s clinical audit facility in the near future.
The BHIVA HIV/HBV guidelines can be found here.
The BHIVA HIV/HCV guidelines can be found here.
de Silva S et al. BHIVA national clinical audit report: Hepatitis B or C co-infection survey. Tenth Anniversary British HIV Association Autumn Conference, London, 2004.