Lesson 3: Treatment as Prevention Core Competency 2: Primary and Secondary Prevention of HCV among PLWH Lesson 3: Treatment as Prevention PLWH = People Living with HIV July 2017

Authors and Funders This presentation was prepared by John Nelson, PhD, CPNP, (AETC National Coordinating Resource Center) for the AETC National Coordinating Resource Center in July 2017. This presentation is part of a curriculum developed by the AETC Program for the project: Jurisdictional Approach to Curing Hepatitis C among HIV/HCV Co-infected People of Color (HRSA 16-189), funded by the Secretary's Minority AIDS Initiative through the Health Resources and Services Administration HIV/AIDS Bureau.

Lesson Objectives This lesson will focus on patient education around best practices for treatment as prevention Discuss viral suppression impact on the transmission of both HCV and HIV Discuss the concept of “treatment as prevention” from the perspective of best health for the PLWH as well as for the prevention of HCV and/or HIV transmission to others Discuss partner(s) testing and treatment as needed for HCV, HIV, and other STIs Review voluntary, confidential partner notification requirements and the role of health department Disease Intervention Specialists

Definition What is “treatment as prevention?” HIV providers saw that PLWH with undetectable HIV VL were less likely to transmit the virus to uninfected sex partners The HIV Prevention Trials Network 052 (HPTN 052) study1 showed that, among heterosexual serodiscordant couples, reducing the HIV VL in the partner living with HIV significantly reduced HIV transmission by that person These findings, first published in 2011, galvanized the concept of “treatment as prevention”2 and led to “test and treat” initiatives as a means of lowering the community HIV VL globally Other studies have found similar results among different subpopulations of PLWH including MSM and PWID. NEXT

Viral Treatment Goals Treatment of HIV with ART reduces the risk of HIV transmission significantly Treatment of HCV with DAAs is done to cure the chronically infected person of HCV, making transmission impossible as long as this person doesn’t become reinfected The treatment of HIV infection with an appropriate ART regimen as early as possible after diagnosis is recommended. However, this requires that all persons be tested, diagnosed, linked to care, prescribed an appropriate ART regimen, remain adherent to this regimen, and remain retained in clinical care over time. For the treatment of HCV infection (in persons with mono-infection or those with HIV co-infection), appropriate directly-acting antivirals (DAAs) are used to eliminate all HCV from the body and to cure the individual of HCV infection. As long as there is no more detectable HCV (24 weeks after treatment end), transmission to another is impossible unless the person has become re-infected. NEXT

Ask, Screen . . .4,5 Ask all patients about sexual behaviors, including genital, anorectal, and oral sex Screen for STIs: genital anorectal oropharyngeal blood

Intervene4,5 Ulcerative lesions (e.g., primary syphilis, chancroid, HSV lesions) may facilitate the transmission of HCV and/or HIV6 Treat and counsel on harm reduction of reinfection (see Lesson 2.1) HSV = Herpes Simplex Virus

Screen for Mental Health Disorders Depression Drugs and Alcohol Use Anxiety Disorders Trauma See also Module 5.2: Neurocognitive Disorders and Mental Illness Validated screening tools for adults and adolescents are available in the AETC National HIV Curriculum: https://aidsetc.org/nhc .

Substance Use/Mental Health Disorders Substance Use Disorder and other Mental Health Disorder treatment must be included to reduce the risks of: Further liver damage (primarily from alcohol) HCV reinfection or superinfection Transmission behaviors associated with substance use3,7-9 NEXT

Partners5 Partner notification counseling should be provided about HIV/HCV testing of past and present sex partners and drug equipment-sharing partners Harm-reduction counseling should be provided for partners who test negative for HIV and/or HCV (see Lesson 2.1) Linkage to care should be provided for those identified to have HIV and/or HCV infection(s) Although Partner Notification with the regional or state department of health is required for voluntary contact tracking related to HIV infection and other sexually transmitted infections (e.g., syphilis, gonorrhea, Chlamydia), however it is not required for HCV infection. However, asking patients/clients to voluntarily identify drug equipment (injection and intranasal) sharing and/or sexual partners (primarily when engaging in anal intercourse) for testing may lead to identification of others in the community with HIV and/or HCV who are unaware of their status. If HIV-uninfected, then HIV pre-exposure prophylaxis (PrEP) could be offered to these partners, and if HCV-uninfected, then harm reduction counseling can be provided and reinforced. If a partner tests HIV and/or HCV infected, linkage should be done to get that person into care. Partner Notification Information: https://www.cdc.gov/nchhstp/partners/ HIV Testing Directory: https://gettested.cdc.gov/ NEXT

Key Points Decrease incidence and risk of new infection or reinfection in a community through: Harm-reduction education and resources Testing, diagnosis, and cure of all persons with chronic HCV infection as early as possible Testing, diagnosis, and treatment for all PLWH as soon as possible Providing needed substance use disorder treatment and other mental health services NEXT

Disclaimer and Permissions Users are cautioned that because of the rapidly changing medical field, information could become out of date quickly. You may use or present this slide set and other material in its entirely or incorporate into another presentation if you credit the author and/or source of the materials. The complete HIV/HCV Co-infection: An AETC National Curriculum is available at: https://aidsetc.org/hivhcv.

Lesson 2.4: Preventing HCV Reinfection Continue to next lesson Lesson 2.4: Preventing HCV Reinfection