1. 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

2. 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 ), funded by the Secretary's Minority AIDS Initiative through the Health Resources and Services Administration HIV/AIDS Bureau.

3. 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

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

7. 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

8. 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: .

9. 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
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10. 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:
HIV Testing Directory:
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11. 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
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12. 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:

13. Lesson 2.4: Preventing HCV Reinfection
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Lesson 2.4: Preventing HCV Reinfection