Co-infected HIV/HCV with Multiple DDIs

A report on Erica Peter's presentation "Interactive Case Study: HIV-HCV and PWIDS"

Dr Erica Peters, a local Glasgow ID physician, has seen a disturbing rise in the incidence of HIV (133 in the last few years, 1/3 women) in the population of people who inject drugs in Glasgow: many are co-infected with HCV. This population poses challenges for decision-making on drug therapy given that many people in this population are both taking both prescribed and recreational drugs.

Dr Peters presented the case of a 43-year-old woman who was diagnosed with HIV as part of an outreach clinic. At time of diagnosis, she had clade C virus with CD4+ 435, VL 63 000, HCV positive (6.02 log GT 1a).

The treating team wanted to find the simplest regimen possible for this woman: single tablet, once daily, and non-boosted. They decided on Triumeq and Epclusa but both interacted with the carbamazepine she took for withdrawal seizures, apixaban for a past DVT, and PRN omeprazole. The challenges of prescribing for cases like this was discussed by Dr Peters and she pointed us to the reference material and other resources (in addition to the interaction checker) that can be accessed on the Liverpool HIV Interactions website.

Their approach was: switch carbamazepine to levetiracetam (Keppra) through a locally developed switch protocol; discontinue the apixaban, which had been prescribed following a provoked DVT several months before (and within local guideline, could easily be stopped); and through careful history revealed that she didn’t feel the need for a PPI often so it was discontinued.

Cases like these give us opportunity to not only reflect on our own practice but how our health systems are meeting the needs of complex and vulnerable clients. By being the prescriber for the HIV and HCV treatment course, we can rationalise other medications -- perhaps even reducing medication burden posed by sporadic interactions with the healthcare system. It also underlines a wonderful opportunity to streamline therapy between specialities: Dr Peters and her team worked with the local neurology unit to develop the switch guideline, meaning that clients wouldn’t have to wait for a specialist appointment. Finally, it also emphasises the need for doctors, nurses and pharmacists to participate in outreach and meet people where they’re at, which can have an amazingly positive effect.

Author bio: Ian is currently a PHO (Registrar) at Cairns Sexual Health Service and a GP Registrar. He has a keen interest in holistic health including the implementation of change on the system level. Ian has a background in education, public health, and leadership having completed a Master of Public Policy at Simon Fraser University and courses in Medical Leadership at UQ. His interests expand to global health and health equity and consequently has been involved in health projects overseas.