Introduction

Human immunodeficiency virus (HIV) and Hepatitis C virus (HCV) infections can cause significant morbidity and mortality if left untreated. The Centers for Disease Control and Prevention (CDC) estimates that 1.1 million adults and adolescents are living with HIV infection¹ and 3.5 million individuals are living with chronic HCV infection.² A significant portion of the individuals infected do not know that they are infected. Fortunately, there are available antiviral treatments that are effective at suppressing HIV replication and eradicating HCV.^3,4 These treatments not only decrease the chances of disease progression but also decrease the risk of transmitting the diseases to other individuals.^3,4 Therefore, it is vital that appropriate patient groups are screened for these viral infections and then linked to care with appropriate healthcare providers.

Patients who should be screened for HCV include both patients who are in certain risk groups as well as those born between 1945-1965.⁴ HCV is most efficiently transmitted by infected blood-to-blood contact. Therefore, those individuals who should be screened due to risk include those who could have come into contact with HCV-infected blood, such as injection drug users, patients on long-term hemodialysis, healthcare workers after a needle stick injury, children born to HCV-infected mothers, and patients receiving blood before 1992.⁴ Additionally, individuals who were ever incarcerated, have HIV infection, have unexplained liver disease, and solid organ donors should be screened for HCV.⁴

All individuals at least 13 years of age should be tested for HIV at least once as a part of routine healthcare.⁵ For those patients who may come into contact with HIV-infected bodily fluids (e.g., blood, semen, vaginal fluids, rectal fluids, breastmilk), at least yearly screening is recommended.⁵

Patients diagnosed with HIV and/or HCV should undergo further testing, evaluation, and counseling. The counseling for both infections includes ways to reduce the risk of transmission to others and encouragement to have sexual partners tested.^3,4 Additionally, counseling should focus on reducing disease progression, both through antiviral treatment and non-pharmacologic methods. For example, alcohol consumption should be avoided in patients with HCV because both can hasten liver function decline.⁴ Patients diagnosed with HIV should be counseled about the risk of and signs and symptoms of opportunistic infections.³

In addition to direct clinical care, pharmacists are involved in the public health aspect of HIV and HCV care by participating in the screening and detection process for both viruses.^6,7 Pharmacists assist in identifying patients and patient groups who should be screened for HIV and/or HCV, conducting the screening test when applicable, counseling patients on the results of the screening test, assisting other health care providers with interpretation of screening results, and linking patients to further care if the screening test returns positive.

Case

CC: “My new fiancée wanted me to get ‘checked up’ by the doctor before we got married.”

Patient: RC is a 55-year-old male (70 in, 200 lb) who works as a car mechanic in Georgia. At his fiancée’s request, he saw his usual PCP who ordered a number of lab tests. He has now received new diagnoses of HIV and HCV infection from his physician and is presenting to the clinic pharmacist.

HPI: Presented to clinic one month ago. No significant complaints at that time or at this visit. Patient denies any history of rash, fever/chills, night sweats, and jaundice.

PMH: Hypertension (x 5 years); HIV (diagnosed at this visit); Hepatitis C (diagnosed at this visit)

FH:

• Father: died at age 75 from a MI, had prior hypertension and dyslipidemia
• Mother: died at age 76 from a CVA, had prior hypertension
• Siblings: One brother, 58 years old, alive with hypertension and dyslipidemia
• Child(ren): One son, 25 years old, alive and well

SH:

• Reports drinking one 12 ounce bottle of beer per day
• Denies current smoking, but smoked one-half pack per day for 10 years and quit 10 years ago
• Denies current illicit drug use, but did inject heroin “just one time” in the mid-1980s

Sexual History:

• Identifies as heterosexual and has been sexually active since 18 years old.
• Monogamous during prior 15 year marriage to a woman.
• For the last five years, he has had vaginal, anal, and oral sex with multiple female sexual partners until meeting current fiancée six months ago.
• Has not participated in oral, anal, or vaginal sex in current relationship with fiancée, but has been monogamous.

SDH: RC is English-speaking with a high-school diploma (with a few trade school courses). His annual income (with fiancée) is approximately $75,000. He lives in a single family home with his fiancée.

Medications:

• Hydrochlorothiazide 25 mg daily
• Ibuprofen 200 mg every 6 hours as needed for “aches and pains”

Allergies: NKDA

Vitals:

• BP (seated) 128/76 mm Hg
• Other vital signs WNL

Labs:

• HIV screen: positive
• HIV viral load: 56,783 copies/mL
• CD4 count: 562
• HIV genotype: wild type virus
• HCV screen: positive
• HCV viral load: 125,000 IU/mL
• Hepatitis A antibody: Nonreactive
• Hepatitis B surface antigen: Nonreactive
• Hepatitis B surface antibody: Nonreactive
• Hepatitis B core antibody: Nonreactive
• Other labs: WNL
• Other health screenings: negative

Case Questions

1. The patient understands how he potentially contracted HIV due to his sexual activity in the last year, but he wants to know if that’s how he got Hepatitis C as well. How do you counsel him about the similarities and differences in the transmission risks of the two viruses?

Hepatitis C is most readily transmitted by infected blood to blood contact. Since he does have a history of injection drug use, which is a very likely source of transmission (even though he only injected “one time”). Hepatitis C is less commonly transmitted sexually. HIV is transmitted by infected bodily fluids (not only blood, but semen, rectal fluids, vaginal fluids, and breast milk).

2. Now that the patient knows how HIV and Hepatitis C are transmitted, he desperately wants to know how to prevent transmitting it to his fiancée. What options are there for both him and his fiancée to lessen transmission risks?

First, the fiancée should be screened for both viruses, as well as other sexually transmitted infections. If she is found to be uninfected, suppressing both viruses with antiviral treatment is an effective way to decrease the risk of transmission. Hepatitis C is curable with up to 12 weeks of treatment in most patients, often with one daily pill. HIV will require lifelong treatment, but effective treatment may be accomplished with as little as one daily pill. Additionally, the couple should use a male condom with all sexual activity to limit transmission risks. He should avoid sharing any toothbrushes and razors, and to cover any bleeding wounds. They should avoid any injection drug use. The fiancée could also be evaluated for the use of HIV Pre-exposure Prophylaxis (PrEP), which has been shown to further reduce the risks of transmission in combination with condom use.

3. RC is unsure that he is ready to start treatment for either disease yet. Besides further discussing treatment details with him, what non-pharmacological recommendations can you give him to help lessen his risk of disease progression?

For Hepatitis C, he should try to avoid drinking alcohol since alcohol and Hepatitis C can both cause damage to the liver and potentially lead to cirrhosis and other complications. The patient should also discuss any new medications with his pharmacist or physician to ensure no additional risk of hepatotoxicity. He appears to be susceptible to both Hepatitis A and B, so he should receive vaccinations for those conditions. Additionally, since his BMI indicates he is overweight, he is at risk for non-alcoholic fatty liver, which is a risk factor for additional liver disease progression; he should make attempts to lose weight through diet and exercise. Based on the patient’s CD4 count, he is not currently at risk for any opportunistic infections. However, he should be counseled about signs and symptoms of common opportunistic infections and other infections and instructed to present to a healthcare provider if he starts to show any signs or symptoms.

4. How would you counsel the patient about the possibility of being a blood and/or organ donor?

Due to his diagnoses of HIV and Hepatitis C, he will not be able to be a blood donor. Being an organ donor is possible, but notification of these diagnoses will need to be made (HOPE act: https://optn.transplant.hrsa.gov/learn/professional-education/hope-act/).

5. Because a diagnosis of HIV and HCV can be devastating and carries negative stigma, what steps can you take to help the patient cope with the new diagnosis?

Asking the patient if he would like a referral to a psychologist, social worker, or a patient support group, if not already a standard part of the clinic’s procedures, is prudent at this point. Encouraging him to share the information with his fiancée and other friends/family whom he thinks will be supportive. Also, ensure that all of the patient’s questions are answered before leaving the appointment; this will help prevent the patient from having additional misconceptions about his diagnosis.

Author Commentary

HIV and HCV are two common viral illnesses that create significant morbidity and mortality. Pharmacists play several important roles in the care of these patients. As modeled in the above case, pharmacists are commonly involved with an interdisciplinary healthcare team and will counsel patients shortly after a diagnosis is made. While the bulk of this conversation usually centers on antiviral medications the patient will receive for treatment, there are other important counseling points that pharmacists should make regarding transmission risks and other management considerations besides antiviral treatment, including but not limited to determining need for vaccinations, particularly Hepatitis A and B, and maintaining a healthy lifestyle.

Patient Approaches and Opportunities

Receiving a diagnosis of HIV and/or Hepatitis C can be a devastating situation for a patient. There is still stigma surrounding diagnoses of these diseases even though they are treatable. Therefore, it is important to assess how the patient is coping mentally and emotionally during this counseling session. It might be prudent to offer a follow-up clinic visit or phone call to discuss some of the necessary counseling points if the patient seems overwhelmed. Additionally, keep in mind possible cultural concerns that might cause patients to feel uncomfortable talking with the pharmacist about these particular diagnoses. Asking the patient what you can do to make them more comfortable for this discussion is prudent. One important counseling point at this time of diagnosis is discussion about risks of transmission with sexual partners. The patient’s sexual partner(s) should be screened for all sexually transmitted infections, including HIV and HCV. This is also an ideal time to counsel a patient on safer sexual practices, such as barrier methods, as well as the possible use of pre-exposure prophylaxis if the sexual partner is not infected with HIV.