Kenneth Sherman, MD, PhD: Challenges in Viral Hepatitis

After presenting on current and future challenges in treating hepatitis B, Kenneth Sherman, MD, PhD, sat down with MD Magazine^® to discuss the current state of viral hepatitis infections.

While attending 2018 ID Week Annual Meeting in San Francisco, CA, the Gould Professor of Medicine and Director of the Division of Digestive Diseases at the University of Cincinnati College of Medicine discussed the treatment of viral hepatitis in a variety of populations, including immunosuppressed patients such as individuals infected with HIV.

MD Mag: Could you speak to the current state of hepatitis B vaccinations? What are patients’ best options for care?

Kenneth Sherman, MD, PhD: When we talk about hepatitis B vaccination, we have 2 populations to consider. First, those who are immunocompetent. The vaccines that we have and have had since the eighties are excellent in that population in terms of preventing infection, with a caveat that we do not do a very good job—as revealed by a recent large study— [in getting] patients [to] receive all 3 shots that are required to achieve protection responses.

In the immunocompromised patients, including those with HIV, we face a different story. In those patients, the current standard vaccination routines are not nearly as effective. In those with HIV, standard vaccination procedures give us a protective response in 35% to 75% of patients, leaving us with a big gap.

In recent years there have been efforts to find ways to bridge that gap and those include more frequent dosing, increased dose of the actual vaccination protein, alteration of the site where the vaccine is given—perhaps intradermal vs subcutaneous vs intramuscular vaccination, and most recently, the addition of adjuvants that may help improve the immune response. All show some benefit in some patients. But we have yet to achieve the nearly 100% vaccine response that we see in immunocompetent patients.

In the era of direct-acting antivirals (DAAs) for hepatitis C, and antiretroviral therapies for HIV, how has the treatment and management of co-infected patients changed?

For many years, when we only have pegylated interferon, the majority of patients with HCV/HIV coinfection were not actually treated. Patients and their health care providers shied away from offering and providing those treatments for hepatitis C because of the high rate of side effects.

In the era of direct-acting antivirals (DAA), which came to fruition with all DAA regimens in 2013, we’re seeing similar rates of response rather than decrements in response and greater patient and physicians’ acceptability of those regimens. And so, the modern era of DAAs has really changed the world in the coinfected patient, and, for the first time, lets us think about the eradication of hepatitis C in HIV, which would eliminate 1 of the important causes of chronic liver diseases.