Hepatitis C virus and HIV: which to treat first?

There remains some disagreement about whether HIV or HCV should be treated first in co-infected individuals. The best time to start treatment for HIV or hepatitis C depends on the stage of each infection. If tests show both diseases should be treated, doctors will usually start treating HIV first, as this is typically the more rapid and life-threatening of the two diseases. Secondly, once HIV is under control and CD4 cell counts rise above 200 cells/mm³, people respond better to interferon and are better able to tolerate the side-effects of HCV therapy (Uberti-Foppa 2003). It is recommended that patients whose immune systems have been significantly depressed should receive antiretroviral treatment for HIV first to increase CD4 T-cell counts before beginning treatment for HCV.¹

Conversely, hepatitis C may be treated first if, for example, a person has rapidly progressing or severe liver disease and a CD4 cell count above 350 cells/mm³.

United States experts have recommended that HCV treatment should be delayed in individuals with highly chaotic or stressful lifestyles, and in those suffering from depression, due to the potential psychiatric side effects of interferon. The 2002 United States National Institutes of Health hepatitis C guidelines recommend that active addictions should be treated prior to treatment for hepatitis C. However, they state that no group should be automatically excluded from treatment, and that each case should be considered on an individual basis.

Until more definitive data is available, concurrent treatment with HAART and interferon and ribavirin should be regarded as experimental, as possible drug interactions are unknown. Close monitoring of people taking both HAART and anti-HCV therapy is advised. At least one study has shown that concurrent HCV treatment does not impair response to HAART.