Hepatitis C virus treatment in co-infected people

As is the case for people with hepatitis C alone, the standard anti-HCV regimen for HIV / HCV co-infected people is peginterferon plus ribavirin. In February 2005, the European Commission and the United States Food and Drug Administration (FDA) approved peginterferon alfa 2a (Pegasys) for use with or without ribavirin for co-infected patients with chronic hepatitis C.

Because co-infection with HIV accelerates HCV-related liver disease progression, some experts argue that all co-infected people should receive anti-HCV therapy.¹ Researchers who found that HAART has no impact on the development of fibrosis in co-infected people have argued that treatment for hepatitis C should be started as soon as possible.²

United Kingdom guidelines recommend that HCV treatment should be considered for all HIV-positive individuals, particularly if they have developed moderate or worse liver disease. Treatment ideally should be initiated whilst a patients CD4 cell count is above 200 cells/mm³, as treatment at lower CD4 cell counts has been associated with a poorer response. Treatment should also be considered in the case of mild disease, particularly if the patient wishes to commence treatment and there are high hopes of success. In cases of advanced cirrhosis or liver cancer, co-infected patients can be good candidates for liver transplant if their HIV prognosis is good.

The usual recommendation is that co-infected individuals should continue HCV therapy for the same duration as people with HCV alone (48 weeks for genotype 1; 24 weeks for genotypes 2 or 3). However, some research suggests that co-infected people clear HCV more slowly after starting treatment, and some experts recommend lengthening treatment duration to 72 weeks for genotype 1 and 48 weeks for genotypes 2 or 3.³ The benefits of 48 weeks' treatment for genotypes 2 or 3 have been confirmed in a small randomised controlled trial of HIV-co-infected patients. In this study, patients receiving peginterferon alfa and ribavirin for 48 weeks were over five times more likely to achieve an SVR than those who stopped therapy after 28 weeks.⁴

As is the case for people with HCV alone, response to treatment at 12 weeks predicts whether or not co-infected individuals will ultimately achieve a sustained virological response One study suggested that early virological response at eight weeks might be adequately predictive of SVR,⁵ but here too some experts think HCV treatment response is delayed in HIV-positive people and even 12 weeks is too early.

Although there is little evidence, treatment of early hepatitis C infection in HIV co-infected patients appears to be less successful than those without HIV.⁶

Guidelines on the management of HIV / HCV co-infection published by the British HIV Association (BHIVA) in 2005 make the following recommendations:⁷

• Screen all HIV-positive patients for HCV at HIV diagnosis and subsequently according to risk.

• Perform a PCR test in patients with unexplained liver disease.

• HIV / HCV co-infected individuals should be vaccinated against hepatitis A and B.

• Monitor patients thoroughly, including liver biopsy to assess disease severity.

• HIV / HCV co-infected patients should abstain from alcohol.

• Consider treatment with peginterferon plus ribavirin, or enter into a clinical trial. Treatment is most appropriate in patients with moderate disease.

• Treat patients who have a CD4 cell count above 200 cells/mm³ before commencing HAART, if possible, to reduce risk of liver toxicity.

• In patients who are already on HAART, delay HCV therapy until CD4 cell count is above 200 cells/mm³.

• AZT (zidovudine, Retrovir) and ddI (didanosine, Videx / VidexEC) ideally should be avoided in patients receiving ribavirin.

• Monitor liver function carefully if HAART is initiated and observe serum lactate for nucleoside analogue toxicity, especially in those on ribavirin.

• All HIV-positive patients with HCV who do not have evidence of liver damage should be screened annually.

• Patients who eradicate HCV should have PCR performed annually to detect relapse or re-infection.

• Patients diagnosed with acute hepatitis C may be treated with pegylated interferon plus ribavirin.

Ideally, assessment and treatment for HIV and HCV should be carried out in a specialised unit experienced in treatment of both conditions and there should be liaison with the local hepatology team.