Treatment for primary hepatitis C virus infection is significantly less likely to be effective in coinfected HIV-positive individuals, than patients who are hepatitis C monoinfected, according to a study presented to the Eleventh Annual Conference of the British HIV Association in Dublin on April 21st. In addition, investigators found that a significant number of HIV-positive patients spontaneously cleared hepatitis C virus within the early weeks of infection, and accordingly they recommend that if treatment for hepatitis C is initiated during acute infection, it should be delayed for twelve weeks.
Approximately 90% - 98% of individuals who are monoinfected with hepatitis C virus achieve a sustained virological response after receiving anti-hepatitis C virus therapy consisting of pegylated interferon during the acute infection period.
There are limited data about the effectiveness of this strategy in HIV-positive patients. It is known however that during acute infection with hepatitis C virus, the HIV-positive individuals have significantly higher hepatitis C viral loads than individuals infected only with hepatitis C.
In a prospective, open label study investigators from the Chelsea and Westminster Hospital in London evaluated the efficacy and safety of treatment for hepatitis C virus during acute infection. Between 1997 and 2003, a total of 50 gay men with a mean age of 37 years were recruited for the study. Hepatitis C virus infection was confirmed by antibody testing. Hepatitis C virus viral load was measured at baseline, and at weeks four, twelve, 24, 32 and 48.
If an individual was still hepatitis C virus RNA-positive at week twelve they were treated with pegylated interferon and ribavirin for 24 weeks. The primary endpoint of the study was the proportion of patients with a sustained virological response to treatment (defined as a negative hepatitis C virus PCR test at 48 weeks). Data on CD4 cell count, HIV viral load, liver function, side-effects and laboratory abnormalities were also gathered.
Of the 50 men included in the investigators’ anaylsis, twelve (24%) spontaneously cleared hepatitis C virus infection by week twelve and therefore did not receive anti-hepatitis C therapy. Spontaneous clearance of hepatitis C virus was significantly associated with a CD4 cell count above 500 cells/mm3 (p = 0.03), and a lower hepatitis C viral load (p = 0.04).
A total of 27 men accepted anti-hepatitis C therapy, 16 (59%) of whom achieved a sustained virological response, and this was significantly associated with a lower mean peak ALT level (p < 0.001). Due to the small number of patients in the study, it was not possible to say if treatment outcome was significantly different between individuals infected with different hepatitis C virus genotypes.
Median CD4 cell count fell by 58 cells/mm3 on the completion of anti-hepatitis C therapy, and the level of HIV viral load did not change significantly. These are usual accounts for individuals receiving hepatitis C virus treatment.
No deaths or new opportunistic infections occurred.
Side-effects were widely reported, the most common being depression and anxiety (33 instances) and flu-like symptoms (22 individuals). In addition, 13 cases of neutropenia and three cases of anaemia were recorded. One patient had to discontinue his treatment because of side-effects.
The investigators concluded that as only 59% of HIV-positive patients who are treated for acute hepatitis C virus infection achieve a sustained virological response, this approach to the management of hepatitis C is less effective in coinfected patients than hepatitis C virus monoinfected-individuals.