Wednesday, January 5, 2011

HIV and Hepatitis C Co-infection: Guideline and Commentary

HIV and Hepatitis C: Expert Commentary
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Douglas G. Fish, MD
Authors and Disclosures
Posted: 01/05/2011
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Approximately 15% to 30% of people with HIV are estimated to be co-infected with hepatitis C virus (HCV) in the United States, and up to 90% of those with HIV secondary to injection drug use are co-infected.1,2 Chronic liver disease from co-infection, including cirrhosis and hepatocellular carcinoma, leads to significant morbidity and mortality.

Most patients who are co-infected with hepatitis C are diagnosed with chronic disease. This is diagnosed when the hepatitis C antibody is reactive and subsequent viral load (RNA) testing is positive. Acute hepatitis C is less common and can be associated with spontaneous clearance. Estimates of spontaneous clearance rates are lower, however, among persons with HIV than in those who are mono-infected.3 Rates of perinatal transmission of hepatitis C are approximately 20% for HIV-infected mothers co-infected with hepatitis C, considerably more than for HCV mono-infected mothers.4

Substantial progress has been made in the treatment of hepatitis C, and more patients are having sustained virologic responses (SVRs) with combination weekly pegylated interferon and twice-daily oral ribavirin therapy. Most of these patients with SVR are thought to be cured of their hepatitis C. Clinical trials involving co-infected patients have informed treatment guidelines, including those of the New York State Department of Health AIDS Institute.5
Pegylated interferon and ribavirin have greatly improved treatment responses, especially for persons with HCV genotypes 2 and 3. Updated recommendations in these guidelines (see the following sections of this document) include annual HCV antibody testing for persons with continued high-risk behaviors, such as injection drug use and multiple sexual partners; quantitative viral load testing to confirm a reactive HCV antibody result on enzyme-linked immunosorbent assay (ELISA) or enzyme immunoassay (EIA); and consultation with a mental health professional when prescribing anti-HCV therapy for persons with mental health disorders.
A section on baseline assessment has been added
(Section 8: Hepatitis C Treatment and Treatment Monitoring), along with a table on treatment recommendations based on liver biopsy results (Table 4) and updates on algorithms for the diagnosis of hepatitis C (Figure 1) and for guiding therapeutic decisions on the basis of HCV RNA responses to treatment (Figure 2).

In summary, we should now be looking for reasons to treat our HIV/HCV co-infected patients, as opposed to looking for reasons not to treat. The therapeutic pipeline for newer anti-HCV therapies -- such as telaprevir, an oral protease inhibitor -- is rich, and these therapies will have to be studied in co-infected populations for safety, tolerability, efficacy, and pharmacokinetic interactions with available antiretroviral medications.

References
Sherman KE, Rouster SD, Chung RT, Rajicic N. Hepatitis C virus prevalence among patients co-infected with human immunodeficiency virus: A cross-sectional analysis of the U.S. Adult AIDS Clinical Trials Group. Clin Infect Dis. 2002;34:831-837.
Centers for Disease Control and Prevention. Recommendations for the prevention and control of hepatitis C virus (HCV) infection and HCV related disease. MMWR Recomm Rep. 1998;47(RR-19):1-39.

Piasecki BA, Lewis JD, Reddy KR, et al. Influence of alcohol use, race, and viral co-infections on spontaneous HCV clearance in a U.S. veteran population. Hepatology. 2004;40:892-899.
National Institutes of Health. NIH Consensus Statement on Management of Hepatitis C: 2002. NIH Consens State Sci Statements. 2002;19:1-46.
Medical Care Criteria Committee. Hepatitis C. New York State Department of Health AIDS Institute.
Accessed October 27, 2010.
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