HIV coinfection with hepatitis c

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Varun Kumar, M.B.B.S. [2]

Overview

HIV has been an important and familiar health and social crisis for two decades. Less familiar, but also important, is HCV infection. In HIV–HCV co-infected patients, the Hepatitis C (HCV) viral load is higher than in HCV-mono-infected patients in both the plasma and liver tissue.

Similarity between Hepatitis C with HIV: These two viruses are similar in a number of ways, and infection with both is a serious problem. Both HCV and HIV are transmitted by exposure to infected blood. About one-quarter of the people infected with HIV also have HCV.

Cause of Co-infection

Patients who are HIV-positive are commonly co-infected with HCV due to the following:

• Shared routes of transmission.
• Percutaneous exposure to blood.
• Sexual intercourse.
• From a mother to her infant.

Epidemiology

The majority of coinfected people are injection drug user (IDUs). HCV is acquired relatively soon after individuals begin injecting drugs. Within 5 years of beginning to inject, 50% to 80% of IDUs are infected with HCV. As a result, many IDUs who become infected with HIV are already infected with HCV. It is estimated that 50% to 90% of IDUs.

Between 1996 and 2000, more than 80% of the patients admitted to a large HIV/AIDS care center in Madrid, Spain, were IDUs. The proportion of these patients who were admitted because of liver failure almost doubled, from 9% to 16%.

Natural History

The effect of HCV on the natural history of HIV remains inconclusive due to contradictory studies documenting no effect, while others show an increase to an AIDS defining illness or death. The morbidity and mortality caused by HCV has increased since the inception of highly active antiretroviral therapy (HAART) because HIV patients are living longer from potent antiretroviral therapies and prophylaxis of traditional opportunistic infections. Infection with HCV can be asymptomatic, self-limiting, or progress to cirrhosis or cancer.

Complications

End-stage liver disease is now the cause of death for 45% of HIV-infected patients in this hospital. HCV infection was the cause of the liver disease in nearly three-quarters of the HIV patients who were admitted or died during the course of the study.

Treatment

The primary objective of HCV therapy is permanent eradication of the virus. The secondary potential benefit of eradication is a reduction in the risk of liver failure and liver cancer.

Role & Importance of treatment

The introduction in the mid-1990s of highly active antiretroviral therapy (HAART) for HIV has caused a sharp drop in the number of deaths from AIDS. This means that people with HIV are living longer. Therefore, if they are coinfected, the complications from HCV have more time to develop. These complications (cirrhosis, liver cancer, end-stage liver disease) generally develop over 20-30 years.

Regimen

The Food and Drug Administration (FDA) has approved two antiviral drugs for the treatment of chronic hepatitis C:

• Alpha interferon or an improved form of interferon, called pegylated interferon
• Ribavirin

Interferon is given alone or in combination with ribavirin usually for a 12-month period to patients with chronic hepatitis C who are at greatest risk of developing serious liver disease.

Recommendations for Diagnosis and Treatment of Persons with HIV Coinfection: AASLD Practice Guidelines 2009

“

1. Anti-HCV testing should be performed in all HIV-infected persons (Class I, Level B). 2. HCV RNA testing should be performed to confirm HCV infection in HIV-infected persons who are positive for anti-HCV, as well as in those who are negative and have evidence of unexplained liver disease (Class I, Level B). 3. Hepatitis C should be treated in the HIV/HCV co-infected patient in whom the likelihood of serious liver disease and a treatment response are judged to outweigh the risk of morbidity from the adverse effects of therapy (Class I, Level A). 4. Initial treatment of hepatitis C in most HIV infected patients should be peginterferon alfa plus ribavirin for 48 weeks at doses recommended for HCV mono-infected patients (Class I, Level A). 5. When possible, patients receiving zidovudine (AZT) and especially didanosine (ddI) should be switched to an equivalent antiretroviral agent before beginning therapy with ribavirin (Class I, Level C). 6. HIV-infected patients with decompensated liver disease (CTP Class B or C) should not be treated with peginterferon alfa and ribavirin and may be candidates for liver transplantation (Class IIa, Level C).

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