Care of Patients With Hepatitis C and HIV Co-Infection

Vincent Soriano; Massimo Puoti; Mark Sulkowski; Stefan Mauss; Patrice Cacoub; Antonietta Cargnel; Douglas Dieterich; Angelos Hatzakis; Jurgen Rockstroh


AIDS. 2004;18(1) 

In This Article

Candidates for Anti-Hepatitis C Virus Treatment


All HIV-infected individuals should be screened for HCV antibodies in the serum or plasma. HCV-antibody-negative but HCV-RNA-positive cases may exist, mainly in patients with severe cellular immune suppression as a result of HIV.[32,33,34] Those with repeatedly elevated aminotransferase levels should be tested for HCV load and HCV genotype, in order to assess anti-HCV therapy.

All HIV-positive individuals with chronic HCV infection should be considered as candidates for anti-HCV therapy, given their higher risk of progression to end-stage liver disease and their higher risk of liver toxicity after beginning antiretroviral therapy, compared with HIV-negative individuals.[4] As the response to anti-HCV therapy is dependent on the CD4 cell count,[35,36] ideally it should be prescribed only when the CD4 cell count is above 350 cells/µl, a threshold that is relatively easy to obtain in most instances when antiretroviral therapy is used properly. Besides, this is currently the immunological cut-off to begin antiretroviral therapy in drug-naive patients.[5] In individuals with CD4 cell counts between 200 and 350 cells/µl, and already under long-term antiretroviral therapy, the decision to treat HCV might be considered taking into account other factors, such as the estimated length of HCV infection, the severity of liver disease, the extent of suppression of HIV replication, and classic predictors of response to anti-HCV therapy, such as HCV genotype and HCV load.

Finally, anti-HCV therapy should be deferred in individuals with CD4 cell counts of less than 200 cells/µl, because the response rate is very low in this subgroup of patients.[35,36] Moreover, the risk of opportunistic infections in the short term may be high, and may worsen with anti-HCV therapy.[37,38] Therefore, they should be treated with antiretroviral therapy and receive prophylaxis for opportunistic infections as a priority. Later on, when their CD4 cell counts have risen and their plasma HIV-RNA level is under control, the prescription of anti-HCV therapy should be assessed again.

Patients with previous liver decompensation (ascites, gastrointestinal bleeding, hepatic encephalopathy, etc.) should not be treated, given the higher risk of serious side-effects using the current drugs, pegylated interferon (peg-IFN) and ribavirin. These patients should be assessed for liver transplantation. However, patients with compensated cirrhosis (Child-Pugh class A) must be treated.

Individuals with a previous history of severe neuropsychiatric disorders should not be treated, because IFN can exacerbate these conditions. Individuals currently engaged in a heavy alcohol intake or illegal drug addiction practices should delay treatment, whereas all efforts should be devoted to put them into detoxification programmes. Patients on methadone are acceptable candidates for anti-HCV therapy. Up to one third of patients may need adjustments in methadone dosage.[39] Ideally, a multidisciplinary team, including experts in addiction medicine, psychologists/psychiatrists and infectologists should take care of these patients.[40,41]

Following recent National Institutes of Health Consensus Conference Recommendations,[3] individuals with repeated normal liver enzymes might benefit from current anti-HCV therapy, particularly those infected with HCV genotypes 2 or 3. However, more data on liver damage in this subgroup of HCV-HIV- co-infected patients are needed to balance the cost-benefit of anti-HCV therapy in them.

In drug-naive individuals with HCV-HIV-co-infection, chronic hepatitis C should be treated first if the CD4 cell count does not require the initiation of antiretroviral therapy. However, in patients with CD4 cell counts greater than 350 cells/µl but high plasma HIV-RNA levels (i.e. above 50 000 copies/ml), it is not clear whether the suppression of HIV replication should be done at first, deferring anti-HCV therapy to the moment when undetectable HIV viraemia is attained. In these patients, a possible greater efficacy of anti-HCV therapy then should be balanced with a higher risk of interactions between antiretroviral agents and anti-HCV drugs.

Panel Recommendation

All HIV-infected individuals should be screened for HCV antibodies. Those with positive HCV serology should be tested for HCV-RNA. Individuals with positive HCV-RNA should be considered as candidates for anti-HCV treatment. A plasma HCV load and genotyping should be requested before initiating therapy. Treatment should be provided to patients with repeated elevated alanine aminotransferase levels, CD4 cell counts greater than 350 cells/µl, relatively low plasma HIV-RNA levels (i.e. less than 50 000 copies/ml), no active consumption of illegal drugs or high alcohol intake, and no previous severe neuropsychiatric conditions. Treatment in patients with normal alanine aminotransferase levels should be carried out in the context of study protocols or when a liver biopsy has proved the presence of clinically significant fibrosis, i.e. F2 or above. Treatment in patients with CD4 cell counts below 350 cells/µl should be prescribed cautiously. The treatment of choice is the combination of peg-IFN plus ribavirin. SCORE: A.II


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