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

Disclosures

AIDS. 2004;18(1) 

In This Article

Liver Biopsy Before Recommending Treatment

Background

Liver histology allows the staging of HCV hepatic damage and predicts in the short-mid term who will develop cirrhosis. At the same time, it may rule out other causes of liver damage, such as haemochromatosis, alcohol-related steatosis, Wilson disease, autoimmune hepatitis, etc., although these conditions may also be recognized by other non-invasive means.[42,43,44,45]

The value of liver biopsy before prescribing anti-HCV therapy is under debate.[42,43,44,45] This controversy may be less justified in HCV-HIV-co-infected patients, in whom the rate of significant liver fibrosis is much higher than in HCV-monoinfected individuals (see Table 2 ).[46,47,48,49]A priori, anti-HCV therapy will be almost always justified considering the extent of histological damage in HIV-HCV-co-infected patients.[50] Moreover, nearly half of HCV-HIV-co-infected patients may show unexpected cirrhosis or pre-cirrhosis.[46,47,48] The main predictor of advanced fibrosis stages seems to be the estimated duration of HCV infection.[48] On average, nearly half of patients will have cirrhosis 25 years after the first HCV exposure. If we consider that the mean age of HCV-HIV-co-infected patients is currently 40 years, and that most are former intravenous drug users who began to exchange needles when they were on average 20 years old, it should be expected that many of them will currently show significant liver fibrosis. Therefore, if not treated, a rapid increase in liver complications among HIV-infected individuals should occur over the next decade.[51,52]

Those who defend performing a liver biopsy before treating chronic hepatitis C in HIV-co-infected patients argue that the side-effects, the risk of interactions with antiretroviral drugs and the relatively low efficacy of current anti-HCV therapy in this population are major limitations that only justify prescribing the medication for those who really need it histologically. However, given that liver damage is a dynamic process and fibrosis progression rate is accelerated in HCV-HIV-co-infected patients,[53,54] supporters of this point of view should be reminded that if treatment is not offered to patients with a lack of or only minimal fibrosis, liver biopsy should be repeated at 2-3 year intervals. However, this option will face opposition from many patients and may increase the costs significantly. Accordingly, a recent analysis has pointed out the cost-effectiveness of therapy in co-infected individuals.[55]

Panel Recommendation

The role of liver biopsy for treatment decision purposes is controversial in HIV-HCV-co-infected patients. The patients' reluctance to accept it or other difficulties should not defer the prescription of anti-HCV therapy once it is considered appropriate, given the faster progression to end-stage liver disease in co-infected patients. When the histological information is available for patients with HCV genotypes 1 or 4, treatment could be deferred if there is no fibrosis (F0), or in patients with F1 willing to accept a second follow-up liver biopsy. In patients with normal transaminase levels, liver biopsy should be performed before prescribing therapy. SCORE: C.III

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