Care of Patients With Hepatitis C and HIV Co-Infection

Treatment of Chronic Hepatitis C in HIV-Positive Patients

Background

Available data from interim analysis of large ongoing clinical trials and from a few studies already completed show that response rates to anti-HCV therapy are lower in HIV-co-infected patients, even using the new peg-IFN formulations with ribavirin ( Table 3 ).^{[56,57,58,59,60,61,62]} Overall, sustained response rates are in the range of 20-35%, which is approximately half the responses seen in HIV-negative individuals.^[63,64] It should be noted that both early virological responses and end-of-treatment responses are equally much lower in HIV-HCV-co-infected patients. Moreover, relapses also seem to be more frequent.^[57,62]

The reasons why anti-HCV therapy provides a poor response in the setting of HIV infection may be varied ( Table 4 ). As both peg-IFN and ribavirin act, at least partly, as immunomodulatory agents, subtle immune defects derived from HIV infection might negatively impact on the performance of these drugs, even in patients with high CD4 cell counts and undetectable plasma HIV-RNA levels under antiretroviral therapy.

In addition, there is a high rate of anti-HCV treatment discontinuation in some of the trials conducted in HIV-co-infected patients, even surpassing 25% of individuals recruited.^{[59,60,61,62]} Although it may reflect a higher rate of serious adverse events in this population compared with HIV-negative individuals, in whom it is usually less than 15%,^[63,64] it might also reflect that some HIV physicians are not quite familiar with the management of side-effects of anti-HCV therapy. Efforts to minimize side-effects with pre-emptive symptomatic treatments and the appropriate management of complications are thus critical to ensure the completion of anti-HCV therapy in most patients.

Panel Recommendation

The overall response to anti-HCV therapy is lower in patients co-infected with HIV. Sustained response rates of 40-60% are seen in patients with HCV genotypes 2 or 3, but lower than 25% in those with HCV genotypes 1 or 4. Both early virological responses and relapses are less and more frequent, respectively, in co-infected patients compared with HCV-monoinfected individuals. The benefit of extending therapy (more than 6 months for HCV genotypes 2 or 3; and more than 12 months for HCV genotypes 1 or 4) in early virological responders should be examined in clinical trials. Moreover, treatment adherence should be considered a critical factor for the attainment of response and must be encouraged actively over the whole treatment period. SCORE: A.II

AIDS. 2004;18(1) © 2004  Lippincott Williams & Wilkins

Cite this: Care of Patients With Hepatitis C and HIV Co-Infection - Medscape - Jan 01, 2004.