Evaluation and Treatment of Hepatitis C in Patients With Coexisting HIV Infection

Scott D. Parker, MD

Disclosures
In This Article

Introduction

In the current era of highly effective antiretroviral therapy, many HIV-infected patients are now surviving to an age when coinfection with hepatitis C virus (HCV) can progress to advanced liver disease. In the absence of routine HCV screening, patients and providers may remain unaware of HCV infections until the onset of cirrhosis and liver failure, when treatment options are limited. Therefore, all HIV-positive patients need routine screening for HCV antibody status. The rate of HIV/HCV coinfection in this population may vary from as low as 10%-15% to as high as 80%-90%, depending on the incidence of injection drug use.[1] Positive HCV serology should be followed up with HCV quantitative serum viral RNA and genotype testing, and patients with HCV viremia warrant further evaluation for treatment. Patients with positive HCV serology but negative HCV RNA testing on at least 2 occasions do not have chronic HCV infection and do not need additional treatment or evaluation. Some HCV-coinfected patients with advanced HIV disease may have negative HCV screening serologic assays; direct testing for HCV viremia should be performed in this patient group if there are clinical or biochemical signs of chronic active hepatitis.

For many coinfected patients, treatment is appropriately deferred due to advanced and poorly controlled HIV infection, severe depression, neuropsychiatric disease, and/or ongoing substance abuse. However, patients recovering from addictions, including those on methadone maintenance programs, and patients with psychiatric symptoms controlled by therapy and regular follow-up with a mental health professional, are often suitable candidates for treatment. In the coinfected patient population, there is an increased risk of developing cirrhosis and liver failure as well as inferior response rates to anti-HCV therapy when compared with HCV-monoinfected patients. The recommended therapy for coinfected patients remains the same as for HCV monoinfection: pegylated interferon-alfa and weight-based dosing of ribavirin; specific recommendations, including dose and duration of therapy for the coinfected patient, have been published in recent HCV treatment guidelines.[2] However, several unique issues need to be considered when evaluating HIV-positive patients with HCV coinfection, and these issues are explored in this article.


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