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

Scott D. Parker, MD

In This Article

Immune System Status and Control of HIV Infection With Antiviral Therapy

When coinfected patients present for care with clear indications for effective HIV antiviral therapy[3] and with uncontrolled HIV viral loads, the first priority must be control of the HIV infection. The clinical trials performed to date did not include substantial numbers of subjects with low CD4+ T-cell counts, and the relationship between baseline CD4+ T-cell count and the safety of and virologic response to HCV therapy have not been clearly defined.[4,5,6] The latest treatment guidelines do not include CD4+ T-cell count as a criterion for the selection of patients for HCV treatment.[2,7] However, the efficacy of standard HCV treatment with interferon and ribavirin may depend on the degree of compromised host immunity. In this physician's own practice, patients with CD4+ T-cell count < 500 cells/mm3 or percentage CD4+ T-cells < 28%-30% (CD4+ T-cell count divided by total lymphocyte count expressed as a percentage) are started and/or monitored on antiretroviral therapy while waiting for full immune reconstitution for at least 6 months or until total CD4+ T-cell counts and percentage of CD4+ T-cells have stabilized at a maximum value before HCV therapy is started. For other patients who are monitored without antiretroviral therapy and who have CD4+ T-cell counts > 500/mm3, HCV therapy may be started in the absence of HIV-specific treatment. For those cases when CD4+ T-cell counts remain < 200 cells/mm3 (or %CD4+ T-cells < 12%-14%), HCV therapy has not been established as a safe and reasonably effective practice. Treatment in this patient population should remain limited to clinical trial settings.


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