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

Scott D. Parker, MD

Disclosures
In This Article

Selection of Patients for HCV Therapy

All HIV-infected patients with HCV viremia should be evaluated for HCV treatment. At the initial visit, the following history must be obtained:

  • The estimated duration of HCV and HIV infection as based on serologic testing, prior use of shared needles, and sex partners;

  • Current and former substance abuse, including alcohol;

  • HIV-related opportunistic infections and prior/current use of antiretroviral therapy;

  • Prior episodes of symptomatic liver disease; and

  • The presence or history of neuropsychiatric disease, anemia, or cardiac disease that might complicate the course of HCV therapy.

The exam should include an evaluation for signs of advanced HIV disease such as significant adenopathy, thrush, and wasting, as well as hepatic and extrahepatic manifestations of HCV infection. The laboratory assessment should include a measurement of total CD4+ T-cell counts and the %CD4+ T-cells HIV viral load, liver function tests, complete blood count, and HCV viral load and genotype. The healthcare provider should counsel the patient regarding side effects, expected response rates, and goals of interferon/ribavirin HCV therapy (discussed later). HCV therapy is deferred in patients with poorly controlled HIV infection, CD4+ T-cell counts < 200/mm3, active substance abuse, and moderate to severe neuropsychiatric disease. For patients without contraindications to treatment, a liver biopsy should be performed to assess the stage of disease and identify patients in need of HCV therapy.[2] Therapy for patients with minimal fibrosis (stage 1 out of 4 on the Metavir scale) may be deferred, with a repeat liver biopsy performed in 3-5 years. For patients with Metavir fibrosis scores ≥ 2, HCV therapy is recommended; coinfected patients may have a high risk for immediate progression to advanced fibrosis and cirrhosis.[2,8] For the minority of patients in the United States who have HCV genotype 2 or 3 infection, or who have low HCV viral loads (< 800,000 IU/mL), sustained virologic response (SVR) rates are > 50% and therapy is strongly encouraged -- and may be given without liver biopsy.[2] Noninvasive imaging should be done in this circumstance to rule out the presence of cirrhosis.

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