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

Scott D. Parker, MD

Disclosures
In This Article

Monitoring Patients During the Course of HCV Treatment

The recommendations for managing coinfected patients throughout the course of HCV treatment are available as published expert opinion guidelines.[2,7] The adverse events observed during the treatment (pegylated interferon + ribavirin) of HIV/HCV-coinfected patients are similar to those seen in HCV-monoinfected patients. Anemia and neutropenia are common, but can be managed with the appropriate use of erythropoietin and filgrastim (granulocyte-colony stimulating factor). Patients using DDI, or those with macrocytic anemia induced by zidovudine, should discontinue these agents and replace them with alternative antiretroviral agents. All patients should have HCV viral loads measured at 12 weeks of therapy in order to assess early response rates. For those patients without a ≥ 2-log reduction in viral load at 12 weeks, achieving an SVR after 48 weeks of therapy is very unlikely. Therapy may be continued in these early nonresponders in the hope of a histologic response, or discontinued if the patient has significant treatment-related toxicity. Reduction in total CD4 cell counts is seen routinely during HCV therapy, whereas the percentage of CD4+ lymphocytes remains constant or increases slightly. The reduction in total CD4 cell counts is reversible at the end of therapy, is not associated with risk of opportunistic infections, and is not considered to be a clinically significant event. Although 24 weeks of pegylated interferon plus ribavirin has been established as sufficient treatment for the HCV-monoinfected patient with genotype 2 or 3 HCV disease, there is insufficient information at this time to support the use of abbreviated courses of therapy in the HIV/HCV-coinfected patient. While there are theoretical concerns regarding interference between ribavirin and the thymidine analog antiretroviral agents (stavudine and zidovudine) at the cellular level, a clinical effect has never been observed and these agents can be used in combination in the coinfected patient. HIV viral loads should be monitored at 3-month intervals during the course of treatment, but are generally unaffected by HCV therapy.

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