Treatment of HIV and Hepatitis C Co-Infection
General Treatment Guidelines- Patients co-infected with HIV and HCV should be encouraged to adopt safe behaviors (as described in the previous section) to prevent transmission of HIV and HCV to others.
- Individuals with evidence of HCV infection should be given information about prevention of liver damage, undergo evaluation for chronic liver disease and, if indicated, be considered for HCV treatment.
- Persons co-infected with HIV and HCV should be advised not to drink excessive amounts of alcohol. Avoiding alcohol altogether might be wise because the effects of even moderate or low amounts of alcohol (e.g., 12 oz. of beer, 5 oz. of wine or 1.5 oz. hard liquor per day) on disease progression are unknown. When appropriate, referral should be made to alcohol treatment programs.
- Because of possible effects on the liver, HCV infected patients should consult with their health care professional before taking any new medicines, including over-the-counter, alternative or herbal medicines.
- Susceptible co-infected patients should receive hepatitis A vaccine because the risk for fatal hepatitis associated with hepatitis A is increased in persons with chronic liver disease.
- Susceptible patients should receive hepatitis B (HBV) vaccine because most HIV-infected persons are at risk for HBV infection. The vaccines appear safe for these patients and more than two-thirds of those vaccinated develop antibody responses. Prevaccination screening for antibodies against hepatitis A and hepatitis B in this high-prevalence population is generally cost-effective. Postvaccination testing for hepatitis A is not recommended, but testing for antibody to hepatitis B surface antigen (anti-HBs) should be performed 1-2 months after completion of the primary series of hepatitis B vaccine. Persons who fail to respond should be revaccinated with a double dose series of hepatitis b vaccine.
Hepatitis A and B Vaccine Fact Sheets
- HIV medications (HAART) has no significant effect on HCV. However, co-infected persons may be at increased risk for HAART-associated liver toxicity and should be closely monitored during antiretroviral therapy. Data suggest that the majority of these persons do not appear to develop significant and/or symptomatic hepatitis after initiation of antiretroviral therapy.
Treatment for HCV Infection
A Consensus Development Conference Panel convened by The National Institutes of Health in 1997 recommended antiviral therapy for patients with chronic hepatitis C who are at the greatest risk for progression to cirrhosis. These persons include anti-HCV positive patients with persistently elevated liver enzymes, detectable HCV RNA, and a liver biopsy that indicates either liver scarring or inflammation and necrosis (tissue death). Patients with less severe liver disease should be managed on an individual basis.In the United States, two different medication regimens have been approved as therapy for chronic hepatitis C:
- monotherapy with alpha interferon
- combination therapy with alpha interferon and ribavirin. Among HIV-negative persons with chronic hepatitis C, combination therapy consistently yields higher rates of sustained response than monotherapy. Combination therapy is more effective against certain types of HCV and requires a shorter course of treatment. Combination therapy is associated with more side effects than monotherapy, but, in most situations, it is preferable. At present, interferon monotherapy is reserved for patients who have contraindications to the use of ribavirin.
Studies thus far, although not extensive, have indicated that response rates in HIV-infected patients to alpha interferon monotherapy for HCV were lower than in non-HIV-infected patients, but the differences were not statistically significant. Monotherapy appears to be reasonably well tolerated in co-infected patients. There are no published articles on the long-term effect of combination therapy in co-infected patients, but studies currently underway suggest it is superior to monotherapy. However, the side effects of combination therapy are greater in co-infected patients. Thus, combination therapy should be used with caution until more data is available.
The decision to treat people co-infected with HIV and HCV must also take into consideration their current medications and medical conditions. If CD4 counts are normal or near normal there is little difference in treatment success rates between those who are co-infected and those who are infected with HCV alone.
