The British HIV Association (BHIVA) has issued draft guidelines for the treatment of people coinfected with HIV and hepatitis C (HCV).
It is thought that 0.4% of the UK population is infected with HCV and that the prevalence is higher amongst people with HIV, although rates vary between treatment centres and according to exposure category for HIV. HIV and HCV coinfection has been seen predominately in injecting drug users and people exposed from infected blood products prior to the introduction of screening. However, there is evidence that sexual transmission of HCV can take place, particularly in the presence of other sexually transmitted infections, particularly syphilis.
BHIVA recommends that all HIV-positive patients be tested for HCV at least once, with subsequent tests for people at higher risk of HCV infection or with unexplained liver disease. Tests should also be performed to exclude coinfection with hepatitis B (BHIVA have also issued guidelines on the management of HIV/hepatitis B coinfection), and HIV patients should be vaccinated for both hepatitis A and B.
People with HIV/HCV coinfection should be counseled about the risk of HCV transmission and advised to abstain from alcohol.
Tests should be performed to determine HCV genotype, as this is a predictor of treatment response. If there are no medical reasons not to, patient consent should be obtained to perform a liver biopsy to determine the extent of liver damage caused by HCV and to rule out other causes of chronic liver disease.
Treatment for HCV should be considered, particularly if a person has suffered moderate liver disease, and treatment should ideally be initiated whilst a patient’s CD4 count is above 200 cells/mm3 as treatment at lower CD4 counts has been associated with a poorer response.
The goal of anti-HCV therapy is viral eradication (negative HCV PCR six months after therapy has finished). Other aims of therapy include reduced risk of transmission and where eradication is not possible, reduced rate of disease progression.
Treatment should also be considered in the case of mild disease, particularly if it is the patient’s wish to commence treatment and there are high hopes of success. A clinical trial should be considered. In cases of cirrhosis, a patient is a good candidate for liver transplant if HIV prognosis is good.
HCV should be treated before HIV if HIV infection is stable and does not require therapy. However, if the CD4 count is low and a person is considered to be at risk of HIV disease progression, then HIV therapy should be initiated first.
Ideally, assessment and treatment for HIV and HCV should be carried out in a specialised unit experienced in treatment of both conditions and there should be liaison with the local hepatology team.
HIV/HCV coinfected people seem to have a slightly poorer response to treatment with non-pegylated interferon and ribavirin. A sustained response is seen in between 20% and 40% of patients and is influenced by genotype. HCV viral load and age also seem to have a role.
Patients with HCV genotype one should have 48 weeks of therapy and those with genotype 2 and 3 should have 24 weeks. Tests to predict the likely outcome of therapy should be performed after twelve weeks, particularly as treatment is unpleasant and expensive.
As depression is a potential side-effect of interferon, there should be a baseline psychiatric assessment prior to the initiation of therapy. Ribavirin can cause anaemia and this should this occur methods of supporting haemoglobin levels other cessation of therapy or dose reduction should be explored.
Treatment with pegylated interferon and ribavirin is becoming the standard therapy due to better efficacy, with improved sustained response seen particularly in patients with genotype 1. Studies are still underway.
In a covering note to the guidelines, views on the use of pegylated interferon are invited. Should pegylated interferon be used for the treatment of all HIV/HCV infected patients or should the recommendations of the National Institute of Clinical Excellence be awaited? Is there enough evidence to recommend pegylated interferon rather than standard interferon in patients with genotype 2 or 3, given that the price differential may influence funding from the commissioners?
As this is a constantly evolving field, HIV/HCV coinfected patients should be given the opportunity to participate in clinical trials.
There is the potential for interaction between ribavirin and anti-HIV drugs, particularly with ddI. Transaminases and serum lactate levels should be observed carefully. The combination of ddI and tenofovir should be used with extreme caution in patients treated with ribavirin.
Patients diagnosed with acute hepatitis C should be offered interferon and consideration should be given to treatment with pegylated interferon and ribavirin as high clearance rates have been seen in monoinfected patients.
To read the full draft guidelines in pdf format click here and here in html.
Comments on the guidelines should be sent to Gary.Brook@nwlh.nhs.uk.
Further information on this website
Hepatitis C - Overview
Hepatitis C - Factsheet
Sexual transmission of HCV - News story
HIV and hepatitis - Booklet in the information for HIV-positive people series