Hepatitis & HIV

Treatment Action Group releases policy recommendations on HIV/hepatitis C coinfection

Keith Alcorn
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The New York-based HIV advocacy organisation Treatment Action Group has released extensive recommendations for research and service development for the estimated 4 million individuals infected with hepatitis C in the United States and the global population of people with hepatitis C, estimated at 170 million.

Hepatitis C Virus (HCV) and HIV/HCV Coinfection: A Critical Review of Research and Treatment, was written by Tracy Swan and Daniel Raymond and edited by Kenneth E. Sherman, MD, PhD.

Volume I (Clinical Science) is a critical review of research on epidemiology, transmission, natural history, diagnosis, and treatment of hepatitis C monoinfection and treatment of HIV and HCV for HIV/HCV coinfected people. Volume II is a critical review of research on molecular virology, immune response and pathogenesis of hepatitis C, and details of HCV drug development.

Glossary

efficacy

How well something works (in a research study). See also ‘effectiveness’.

prospective study

A type of longitudinal study in which people join the study and information is then collected on them for several weeks, months or years. 

natural history

The natural development of a disease or condition over time, in the absence of treatment.

acute infection

The very first few weeks of infection, until the body has created antibodies against the infection. During acute HIV infection, HIV is highly infectious because the virus is multiplying at a very rapid rate. The symptoms of acute HIV infection can include fever, rash, chills, headache, fatigue, nausea, diarrhoea, sore throat, night sweats, appetite loss, mouth ulcers, swollen lymph nodes, muscle and joint aches – all of them symptoms of an acute inflammation (immune reaction).

capacity

In discussions of consent for medical treatment, the ability of a person to make a decision for themselves and understand its implications. Young children, people who are unconscious and some people with mental health problems may lack capacity. In the context of health services, the staff and resources that are available for patient care.

Key recommendations include:

Prevention and surveillance

  • Implement national surveillance for chronic HCV infection.
  • Provide HCV testing and education for high-risk and high-prevalence populations.
  • Increase access to sterile injection equipment.
  • Increase access to drug treatment and methadone maintenance programs.
  • Institute CDC's recommendations for prevention of HCV transmission in hemodialysis facilities. Clarify routes and risks of HCV sexual transmission.
  • Clarify the risk of non-injection drug use behaviors associated with HCV transmission, such as smoking or sniffing.
  • Research mechanisms and interventions to decrease mother-to-infant transmission.
  • Develop protocols for HCV counseling and testing for pregnant women, and offer voluntary HCV counseling and testing to pregnant women.
  • Develop and implement HCV prevention strategies for the developing world.
  • Promote screening and vaccination for hepatitis A and hepatitis B among individuals infected with HCV or coinfected with HIV/HCV.
  • Create an "opt-out" system for organ donation in the United States and include discussion of organ donation as part of school health education programs and regular medical care.

Diagnosis

  • Educate primary care providers about diagnosis of acute and chronic HCV infection.
  • Develop and market oral fluid test kits for HCV-antibody testing.
  • Promote use of a standardized system for evaluation of liver biopsy.
  • Continue research on non-invasive testing methods to replace or reduce the need for liver biopsy.
  • Identify and validate prognostic markers and more effective screening methods for early diagnosis of hepatocellular carcinoma.

Treatment of HCV infection

  • Increase knowledge of treatment and care for hepatitis C patients among primary care providers.
  • Identify optimal dosing strategies.
  • Increase research on treatment safety and efficacy in understudied populations.
  • Increase research on strategies to manage side effects of HCV treatment.
  • Identify when and in whom treatment for acute HCV should be initiated; optimal regimen; and duration of treatment.
  • Establish prospective, long-term follow-up studies to assess the durability and clinical benefit of histological responses in virological responders, relapsers, and non-responders.
  • Investigate safety and efficacy of alternative therapies for HCV infection.
  • Establish prospective, longitudinal cohort studies of the natural history of HIV/HCV coinfection in the era of HCV treatment and HAART.
  • Develop guidelines for the care and treatment of coinfected individuals.
  • Establish a universal definition of hepatotoxicity and characterize its severity.
  • Explore pharmacokinetics and drug levels of antiretroviral agents and other drugs commonly used by coinfected individuals.
  • Include HIV/HCV-coinfected individuals in early-phase HCV treatment trials.
  • Explore strategies to optimize HCV treatment for HIV/HCV-coinfected persons.
  • Support access to and research on liver transplantation for HIV-positive and HCV/HIV-coinfected individuals.

Care and support

  • Provide full access to hepatitis C care and treatment for all of those in need.
  • Do not withhold treatment from active drug users; decisions should be made on an individualized basis.
  • Strengthen linkages among substance abuse treatment programs, methadone maintenance programs, medical and mental health providers, and HIV/HCV prevention programs.
  • Increase capacity to provide individualized medical care and treatment to coinfected active drug users.
  • Develop integrated, multidisciplinary systems of care for individuals with multiple co-morbidities (HIV, HCV, psychiatric disorders, addiction).
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