Treatment of patients with hcv-hiv co-infection

The development of highly active antiretroviral therapy (HAART) and the resulting increased survival rate of patients with HIV have led to an increase in HCV-induced liver disease among patients co-infected with HIV and HCV. HIV has been shown to accelerate progression of HCV-related liver disease and mortality. HCV infection may worsen the prognosis of HIV infection and decrease the rate of CD4 recovery on antiretroviral therapy.

Initially, HAART is used before HCV treatment is initiated to stabilize the CD4 count in patients who are co-infected. In certain cases, including patients with an intact immune system (ie, high CD4 counts and no history of opportunistic infections) and patients with advanced liver disease, treatment of HCV may be initiated first to reduce hepatotoxicity for the treatment of HIV. Treatment with pegylated interferon and ribavirin is usually offered to patients with a CD4 cell count greater than 200/µL.

In patients with preexisting liver disease, transaminase levels should be monitored every 2 weeks initially, then monthly (once stabilized). Regular liver biopsies are also needed to monitor inflammation and fibrosis. Side effects tend to be more severe in patients with preexisting liver disease; therefore, these patients should be monitored closely for therapy compliance.

Upon completion of therapy, patients demonstrated better tolerance to HAART and slower progression of liver damage.

Important studies

A comparative analysis of the old qualitative classification of chronic hepatitis and the newer semiquantitative scoring systems was performed by Okafor et al. A good statistical correlation was found among the semiquantitative scoring systems. This study has important implications in comparison of results of therapeutic trials using any of the 5 studied semiquantitative scoring systems. Also, the analysis makes it possible to compare biopsied specimens from patients with chronic hepatitis from different centers where any of those 5 semiquantitative scoring systems are used.

Three important studies in 2004 supported the use of peginterferon in combination with ribavirin in patients co-infected with HCV and HIV. Torriani et al and Carrat et al showed the superiority of peginterferon alfa-2a and peginterferon alfa-2b, respectively, when combined with ribavirin as compared to the combination of standard interferon and ribavirin in patients with chronic hepatitis C who were co-infected with HIV. A study by Chung et al that supports these findings showed, interestingly, a histologic improvement in 35% of subjects with no virologic response who underwent liver biopsy procedures.

Future directions

Despite recent advances, improvement in the prevention, diagnosis, and treatment of HCV infection remains necessary. Prevention is of vital importance, given the chronicity of the disease and the asymptomatic onset of acute infection. Stricter strategies to screen and identify infected persons need to be in place. A prophylactic vaccine may result in better control of this epidemic.

Future research efforts also need to focus on providing better treatment options for patients with HCV. Newer treatments must be more tolerable, more efficacious, cost effective, and available to all patients.

More studies comparing efficacy, safety, and side effects of peginterferon alfa-2a and peginterferon alfa-2b need to be conducted, taking into consideration special patient populations such as patients co-infected with HCV and HIV.