Treatment of Hepatitis C in People Living With HIV
June 17, 2015
Table of Contents
Hepatitis C is a disease of the liver caused by the hepatitis C virus (HCV). Over time, HCV can cause serious liver damage including cirrhosis (scarring), liver cancer, and life-threatening liver failure. For more information on HCV, including how it is spread, tests for HCV, and co-infection with HIV and HCV, see our article on Hepatitis C.
Treatment options for those infected with HIV and HCV have improved a great deal in recent years, and there are several promising new drugs in the research pipeline. In the past, the standard backbone of treatment was a combination of two medications:
Victrelis and Incivek
In 2011, the FDA approved two new drugs for hepatitis C treatment: Victrelis (boceprevir) and Incivek (telaprevir). Both drugs are HCV protease inhibitors and are considered direct-acting antivirals (DAAs).They work directly against the virus by interrupting HCV's ability to multiply or replicate. Both Victrelis and Incivek are taken in addition to the standard treatment combination of pegylated interferon plus ribavirin.
Studies of Victrelis and Incivek have shown that they interact significantly with some HIV drugs. Victrelis interacts with Norvir (ritonavir)-boosted protease inhibitors (boosted PIs). Because Victrelis and Norvir-boosted protease inhibitors are processed by the body in the same way, the two types of drugs can interact, or get in the way of one another. As a result, the HIV drugs may be less effective. The DHHS suggests that Victrelis not be used with boosted PIs; it adds that Victrelis should not be used with Sustiva (efavirenz).
Research on Incivek suggests that it can be given with Norvir-boosted Reyataz (atazanavir), unlike Victrelis. Incivek can also be given with Sustiva, but should be given at an increased dose when both are taken at the same time. Either Victrelis or Incivek can be given with Isentress (raltegravir).
The makers of Incivek removed it from the US market in the fall of 2014 due to poor sales and stiff competition from Solvadi (see below). Incivek continues to be FDA-approved and is still available outside the US.
Solvadi and Olysio
In late 2013, the FDA approved two more new drugs for chronic hepatitis C treatment: the nucleotide polymerase inhibitor Solvadi (sofosbuvir) and the protease inhibitor Olysio (simeprevir). Both of these drugs are also considered direct-acting antivirals that work by interrupting HCV's ability to multiply.
Olysio is given in combination with pegylated interferon and ribavirin. A protease inhibitor, Olysio has the potential to interact with other HIV drugs, including all non-nucleoside reverse transcriptase inhibitors (NNRTIs) and all Norvir-based protease inhibitors (PIs). Therefore, it will be important for your provider to ensure that it is used only with HIV drugs with which Olysio does not have significant interactions.
Solvadi is given either (1) in combination with pegylated interferon and ribavirin in those with genotypes 1 or 4 who have never taken HCV treatment ("treatment-naive"), or (2) in combination with ribavirin for those with genotypes 2 and 3. For those with genotypes 2 or 3, this represents the first interferon-free HCV treatment regimen. It is recommended that Sovaldi not be used in combination with the HIV drugs Aptivus (tipranavir) and Norvir (ritonavir). However, it does not appear to interact with other HIV drugs, making it much more "user friendly" than the new HCV protease inhibitors for people living with HIV and HCV.
If you or your provider has questions about potential interactions between any drugs you currently take and hepatitis C drugs, you may find the interactive drug chart helpful.
Daklinza and Harvoni
In August 2014, Daklinza (daclatasvir) received European approval for use with Solvadi in the treatment of hepatitis C. Daklinza (NS5A inhibitor) is made by Bristol-Myers Squibb. It works by interfering with a protein necessary for HCV to reproduce. Harvoni, approved in Europe in November 2014, is a combination of Solvadi (sofosbuvir) plus ledipasvir, both of which are produced by Gilead. Ledipasvir, like Daklinza, is an NS5A inhibitor. Daklinza acts on several HCV genotypes and not just on genotype 1 (most common type in the US and Europe). Harvoni is mostly active against genotype 1.
In December 2014, the FDA approved the use of Abbvie's Viekira Pak™ for treatment of chronic genotype 1 hepatitis C. The Viekira Pak™ is an all-oral, interferon-free treatment including two types of tablets: (1) paritaprevir + ritonavir + ombitasvir, and (2) dasabuvir. One month later, the European Commission approved the same combination, known as Viekirax (ombitasvir/paritaprevir/ritonavir) and Exviera (dasabuvir). Paritaprevir is a boosted protease inhibitor; ombitasvir is an NS5A inhibitor; and dasabuvir is a non-nucleoside NS5B inhibitor. This triple DAA combination works against HCV at three different stages of its lifecycle to keep the virus from multiplying and may be given with or without ribavirin.
New Drugs in the Pipeline
There are also several HCV drugs and new combinations of recently approved drugs in the development process. The treatments currently being studied are interferon-free, direct-acting antiviral combinations.
In April 2014, the World Health Organization (WHO) released guidelines for the screening and treatment of hepatitis C. These guidelines suggest that all people living in areas where hepatitis is common ("high prevalence areas") be offered a HCV test. People who are co-infected with HCV/HIV can be treated with pegylated interferon + ribavirin + either Victrelis or Incivek or Olysio or Solvadi. People who are co-infected with HCV/HIV can also be treated with ribavirin + Solvadi.
The 2015 clinical treatment guidelines released by the European Association for the Study of the Liver (EASL) recommend that HCV treatment be prioritized in people living with HIV and HCV. Moreover, the EASL suggests that HCV treatment be prioritized regardless of the degree of liver cirrhosis (scarring). It recommends interferon-free treatment regimens when possible, in part because they are more effective in curing HCV, and in part because they have fewer side effects. Lastly, the EASL guidelines recommend that those co-infected with HIV and HCV receive the same treatments as those with HCV alone (mono-infected).
The British HIV Association (BHIVA) issued a January 2015 update to its treatment guidelines. This update includes recommendations that (1) all people infected with HCV receive treatment, regardless of the level of liver injury, and (2) DAAs should form the backbone of treatment and interferon should be avoided if possible.
This article was provided by The Well Project. Visit The Well Project's Web site to learn more about their resources and initiatives for women living with HIV. The Well Project shares its content with TheBody.com to ensure all people have access to the highest quality treatment information available. The Well Project receives no advertising revenue from TheBody.com or the advertisers on this site. No advertiser on this site has any editorial input into The Well Project's content.