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Treatment of Hepatitis C in People Living With HIV

March 25, 2014

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Treatment of HCV/HIV Co-Infection

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:

  • Pegylated interferon (Pegasys or Peg-Intron), taken by injection (shot)
  • Ribavirin (Rebetol, Copegus), a pill taken by mouth

There are several different types of HCV, called genotypes. Genotypes 2 and 3 are easier to treat, while genotype 1 -- the most common in the US -- is generally harder to treat.

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; they work 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).

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 drugs 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 at helpful.

New Drugs in the Pipeline

There are also several HCV drugs in the development process. In January 2014, study results were released showing that daclatasvir, when combined with Solvaldi, produces promising cure rates among genotypes 1, 2 and 3. This combination would be entirely oral (no injections!) and would include neither pegylated interferon nor ribavirin. Similarly, a small study of an interferon-free regimen of drugs showed promising results among those with genotype 1. Ledipasvir is another drug that, when combined with Solvadi, shows promising results for those with genotype 1, without either interferon or ribavirin.

Side Effects of Treatment

Like most medications, the drugs used to treat HCV can cause side effects. The most common side effects of pegylated interferon include:

  • Flu-like symptoms (fever, nausea, muscle aches)
  • Depression
  • Anxiety or irritability
  • Low white blood cell count (neutropenia)

While women tend to do better on HCV therapy than men, studies show that depression is more likely to affect women taking interferon. It is very important to speak to your health care provider about any side effects you are experiencing so he or she can help you manage them properly.

The most serious side effect of ribavirin is anemia, or a reduced number of red blood cells that carry oxygen throughout the body. This side effect can often be managed using a drug called Procrit or Epogen (erythropoietin or EPO).

Ribavirin can also cause serious birth defects. Do not take ribavirin if you are pregnant or planning to become pregnant, and stop taking ribavirin at least six months before becoming pregnant. Women and their male partners must use effective birth control while taking ribavirin. Many providers recommend that women use two forms of birth control to prevent pregnancy while taking ribavirin. Additionally, men taking ribavirin who have female partners are encouraged to use two forms of birth control since sperm exposed to ribavirin can cause birth defects.

Both Incivek and Victrelis commonly cause fatigue and nausea. Many people who have taken Incivek have also reported having a rash. For most people, the rash was mild and they did not have to stop taking Incivek. However, in a very few cases, the rashes were severe and life-threatening due to an immune reaction known as Stevens Johnson Syndrome. Many people who have taken Victrelis have also reported a bad taste in their mouth (this is called dysgeusia).

Incivek and Victrelis can also cause anemia. This is especially concerning because ribavirin can also cause anemia, and because anemia is already a common problem among HIV+ people.

Olysio, another protease inhibitor, can cause rash, itching, nausea, and muscle pain. It can also cause photosensitivity, or sensitivity to sunlight. Protecting yourself from the sun, either by using sunblock or limiting time spent outdoors, is suggested when using Olysio.

Solvadi can cause headache, difficulty sleeping, and fatigue (extreme tiredness). Overall, it appears to produce fewer side effects than the other drugs that have been recently approved.

Because the newer HCV drugs – Incivek, Olysio, Solvadi, Victrelis – are given in combination with ribavirin to treat co-infected people, the recommendations for use of any of these new drugs in pregnant women or women planning to become pregnant are the same as for taking ribivirin: do not take them if you are pregnant or planning to become pregnant, and stop taking them at least six months before becoming pregnant.

While treatment for HCV can be challenging, it may help to know in advance what side effects to expect. Various medications can help manage these side effects. Peer support groups can also help you get through treatment. And remember, unlike HIV therapy, HCV treatment usually lasts no more than six to 18 months.

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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 to ensure all people have access to the highest quality treatment information available. The Well Project receives no advertising revenue from or the advertisers on this site. No advertiser on this site has any editorial input into The Well Project's content.
See Also
Talk to a Physician About HIV/Hepatitis Coinfection in Our "Ask the Experts" Forums
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