Medicine Chest: HCV/HIV Co-Infection Therapy
How's your liver? Did you know that about one-third of HIV-positive people are also positive for hepatitis C? Many of the co-infected individuals don't know that there are treatments now for hepatitis C (HCV). Like HIV, hepatitis is a virus transmitted by blood. Behaviors especially at risk for transmission of HCV are the sharing of needles or works for drug use and any other activity that causes blood to be shared through broken skin. Theoretically, this may include the sharing of straws for snorting cocaine. The hepatitis C virus damages the liver over time and causes cirrhosis and possible cancer of the liver. Half of all the liver transplants performed today are done in patients with hepatitis C.
If it may take up to 20 years for a liver to fail in those without HIV, why worry about treatment for HCV now? For starters, there are higher viral loads of HCV in the liver of co-infected people. On average, it only takes seven years for severe liver damage to show in those with HCV and HIV. This is generally true for people with low T-cell counts, but not necessarily true for people with higher T-cells. Hepatitis C virus replicates faster and in greater numbers in HIV positive patients. You need your liver to function at full capacity to handle all of those HIV medications that get processed through the liver (protease inhibitors and non-nucleosides). HAART (highly active antiretroviral therapy) can keep HIV in check for many years. Many new drugs and combinations require a healthy liver to be effective, therefore, having liver damage will restrict your HIV options in the future. There is also some new evidence that suggests that HIV disease progresses faster in co-infected patients as well.
If HCV therapy is decided upon, standard of care is interferon and ribavirin (combination therapy again), used together to reduce the hepatitis C viral load. The therapy could last for up to one year, but could be discontinued after six months if it is successful at that point. Less than half of patients on this therapy are successful after one year, but it could be tried again. Deciding on therapy includes a look at your genotype for HCV. Treatment is more successful in people with genotypes 2a, 2b, or 3b (perhaps as much as 60%), compared with less than one out of five people (20%) with genotype 1a or 1b.
A new treatment, Peg-Intron brand of pegylated interferon alpha, was approved for use in 2001, and Pegasys pegylated interferon alpha is expected to be approved early next year. These are long-acting injectable drugs given once weekly. The injection is done at home by the patient and is very similar to an insulin injection millions of diabetics do every day. In addition, a single capsule of ribavirin must be taken twice daily. It can be compounded in a pharmacy and thus be less expensive than the brand drug, Rebetol. (See "HCV/HIV Co-Infection II: Sobriety and Treatment" in this issue.)
If you were thinking there would be no side effects with this therapy, sorry. Severe flu-like symptoms are very common with interferon treatments. Because this new therapy is given once a week, the duration of side effects should be more manageable than prior three times a week doses. As with HAART, proper adherence and management of side effects are important issues to examine before beginning treatment.
Always speak to your healthcare provider if you experience any problems with this or any drug therapies.
Tips for Success
Avoid alcohol: Alcohol passes through the liver and will affect the results of therapy of both HIV medications and those used for hepatitis C. Give your liver a break!
Flu-like symptoms: Do the interferon before bedtime, and pre-treat with pain relievers and antihistamines recommended by your healthcare providers. Drink plenty of water and clear fluids each day.
Nausea and vomiting: Try eating smaller meals on injection day. Increase the number of times you brush your teeth. Avoid trigger foods and odors. Sugar-free lozenges and chewing gum helps. Over-the-counter and prescription medicines are also available if needed.
Diarrhea: Over-the-counter and prescription drugs available if needed.
Fatigue: Get plenty of sleep, and make sure you know how tired the medication makes you before driving or performing complex tasks.
Anemia: Anemia is common in co-infected people on dual hepatitis C therapy. Procrit, another injectable drug, may be prescribed.
Irritability, depression and suicidal thoughts: Relaxing techniques can help with irritability. Speak with your healthcare provider about your symptoms and possible solutions. Pre-treatment with anti-depressants, a month before going on hepatitis C therapy, is common.
Loss of appetite: Eat regularly even if you have no appetite. Drink clear juices in addition to water. Brushing your teeth can get rid of the metallic taste in your mouth. Zinc supplements may also help with this problem.
Hair loss: It is only temporary! If you lose some hair during therapy, it will grow back.
Most insurance companies and Medicaid plans will pay for the cost of the interferon and ribavirin. These are very expensive drugs. AIDS Drug Assistance Programs (ADAP) vary from state to state, but in general, these drugs are not included in the ADAP formularies. Manufacturer of Peg-Intron interferon alpha (Schering), Rebetol ribavirin (Schering) and Pegasys interferon alpha (Roche) have a compassionate care program available. Manufacturers and pharmacies have support programs available at no cost to help patients manage side effects and ensure continued availability of drug product and insurance coverage.
Glen Pietrandoni is director of Clinical Pharmacy Services for the Walgreen Specialty Pharmacy, focusing on HIV, located in the Howard Brown Health Center of Chicago. Thanks to Ted Terziev for help with this article.
Editor's note: HIV-positive persons enrolled in the Peg-Intron free access program have reported missing doses of the hepatitis C medication. Advocates from the Hepatitis C Action and Advocacy Coalition (HAAC) have sent out a community notice explaining a procedure that Peg-Intron's manufacturer provided to the US Food and Drug Administration (FDA) for avoiding this problem. Enrolled patients who are already on the drug should call toll-free at 1-888-437-2608 and talk to someone about the problem they're having getting their new doses. You should be able to get past voice mail by following the instructions, after a couple of presses of the keypad. If you still have problems, call the customer service number, 1-800-222-7579. HAAC would like your feedback. Contact them via e-mail, HAAC_sf@hotmail.com. -- CC
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