In the United States, over four million people are infected with hepatitis and of those, approximately 300,000 have a coinfection with HIV. The term hepatitis is actually a general term used to refer to an inflammation or swelling of the liver. A number of factors influence the development of hepatitis. Excessive use of alcohol and drugs, exposure to poisonous toxins and certain infections, such as Mycobacterium avium complex (MAC) or cytomegalovirus (CV), can produce an autoimmune response, causing the body to attack the liver, leading to inflammation and swelling, known as hepatitis. However, viral hepatitis is the most common cause of this condition. There are seven known viruses which can cause hepatitis, but over 90% of cases are mainly caused by hepatitis A, B and C. Of these, hepatitis C (HCV) is the most common to individuals living with HIV. Hepatitis is a very common disease, yet extremely complex. Unfortunately, many people do not know of their infection and those who do are unsure of the standard of care or the complexities that surround living with both HIV and hepatitis.
What Is Hepatitis C?
Hepatitis is a virus that causes direct damage to the liver. Signs and symptoms of HCV are jaundice, fatigue, dark urine, abdominal pain, loss of appetite and nausea. Chronic infection can result in cirrhosis or scarring of the liver, liver cancer and liver failure, which can potentially result in death. Modes of transmission are similar to that of HIV and HBV. HCV can spread more easily than HIV through contact with infected blood. Infection occurs when blood or body fluids from an infected person enters the body of a person who is not infected. HCV is most commonly spread through the sharing of needles when engaging in intravenous drug activity. Over 80% of injection drug users have HCV. However, there is also a transmission risk with HCV through sexual activity. Unfortunately, there is no vaccination for HCV to help prevent infection.
How Is it Diagnosed?
Since HCV directly affects the liver, one of the first steps to a diagnosis is to perform a liver enzyme test. Often, individuals with HCV have abnormal liver enzymes, which are often elevated, potentially revealing liver disease or damage. However, there are two problems with liver enzyme tests. First, abnormal liver enzymes signify liver damage, but it doesn't necessary confirm HCV because of several external factors that may cause liver damage. The second problem is HCV can cause liver damage that might not be reflected in the liver enzymes. An individual could potentially have HCV and produce a normal liver enzyme test. To account for these uncertainties with liver enzyme tests, there are blood tests for HCV which include an antibody test and a viral load test. These tests are similar to the antibody tests and viral load tests performed for HIV. These tests can be much more accurate in diagnosing HCV; however, the best way to know if your liver has been damaged is through a biopsy. In a biopsy, doctors collect liver cells by using a thin needle, then study the collected cells under a microscope to determine whether the liver has been damaged.
|Microscopic view of the hepatitis virus.|
What Is the Standard of Care?
There are six different types of HCV, called genotypes. Most people in the Unites States infected with HCV have genotype 1. Unfortunately, genotype 1 is often much harder to treat than genotypes 2 or 3. Because of this, an important first step in treatment is to find out your genotype. Typically, the treatment for HCV is a combination of the drugs interferon and ribavirin. Pegylated interferon alfa is a drug that is injected under the skin once a week and ribavirin is a pill that is taken every other day. Both of these medications can create serious side effects, including depression, anemia and neutropenia. It is most important to know and understand there are potentially dangerous drug interactions between ribavirin and other nucleoside analogues -- ddI (Videx) and d4T (Zerit). Ribavirin can increase the levels of these drugs in your blood, causing toxic effects on the body, which may be fatal.
Treatment for HCV usually lasts six to twelve months and can be a long, difficult process. There are two goals for treatment. The primary goal is to sustain the virus in an undetectable state, and the secondary goal is to bring liver enzymes to a normal level with the desired outcome of reducing inflammation of the liver. Unfortunately, only half of the individuals experience a successful treatment. Various uncontrollable factors influence treatment outcome: HCV genotype, HIV status, race, age and body weight. Two factors play a role in the success rate of treatment: early detection of HCV infection and refraining from substances that also damage the liver, such as drugs and alcohol.
Coinfection: Hepatitis C and HIV
Because of the similarities in transmission between HCV and HIV, many people are infected with both viruses and are described as having a coinfection. When two viruses are impacting your body, there are complications that may occur because of the relationship between them. You must be aware of these factors to understand the changes your body may face, as well as issues that may arise during treatment. HCV can make the impacts of HIV on your body worse. HCV is directly damaging your liver, while HIV medications may be stressing your liver even further, often creating an environment for liver damage to become more severe with the potential to progress more rapidly then a person only infected with HIV or HCV. Also, individuals who are coinfected often experience more severe side effects and repercussions during HCV treatment. The HCV medications' side effects can compound the effects of HIV as well as the side effects of HIV medications, often making treatment unbearable, directly impacting adherence. The other difficulty with HCV and HIV coinfection is the limited amount of research to support a definite standard of care. Most often, if someone meets the criteria to start treatment for HIV and their case of HCV is mild, treatment for hepatitis is placed on hold until their HIV treatments are started and stabilized. However, if a person doesn't need to immediately start HIV treatment and is infected with HCV, then the consensus is to begin HCV treatment first because the earlier you start treatment, the easier it is to control the HCV infection.
Decisions involving treatment of both HIV and HCV can be extremely complicated. It is important that you have a physician that you can work with and who is knowledgeable about both diseases to help you decide on the best time for treatment.
HCV is a very serious health problem in the United States. Unfortunately, many affected by this disease are unaware of the infection. Early detection can often mean a more successful chance at treatment if the situation is right for one to begin the complex drug regimen. However, for those individuals who have a coinfection, the outcomes from treatment are still not as effective as one should expect them to be. That is why it is important for us, as health advocates, to concentrate our efforts toward HCV drug development.