Guide to Hepatitis C for People Living With HIV
Testing, Coinfection, Treatment and Support
One approach is to decide first exactly what your priority is. Clearing the virus now is not the most important goal for everyone. In some cases, treatment may be more likely to improve the condition of your liver than to clear the virus. In other cases, treatment may not be necessary right away, or ever.
For some people, deciding whether to do treatment is an easy decision; for most, it isn't. There are a lot of factors to be considered.
This section focuses on conventional treatment. Lifestyle-related choices that help your liver are covered later in the section, "Living With HCV/HIV Coinfection."
Deciding Whether to Treat HCV
Deciding whether or not to treat hepatitis C is an individual and complex decision. Some people really need HCV treatment now. It may be a bridge until newer, more effective, and less toxic therapies are available. Medical need is one of several other factors to be taken into account.
You may know early on whether it is necessary to use the full course of HCV treatment. If, after 12 weeks, it looks like treatment will not work for you, you may decide to stop.
Advantages of Using HCV Treatment
Advantages of Delaying Treatment
Who Needs HCV Treatment?
Treatment guidelines generally agree about when to treat, and who to treat, regardless of HIV status. Sometimes treatment is recommended more aggressively, such as for all coinfected people when "the benefits of therapy outweigh the risks."
Hepatitis C treatment is a combination of two drugs, pegylated interferon and ribavirin. Pegylated interferon is a man-made version of a chemical messenger made by the human body. Interferon stimulates the immune system to fight viruses, so it has antiviral and immunologic activity. Pegylation means that a small molecule has been attached to interferon to keep it in the body longer, to make dosing more convenient, and to render treatment more effective.
There are two types of pegylated interferon (PegIFN):
Pegasys is a liquid that comes in one vial and is stored in the refrigerator. Everyone uses the same dose of Pegasys, regardless of their weight. PEG-Intron is a powder that has to be reconstituted with purified water, both of which come in separate vials. PEG-Intron is dosed by weight.
Both types of pegylated interferon -- Pegasys and PEG-Intron -- have been studied in patients with varying severity of disease. They have not been compared directly, and so it is difficult to know whether one may be better than another in different circumstances.
Ribavirin is a nucleoside analog from the same family as many HIV drugs, but it does not work against HIV. On its own, ribavirin is not an effective treatment for hepatitis C; it needs to be used with pegylated interferon. It is given as a pill or capsule, twice daily. Ribavirin is usually dosed differently depending on body weight and genotype in HCV monoinfection, and often in HCV/HIV coinfection as well.
In coinfection, treatment is currently recommended for at least 48 weeks for all genotypes. Some doctors are extending treatment for people with genotypes 1 and 4.
Recent research has looked at tailoring treatment according to individual response. In particular, people who are HCV/HIV-coinfected may require a longer course of HCV treatment than those who are HCV-monoinfected, especially persons with HCV genotype 1.
Goals of HCV Treatment
The primary goal is to get rid of HCV -- treating to cure.
In hepatitis C, a sustained virological response, or SVR, means that a person does not have detectable virus in his/her bloodstream six months after completing hepatitis C treatment.
Most people who have had an SVR remain virus-free, although there have been fewer long-term studies of coinfected people than those with HCV alone.
Although some recent research has found very low levels of hepatitis C in the blood and liver tissue of some sustained virological responders, this small quantity of virus may not have any significant effect on liver health.
Improving Liver Health
A secondary goal of HCV treatment is to improve liver health by reducing inflammation, and sometimes, reversing fibrosis. This even happens in patients who do not have an SVR, although only in about half the number of cases.
In some cases, the condition of the liver may worsen after HCV treatment, particularly among people who did not clear the virus; the reasons for this are unclear.
Maintenance therapy (with full- or reduced-dose pegylated interferon, either continuously or intermittently) may provide people with serious liver scarring who do not respond, or who relapsed after HCV treatment, with a holding strategy until better treatments become available.
Long-term studies of people with HCV alone have reported that treatment reduces the risk of cirrhosis, liver cancer, and liver-related death, even in people who did not have an SVR.
For HCV/HIV-coinfected people, there may be an additional benefit from HCV treatment: less risk of liver-related side effects from HIV drugs.
Several factors can help you predict the likelihood of HCV treatment response, but the only way to know how you will respond is to treat. The most significant factors are:
Fig 2: Timeline for HIV-Positive People on HCV Treatment
How Well Does Treatment Work?
Clearly, many factors are involved with response to treatment. The information in Table 4 is an overall snapshot of response rates from clinical trials of HCV treatment with pegylated interferon plus ribavirin.
Table 4: Sustained Virological Response (SVR) to Treatment per HCV Genotype
The number of monoinfected and HCV/HIV-coinfected people who did not clear the virus during treatment is increasing. Strategies for re-treating HCV, such as using different types of interferon, higher doses of pegylated interferon and/or ribavirin, and a longer course of treatment, are currently being researched.
Should HIV Be Treated First?
Generally, HIV treatment should be started first if the CD4 count is under 200 cells/mm3, and probably started first if it is between 200 and 350 cells/mm3.
There might be some circumstances -- perhaps when HCV treatment is likely to be used soon in someone whose CD4 count is already falling -- where HIV treatment may be started earlier. So long as HCV infection is stable, many people -- especially if they have been infected with HCV for a long time -- will treat their HIV first. Treating HIV may delay HCV disease progression by maintaining immune health.
In someone whose CD4 count is already strong (above 500 cells/mm3) there is no need to use HIV treatment before HCV treatment.
Using HCV treatment depends on:
Detailed information about HIV treatment is available from many different sources. For example, the i-Base "Introduction to Combination Therapy" deals with many questions (see "Resources and Further Information").
The most important aspects of HIV treatment are just as relevant in coinfection as in HIV monoinfection, including choice of treatment, adherence, side effects, and resistance. The main differences in considering HIV treatment for someone coinfected with HCV relate to timing (since some studies have found that coinfected people have a blunted CD4 cell response to HIV treatment), and concern about liver toxicity and damage as a side effect of HIV drugs.
Some HIV drugs are less liver-friendly than others, although it is not clear whether small increases in liver enzymes increase the risk of clinical disease. Caution is clearly important; ARVs should be selected carefully and liver enzyme levels monitored regularly.
(For more information, see "HIV Drugs and HCV Infection").
When Should HCV Be Treated First?
If HCV treatment is necessary, it is possible to treat people on a stable ARV regimen even if their CD4 count is less than 200 cells/mm3. Studies using an older form on interferon suggested that HCV treatment is less effective for people with low CD4 counts, but in more recent studies of pegylated interferon plus ribavirin, CD4 cell count does not seem to be a factor in the success of treatment, although the overall number of people with less than 200 cells/mm3 was small.
The advantage to treating HCV first if you have a strong immune system is that you can do this without worrying about drug interactions or increased risk of side effects from two sets of treatment.
If you clear HCV, it may also reduce the risk of side effects from HIV drugs when you use them in the future.
It is better not to start treatment for both HIV and HCV at the same time, because side effects can make each other worse.
This article was provided by Treatment Action Group. It is a part of the publication Guide to Hepatitis C for People Living With HIV.