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Massive Change in U.S. Treatment Guidelines

January 2010

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Hepatitis C Virus Co-Infection

Long-term studies have found that about 33% of people with HCV mono-infection develop severe liver damage in about 20 years after infection. However, the following factors can accelerate the course of liver disease:

  • older age
  • alcohol abuse
  • being male
  • having HIV infection

Analysis of several studies in people co-infected with HCV and HIV suggest that the speed at which severe liver damage occurs is about three times greater in cases of co-infection, particularly when CD4+ counts are low.

Before beginning HIV therapy, the panel encourages doctors to test their HIV-positive patients for HCV infection.

Here are some critical points about care that the panel mentions:

  • "Co-infected patients should be advised to avoid alcohol consumption, use appropriate precautions to prevent the transmission of both viruses to others, and should be given hepatitis A and B vaccines if [they do not have immunity to these germs]."
  • All co-infected patients should be evaluated for HCV therapy.
  • The panel recommends treatment for co-infected patients, particularly those with high CD4+ cell counts, according to standard HCV guidelines.
  • In patients with less than 200 CD4+ cells, the panel suggests initiating anti-HIV therapy and waiting until cell counts increase before starting HCV therapy.
  • Bone marrow stimulants may be needed to reduce the impact of side effects from HCV medicines.

HIV treatment considerations for people with HCV co-infection:

  • ddI should not be used with the antiviral drug ribavirin because of the potential for severe toxicity.
  • AZT should not be used by people taking ribavirin because of the potential for increased toxicity.
  • Although some retrospective studies suggest that the drug abacavir (Ziagen and in Kivexa) may not work well in people taking HCV therapy, there is no robust data from well-designed trials to confirm this. Therefore, the panel does not discourage the use of abacavir in cases of co-infection.

Liver Injury

Exposure to anti-HIV drugs may cause liver injury, particularly in people co-infected with HCV and HIV. The greatest risk for this toxicity occurs in people with severe liver damage, cirrhosis or end-stage liver disease. Successful treatment of HCV infection may decrease the chance of liver injury caused by anti-HIV therapy.

Starting Anti-HIV Therapy

The panel recommends that co-infected people begin therapy once CD4+ counts fall below the 500-cell mark. It recommends the same combinations for co-infected people as for HIV-mono-infected people.

Anti-HIV Drugs to Avoid

The panel recommends that patients considering or receiving ribavirin should avoid the use of these anti-HIV drugs:

  • AZT (zidovudine, Retrovir and in Combivir)
  • d4T (stavudine, Zerit)
  • ddI (Videx EC)
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This article was provided by Canadian AIDS Treatment Information Exchange. It is a part of the publication TreatmentUpdate. Visit CATIE's Web site to find out more about their activities, publications and services.
See Also
Read the Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents
More News and Analysis on HIV Treatment Guidelines