Treatment of Hepatitis C if You Have HIV/AIDS

Table of Contents

• What Is Hepatitis C?
• HIV and HCV Co-Infection
• Treatment of HCV/HIV Co-Infection
• Who Should Get Treatment?
• What Treatments Are Available?
• HIV Treatment for People Who Are Also Infected with HCV
• How Effective Is Treatment?
• Side Effects of Treatment
• Which to Treat First?
• Taking Care of Yourself

What Is Hepatitis C?

Hepatitis C is a disease of the liver caused by the hepatitis C virus (HCV). Over time, HCV can cause serious liver damage including cirrhosis (scarring), liver cancer, and life-threatening liver failure.

HIV and HCV Co-Infection

Because both HIV and HCV can be spread by contact with infected blood, many people are infected with both viruses. This is called co-infection. About one in four people living with HIV (HIV+) in the US are co-infected with HCV. Co-infection is even more common among HIV+ injection drug users, of whom about 80 percent also have HCV.

HCV can progress more rapidly and lead to serious liver damage more often in HIV+ people. According to the Centers for Disease Control and Prevention (CDC), having HIV more than triples the risk of liver disease, liver failure, and liver-related death due to HCV. Co-infection with HCV may also make HIV treatment more challenging. Therefore, it is important for HIV+ people to know whether they have HCV. The CDC recommends that all HIV+ people be screened for both hepatitis B and hepatitis C. Some experts recommend that HIV+ people at risk for HCV be screened every year.

Treatment of HCV/HIV Co-Infection

Treatment of HIV/HCV co-infection is complicated. It is important to have a health care provider who is familiar with HIV and HCV to get the best treatment for both diseases. The good news is that HCV can be treated successfully, even in HIV+ people.

There are many things to consider when deciding if and when to begin treatment for HCV. Talk to your health care provider about all your options before deciding. If you are at risk for HCV disease progression and liver damage, you may want to consider starting HCV treatment sooner rather than later since research shows that earlier treatment has a better outcome.

Who Should Get Treatment?

Not everyone who has HCV needs treatment. Among those who develop chronic HCV, many will not develop serious liver damage. Research shows, however, that HIV+ people are more likely to develop HCV-related liver damage and develop it faster than HIV-negative people.

Health care providers look at a variety of tests and health-related factors when deciding whether or not to recommend HCV treatment. Treatment decisions are not based on symptoms alone, since the early stages of liver damage do not always cause symptoms or abnormal lab test results. Instead, health care providers consider any symptoms, your overall health, the results of liver enzyme tests, and the results of tests that determine the extent of any liver damage.

Tests for HCV include:

• HCV viral load
  This blood test cannot tell if or when someone with HCV will develop liver damage. However, the HCV viral load (amount of HCV in the blood) can help predict how well someone will respond to HCV treatment. Generally, the lower the HCV viral load, the better the chances that treatment will work well. Decisions about HCV treatment are not based on specific viral load levels; however, people with undetectable HCV viral load do not need treatment.
• Liver function (including liver enzyme) tests
  Liver function tests are blood tests that look at levels of liver enzymes (ALT, AST, GGT and alkaline phosphatase), as well as bilirubin, albumin, and prothrombin time (PT). Elevated liver enzymes may indicate liver damage. However, some people with HCV have normal liver enzymes.
• Genotype tests
  There are different types of HCV called genotypes. In the US, genotype 1 is most common. Genotypes 2 and 3 are less common. HCV genotypes can predict how well treatment will work. HCV genotype 1 is less likely to respond to treatment than HCV genotypes 2 and 3. Before you begin treatment, you should have a genotype test to find out which genotype you have. This will help you and your health care provider make decisions about which treatments to use and how long to use them.
• Liver biopsy
  A liver biopsy (inserting a needle through the skin and into the liver to obtain a small sample that is examined under a microscope) is the most reliable way to determine how much damage has been done to your liver. It can also help you and your health care provider figure out when to start HCV treatment. However, a liver biopsy is not necessary in order to start treatment.
• FibroSURE^TM (or FibroTest)
  FibroSURE^TM is a blood test that looks at six markers of liver activity to measure liver damage. It is often used as a non-invasive alternative to liver biopsy.

In general, health care providers are more likely to suggest treatment if you:

• want and are motivated to be treated
• have a liver biopsy or FibroSURE^TM test that shows liver damage (inflammation, and particularly fibrosis)
• have genotype 2 or 3 HCV
• have early cirrhosis (scarring of the liver) but are not ill
• have HIV in addition to HCV
• are otherwise in good health or with well controlled other medical problems
• have acute hepatitis C (infected within the last 6 months)

There are also several factors to consider that have been shown to be associated with faster disease progression in HCV-infected people. Some of these factors include:

• Being older than 50
• Being male (most women with HCV do not develop liver damage as quickly as men)
• Alcohol use
• Co-infection with HBV or HIV

What Treatments Are Available?

Treatment options for HCV have improved a great deal in recent years. Today, the standard treatment is a combination of two medications:

• Pegylated interferon (Pegasys or Peg-Intron)
• Ribavirin (Rebetol, Copegus)

The length of HCV treatment depends on the type of HCV a person has and whether they are co-infected with HIV. There are several different types of HCV, called genotypes. Genotypes 2 and 3 are easier to treat and treatment usually lasts six months for HIV-negative people. Genotype 1 -- the most common in the US -- is harder to treat, so treatment usually lasts 12 months for HIV-negative people. One year of HCV treatment is recommended for people with both HIV and HCV.

Last year, the US Food and Drug Administration (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. They are both meant to be taken in addition to the standard treatment combination of pegylated interferon plus ribavirin. Recent studies have shown that people who took either Victrelis or Incivek in addition to pegylated interferon and ribavirin had higher cure rates than those taking pegylated interferon and ribavirin alone. Studies directly comparing Victrelis to Incivek have not yet been done.