Page 153 - HIV/AIDS Guidelines

HIV/Hepatitis C Virus (HCV) Coinfection (Last updated March 27, 2012; last reviewed March 27,
2012)

Key Considerations When Managing Patients Coinfected with HIV and Hepatitis C Virus
• All HIV-infected patients should be screened for hepatitis C virus (HCV) infection, preferably before starting
antiretroviral therapy (ART).
• ART may slow the progression of liver disease by preserving or restoring immune function and reducing HIV-related
immune activation and inflammation. For most HIV/HCV-coinfected patients, including those with cirrhosis, the
benefits of ART outweigh concerns regarding drug-induced liver injury (DILI). Therefore, ART should be considered
for HIV/HCV-coinfected patients, regardless of CD4 count (BII).
• Initial ART combination regimens for most HIV/HCV-coinfected patients are the same as those for individuals without
HCV infection. However, when treatment for both HIV and HCV is indicated, consideration of potential drug-drug
interactions and overlapping toxicities should guide ART regimen selection or modification (see discussion in the text).
• Combined treatment of HIV and HCV can be complicated by large pill burden, drug interactions, and overlapping
toxicities. Although ART should be initiated for most HIV/HCV-coinfected patients regardless of CD4 cell count, in ART-
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naive patients with CD4 counts >500 cells/mm some clinicians may choose to defer ART until completion of HCV
treatment.
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• In patients with lower CD4 counts (e.g., <200 cells/mm ), it may be preferable to initiate ART and delay HCV therapy
until CD4 counts increase as a result of ART.

Rating of Recommendations: A = Strong; B = Moderate; C = Optional
Rating of Evidence: I = data from randomized controlled trials; II = data from well-designed nonrandomized trials or observational
cohort studies with long-term clinical outcomes; III = expert opinion
Approximately one-third of patients with chronic hepatitis C virus (HCV) infection progress to cirrhosis at a
median time of less than 20 years. 1, 2 The rate of progression increases with older age, alcoholism, male sex,
and HIV infection. 3-6 In a meta-analysis, individuals coinfected with HIV/HCV were found to have three
times greater risk of progression to cirrhosis or decompensated liver disease than were HCV-monoinfected
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patients. This accelerated rate is magnified in HIV/HCV-coinfected patients with low CD4 counts. Although
ART appears to slow the rate of HCV disease progression in HIV/HCV-coinfected patients, several studies
have demonstrated that the rate continues to exceed that observed in those without HIV infection. 7, 8 Whether
HCV infection accelerates HIV progression, as measured by AIDS-related opportunistic infections (OIs) or
death, is unclear. If such an increased risk of HIV progression exists, it may reflect the impact of injection
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drug use, which is strongly linked to HCV infection. 10,11 The increased frequency of antiretroviral (ARV)-
associated hepatotoxicity with chronic HCV infection also complicates HIV treatment. 12, 13

A combination regimen of peginterferon and ribavirin (PegIFN/RBV) has been the mainstay of treatment for
HCV infection. In HCV genotype 1-infected patients without HIV, addition of an HCV NS3/4A protease
inhibitor (PI) boceprevir or telaprevir to PegIFN/RBV significantly improves the rate of sustained virologic
response (SVR). 14, 15 Clinical trials of these HCV PIs in combination with PegIFN/RBV for the treatment of
HCV genotype 1 infection in HIV-infected patients are currently under way. Both boceprevir and telaprevir
are substrates and inhibitors of cytochrome P (CYP) 3A4/5 and p-glycoprotein (p-gp); boceprevir is also
metabolized by aldo-keto reductase. These drugs have significant interactions with certain ARV drugs that
are metabolized by the same pathways. As such, the presence of HCV infection and the treatment of HCV
may influence HIV treatment as discussed below.

Assessment of HIV/Hepatitis C Virus Coinfection Before Initiation of Antiretroviral
Therapy

• All HIV-infected patients should be screened for HCV infection using sensitive immunoassays licensed
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for detection of antibody to HCV in blood. HCV-seronegative patients at risk for the acquistion of HCV
Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents J-5

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