Hepatitis C virus infection in patients with HIV-1: epidemiology, natural history and management

Abstract

Hepatitis C virus (HCV)-related liver diseases have contributed to increased morbidity and mortality in HIV-1-infected individuals in the era of effective antiretroviral therapy. HCV transmission patterns have changed among the HIV co-infected population during the last decade, with acute HCV infection emerging worldwide. HIV infection accelerates the progression of HCV-related liver diseases and consequently cirrhosis, liver failure, and hepatocellular carcinoma. However, the current standard treatment of HCV infection with pegylated interferon plus ribavirin results in only a limited viral response. Furthermore, cumbersome pill regimens, antiretroviral related hepatotoxicity, and drug interactions of HCV and HIV regimens complicate therapy strategies. Fortunately, in the near future, new direct-acting anti-HCV agents will widen therapeutic options for HCV/HIV co-infection. Liver transplantation is also gradually accepted as a therapeutic option for end stage liver disease of HCV/HIV co-infected patients.

Keywords::

• antiretroviral agents
• direct-acting anti-HCV agents
• drug interaction
• drug therapy
• epidemiology
• orthotropic liver transplantation
• pathogenesis

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Co-infection with HCV and HIV is increasingly.

• Although injecting drug user is the main transmission route of HCV infection among HIV-infected population, sexual transmission has become a key route in HCV transmission in HIV-infected men who have sex with men.

• All newly diagnosed HIV individuals should be screened for anti-HCV antibody. Anti-HCV test should be performed at least annually in HIV-infected population at high risk, such as men who have sex with men and injecting drug users. HCV RNA detection should be performed to confirm a diagnosis HCV infection.

• HIV infection accelerates the progression of HCV-related liver diseases including cirrhosis, end-stage liver disease and hepatocellular carcinoma and increase the risk of HCV-related mortality and morbidity.

• Antiretroviral therapy should be initiated first for patients who have CD4 cell counts lower than 500/µl, while anti-HCV therapy would be prior in naïve patients with CD4 counts >500/µl.

• Pegylated interferon (PEG-IFN) (PEG-IFNα-2a 180 µg/week or PEG-IFNα-2b 1.5 µg/kg/week) in combination with RBV (1000 mg for weight <75 kg and 1200 mg for weight >75 kg) is the currently recommended therapy for chronic HCV infection in HIV co-infected patients. Longer duration of treatments, 72 weeks for genotypes 1 and 4 and 48 weeks for genotypes 2 and 3, is recommended. Response-guided therapy and the detection of IL28B single-nucleotide polymorphism should be performed to optimize the individual outcome of HCV treatment.

• Boceprevir or telaprevir in combination with PEG-IFN/RBV could be an important therapeutic option for chronic HCV genotype 1 co-infected patients with HIV infection. Interested co-infected patients should be referred for approved direct-acting anti-HCV agents or those being investigated if feasible. Interferon-free combinations of direct-acting anti-HCV agents will be available in the next 3–5 years.

• The interaction effects between antiretroviral regimens and anti-HCV reagents must be considered before treatment.

• For acute HCV infection in HIV co-infected patients, treatment is recommended in those with persistent HCV RNA reactivity 12 weeks after onset of symptoms or 12 weeks after putative exposure. The minimum of a 24-week course of PEG-IFN plus RBV is recommended.

• Orthotropic liver transplantation is an optional therapeutic strategy for ESLD of HCV/HIV co-infected patients.