Abesha Care HIV/AIDS Initiative

Frequently Asked Questions and Answers About Coinfection with
Hepatitis C Virus

Why should HIV-infected persons be concerned about coinfection
with HCV?

About one quarter of HIV-infected persons in the United States are also
infected with hepatitis C virus (HCV). HCV is one of the most important
causes of chronic liver disease in the United States and HCV infection
progresses more rapidly to liver damage in HIV-infected persons. HCV
infection may also impact the course and management of HIV infection.

The latest U.S. Public Health Service/Infectious Diseases Society of America
(USPHS/IDSA) guidelines recommend that all HIV-infected persons should
be screened for HCV infection. Prevention of HCV infection for those not
already infected and reducing chronic liver disease in those who are
infected are important concerns for HIV-infected individuals and their health
care providers.

Who is likely to have HIV-HCV coinfection?

The hepatitis C virus (HCV) is transmitted primarily by large or repeated
direct percutaneous (i.e., passage through the skin by puncture) exposures
to contaminated blood. Therefore, coinfection with HIV and HCV is common
(50%-90%) among HIV-infected injection drug users (IDUs). Coinfection is
also common among persons with hemophilia who received clotting factor
concentrates before concentrates were effectively treated to inactivate both
viruses (i.e., products made before 1987). The risk for acquiring infection
through perinatal or sexual exposures is much lower for HCV than for HIV.
For persons infected with HIV through sexual exposure (e.g., male-to-male
sexual activity), coinfection with HCV is no more common than among
similarly aged adults in the general population (3%-5%).

What are the effects of coinfection on disease progression of HCV
and HIV?

Chronic HCV infection develops in 75%-85% of infected persons and leads
to chronic liver disease in 70% of these chronically infected persons.
HIV-HCV coinfection has been associated with higher titers of HCV, more
rapid progression to HCV-related liver disease, and an increased risk for
HCV-related cirrhosis (scarring) of the liver. Because of this, HCV infection
has been viewed as an opportunistic infection in HIV-infected persons and
was included in the 1999 USPHS/IDSA Guidelines for the Prevention of
Opportunistic Infections in Persons Infected with Human Immunodeficiency
Virus. It is not, however, considered an AIDS-defining illness. As highly
active antiretroviral therapy (HAART) and prophylaxis of opportunistic
infections increase the life span of persons living with HIV, HCV-related liver
disease has become a major cause of hospital admissions and deaths
among HIV-infected persons.

The effects of HCV coinfection on HIV disease progression are less certain.
Some studies have suggested that infection with certain HCV genotypes is
associated with more rapid progression to AIDS or death. However, the
subject remains controversial. Since coinfected patients are living longer on
HAART, more data are needed to determine if HCV infection influences the
long-term natural history of HIV infection.

How can coinfection with HCV be prevented?

Persons living with HIV who are not already coinfected with HCV can adopt
measures to prevent acquiring HCV. Such measures will also reduce the
chance of transmitting their HIV infection to others.

Not injecting or stopping injection drug use would eliminate the chief route
of HCV transmission; substance-abuse treatment and relapse-prevention
programs should be recommended. If patients continue to inject, they
should be counseled about safer injection practices; that is, to use new,
sterile syringes every time they inject drugs and never reuse or share
syringes, needles, water, or drug preparation equipment.

Toothbrushes, razors, and other personal care items that might be
contaminated with blood should not be shared. Although there are no data
from the United States indicating that tattooing and body piercing place
persons at increased risk for HCV infection, these procedures may be a
source for infection with any bloodborne pathogen if proper infection control
practices are not followed.

Although consistent data are lacking regarding the extent to which sexual
activity contributes to HCV transmission, persons having multiple sex
partners are at risk for other sexually transmitted diseases (STDs) as well
as for transmitting HIV to others. They should be counseled accordingly.

How should patients coinfected with HIV and HCV be managed?

General guidelines

Patients coinfected with HIV and HCV should be encouraged to adopt safe
behaviors (as described in the previous section) to prevent transmission of
HIV and HCV to others.

Individuals with evidence of HCV infection should be given information
about prevention of liver damage, undergo evaluation for chronic liver
disease and, if indicated, be considered for treatment. Persons coinfected
with HIV and HCV should be advised not to drink excessive amounts of
alcohol. Avoiding alcohol altogether might be wise because the effects of
even moderate or low amounts of alcohol (e.g., 12 oz. of beer, 5 oz. of wine
or 1.5 oz. hard liquor per day) on disease progression are unknown. When
appropriate, referral should be made to alcohol treatment and
relapse-prevention programs. Because of possible effects on the liver,
HCV- infected patients should consult with their health care professional
before taking any new medicines, including over-the-counter, alternative or
herbal medicines.

Susceptible coinfected patients should receive hepatitis A vaccine because
the risk for fulminant hepatitis associated with hepatitis A is increased in
persons with chronic liver disease. Susceptible patients should receive
hepatitis B vaccine because most HIV-infected persons are at risk for HBV
infection. The vaccines appear safe for these patients and more than
two-thirds of those vaccinated develop antibody responses. Prevaccination
screening for antibodies against hepatitis A and hepatitis B in this
high-prevalence population is generally cost-effective. Postvaccination
testing for hepatitis A is not recommended, but testing for antibody to
hepatitis B surface antigen (anti-HBs) should be performed 1-2 months
after completion of the primary series of hepatitis B vaccine. Persons who
fail to respond should be revaccinated with up to three additional doses.

HAART has no significant effect on HCV. However, coinfected persons may
be at increased risk for HAART-associated liver toxicity and should be
closely monitored during antiretroviral therapy. Data suggest that the
majority of these persons do not appear to develop significant and/or
symptomatic hepatitis after initiation of antiretroviral therapy.

Treatment for HCV Infection

A Consensus Development Conference Panel convened by The National
Institutes of Health in 1997 recommended antiviral therapy for patients with
chronic hepatitis C who are at the greatest risk for progression to cirrhosis.
These persons include anti-HCV positive patients with persistently elevated
liver enzymes, detectable HCV RNA, and a liver biopsy that indicates either
portal or bridging fibrosis or at least moderate degrees of inflammation and
necrosis. Patients with less severe histological disease should be managed
on an individual basis.

In the United States, two different regimens have been approved as therapy
for chronic hepatitis C: monotherapy with alpha interferon and combination
therapy with alpha interferon and ribavirin. Among HIV-negative persons
with chronic hepatitis C, combination therapy consistently yields higher
rates (30%-40%) of sustained response than monotherapy (10%-20%).
Combination therapy is more effective against viral genotypes 2 and 3, and
requires a shorter course of treatment; however, viral genotype 1 is the
most common among U.S. patients. Combination therapy is associated with
more side effects than monotherapy, but, in most situations, it is preferable.
At present, interferon monotherapy is reserved for patients who have
contraindications to the use of ribavirin.

Studies thus far, although not extensive, have indicated that response rates
in HIV-infected patients to alpha interferon monotherapy for HCV were lower
than in non-HIV-infected patients, but the differences were not statistically
significant. Monotherapy appears to be reasonably well tolerated in
coinfected patients. There are no published articles on the long-term effect
of combination therapy in coinfected patients, but studies currently
underway suggest it is superior to monotherapy. However, the side effects
of combination therapy are greater in coinfected patients. Thus,
combination therapy should be used with caution until more data are
available.

The decision to treat people coinfected with HIV and HCV must also take
into consideration their concurrent medications and medical conditions. If
CD4 counts are normal or minimally abnormal (> 400/ul), there is little
difference in treatment success rates between those who are coinfected
and those who are infected with HCV alone.

Other Treatment Considerations

Persons with chronic hepatitis C who continue to abuse alcohol are at risk
for ongoing liver injury, and antiviral therapy may be ineffective. Therefore,
strict abstinence from alcohol is recommended during antiviral therapy, and
interferon should be given with caution to a patient who has only recently
stopped alcohol abuse. Typically, a 6-month abstinence is recommended
for alcohol abusers before starting therapy; such patients should be treated
with the support and collaboration of alcohol abuse treatment programs.

Although there is limited experience with antiviral treatment for chronic
hepatitis C of persons who are recovering from long-term injection drug
use, there are concerns that interferon therapy could be associated with
relapse into drug use, both because of its side effects and because it is
administered by injection. There is even less experience with treatment of
persons who are active injection drug users, and an additional concern for
this group is the risk for reinfection with HCV. Although a 6-month
abstinence before starting therapy also has been recommended for
injection drug users, additional research is needed on the benefits and
drawbacks of treating these patients. Regardless, when patients with past
or continuing problems of substance abuse are being considered for
treatment, such patients should be treated only in collaboration with
substance abuse specialists or counselors. Patients can be successfully
treated while on methadone maintenance treatment of addiction.

Because many coinfected patients have conditions or factors (such as
major depression or active illicit drug or alcohol use) that may prevent or
complicate antiviral therapy, treatment for chronic hepatitis C in HIV-infected
patients should be coordinated by health care providers with experience in
treating coinfected patients or in clinical trials. It is not known if maintenance
therapy is needed after successful therapy, but patients should be
counseled to avoid injection drug use and other behaviors that could lead
to reinfection with HCV and should continue to abstain from alcohol.

Infections in Infants and Children

The average rate of HCV infection among infants born to women coinfected
with HCV and HIV is 14% to 17%, higher than among infants born to women
infected with HCV alone. Data are limited on the natural history of HCV
infection in children, and antiviral drugs for chronic hepatitis C are not
FDA-approved for use in children under aged 18 years. Therefore, children
should be referred to a pediatric hepatologist or similar specialist for
management and for determination for eligibility in clinical trials.

REFERENCE
CDC. HIV and AIDS: Are You at Risk?

Content Source:
Divisions of HIV/AIDS Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention