Hepatitis C Virus Infection

Prevention of Exposure
(1) The chief route of hepatitis C virus (HCV) transmission in the United States is injection drug use. Because injection drug use is a complex behavior, assessment of an individual's readiness to change this practice and efforts to provide education and support directed at recovery should be encouraged. Patients should be counseled (70-72):

• to stop using injection drugs (AIII),
• to enter and complete a substance-abuse treatment program, including a relapse prevention program (AIII).
• If continuing to inject, patients should be counseled (BIII):
  • To never reuse or "share" syringes, needles, water, or drug preparation equipment; if, nonetheless, injection equipment that has been used by other persons is shared, to first clean the equipment with bleach and water as for prevention of HIV;
  • To use only sterile syringes obtained from a reliable source (e.g., pharmacies or syringe exchange programs);
  • To use sterile (e.g., boiled) water to prepare drugs; if not possible, to use clean water from a reliable source (such as fresh tap water).
  • To use a new or disinfected container ("cooker") and a new filter ("cotton") to prepare drugs;
  • To clean the injection site before injection with a new alcohol swab; and
  • To safely dispose of syringes after one use.
• If continuing to use illegal drugs intranasally ("snorting"), patients should be counseled that this practice has been associated with HCV transmission and should be instructed not to share equipment (e.g. "straws") with other users (BIII).

(3) To reduce risks of acquisition of bloodborne infections, patients should be advised not to share dental appliances, razors, or other personal care articles (BIII).

(4) Although the efficiency of sexual transmission of HCV remains controversial, safe-sexual practices should be encouraged, and barrier precautions (e.g., latex condoms) are recommended to reduce the risk of exposure to sexually transmitted pathogens (AII).

Prevention of Disease
(5) HIV-infected patients should be screened for HCV infection using enzyme immunoassays (EIA) licensed for detection of antibody to HCV (anti-HCV) in blood (BIII). Positive anti-HCV results should be verified with additional testing (i.e., RIBA™ or RT-PCR for HCV RNA). The presence of HCV RNA in blood might also be assessed in HIV-infected persons with undetectable antibody but other evidence of chronic liver disease (e.g., unexplained elevated liver-specific enzymes) or when acute HCV infection is suspected (CIII).

(6) HIV-HCV coinfected persons should be advised not to drink excessive amounts of alcohol (AII). It may be prudent to avoid alcohol altogether since it is unclear whether even occasional moderate alcohol use (e.g., less than 12 ounces of beer or 10 grams of alcohol per week) increases the incidence of cirrhosis in HIV-infected persons (see below) (CIII).

(7) Patients with chronic hepatitis C should be vaccinated against hepatitis A since: (1) the risk of fulminant hepatitis associated with hepatitis A appears increased in HCV-coinfected persons; (2) hepatitis A vaccine is safe in HIV-infected persons; and (3) although immunogenicity is reduced in patients with advanced HIV infection, more than two thirds develop protective antibody responses (BIII). Prevaccination screening for antibody to hepatitis A virus is cost-effective and therefore recommended when greater than thirty percent prevalence of HAV is expected in the population being screened (e.g., persons >40 years of age) (73) (BIII).

(8) HIV-HCV-coinfected patients should be evaluated for chronic liver disease and for possible need for treatment (71). However, there are limited data regarding the safety and efficacy of antiviral treatment of HIV-HCV-coinfected patients. Moreover, since the optimal means of treating HIV-HCV-coinfected patients has not been established and many HIV-infected patients have conditions which complicate therapy (e.g., depression or illicit drug use), this care should occur in a clinical trial or be coordinated by providers with experience treating both HIV and HCV infections (BIII).

(9) The incidence of antiretroviral-associated liver enzyme elevations is increased in HIV-HCV coinfected patients in some but not all studies; such increases may not require treatment modifications. Thus, while liver enzymes should be carefully monitored, HAART therapy should not be routinely withheld from HIV-HCV infected patients (DIII). However, HIV-HCV-coinfected patients receiving antiretroviral therapy may experience an inflammatory reaction that may mimic an exacerbation of underlying liver disease. In this setting, careful monitoring of liver function is required.

Prevention of Recurrence
(10) If the serum HCV RNA level becomes undetectable on therapy and remains undetectable for 6 months after stopping HCV therapy (sustained virologic response), more than 90% of HIV-uninfected patients with hepatitis C will remain HCV RNA negative for >5 years and have improved liver histology. In HIV-HCV-coinfected patients, the durability of treatment response and requirement for maintenance therapy in sustained responders are unknown.

Note

Pediatric Note
(11) Children born to HIV/HCV-infected women should be tested for HCV infection (70) (BI). In children with perinatal HCV infection, maternal HCV antibody may persist for up to 18 months and HCV RNA can be intermittently undetectable. Thus, testing should be performed at or after two years of age. If earlier diagnosis is needed, HCV RNA should be assessed in more than one infant blood specimen obtained after one month of age. The average rate of HCV infection among infants born to HIV-HCV coinfected women is approximately 15 percent (range 5-36 percent). There are limited data regarding the natural history and treatment of HCV infection in children.

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