Hepatitis C in Patients with Human Immunodeficiency Virus Infection: Diagnosis, Natural History, Meta-Analysis of Sexual and Vertical Transmission, and Therapeutic Issues [Bonacini M and Puoti M. Arch Intern Med 2000;160:3365]: The authors searched AIDSLINE and MEDLINE from 1993 through November 30, 1999 for articles dealing with this co-infection. Conclusions follow:
Prevalence: >60% with HIV who inject drugs have HCV. The overall prevalence in the VA Cooperative Study was 33% [CID 1999;29:150].
HCV RNA Levels: These levels appeared to be increased in persons with co-infection, presumably due to increased viral replication with immunosuppression. Nevertheless, there is a poor inverse correlation between HCV viral load and CD4 cell count.
Natural History of HCV: For co-infected patients with hemophilia, the time from HCV exposure to clinical liver disease is calculated at 15-20 years, which is ten years earlier than patients with HCV only [Lancet 1997;349:825]. There are six articles concerning co-infection in patients without hemophilia demonstrating an inverse correlation between CD4 cell count and cirrhosis. However, the data are not consistent, and the conclusion is the following: Accelerated liver disease early in the course of HIV infection is noted primarily in patients with hemophilia and/or alcoholism. Hepatic fibrosis is not accelerated in patients without hemophilia with CD4 cell counts >200/mm³.
HIV Course: In general, available data suggests that HCV co-infection does not alter the course of HIV infection.
Response to HCV Treatment: Results with interferon (without ribavirin) showed that about 40% of 198 patients with CD4 cell counts >150/mm³ had a virologic and ALT response, which was sustained in 24%. The treatment was reasonably well tolerated, and 90% completed the course. There have been no published studies of interferon plus ribavirin. Interferon had no effect on HIV RNA levels. It is anticipated that liver transplantation will be considered in selective cases, but the experience with co-infection in hemophilia patients who have undergone liver transplants shows a low survival rate of 16% compared to 75% in HIV-negative patients [GUT 1998;42:7440].
Influence of Antiretroviral Treatment on HCV: Studies show inconsistent results with respect to the impact of antiretroviral therapy on HCV viral load and ALT levels. All antiretroviral agents are potentially hepatotoxic, and ritonavir appears to be the most likely to cause severe hepatotoxicity [JAMA 2000;283:74]. The conclusion is that HAART must be given carefully with frequent monitoring of liver function tests.
Vaccination Response: The rate of response to HAV vaccination for patients with HIV infection is 88%, and the response to HBV is about 50%.
Perinatal HCV Transmission: This is increased about 2-fold with HIV co-infection, and 25% of cases involve transmission of both HCV and HIV.
Management: Alcohol should be eliminated. Co-infected patients should be considered for interferon plus ribavirin therapy, especially when CD4 cell counts are high, HCV viral loads are low, and there is a genotype other than type one, since these patients are more likely to respond. HCV-induced liver disease seems best correlated with low CD4 cell counts in co-infected patients so that HAART may be doubly important in this group.
posted 12/14/2000