Managing treatment in people co-infected with HIV and HCV is more complex than treating people with only one of the infections.
Starting Treatment
If a person has never been on HIV or HCV medications before, the decision about which condition to treat first varies from person to person. Some doctors choose to treat HIV first because this will raise CD4+ cell counts, especially if the CD4+ count is below 350. This is important to prevent life-threatening infections related to having HIV. People with CD4+ counts over 350 have slightly stronger immune systems and may be treated with HCV meds first. Starting treatment is a decision to be made in consultation with a doctor and takes into account more than just CD4+ count. For more information on starting Hep C treatment, see the section on Before Starting Treatment.
Starting therapy to treat both infections at once is not recommended; however, people whose HIV is under control with anti-HIV meds (highly active antiretroviral treatment, or HAART) can consider Hep C treatment and take treatment for both infections at the same time. In fact, having the treatment experience of taking HAART on a daily basis and managing its side effects can help a person cope better with the side effects of HCV treatment and adherence to it.
Other factors that may play a role in the decision about HCV therapy include the following:
Treatment Success
The goal of hepatitis C treatment is to achieve a sustained virological response (SVR). This is defined as a negative HCV RNA test result six months after the end of treatment. The rate of treatment success is lower if a person is co-infected, with generally 25–50% of co-infected people responding to treatment, depending on the HCV genotype. The treatment regimens are similar in co-infection and mono-infection. Co-infected individuals may start treatment for Hep C earlier because the rate of liver damage caused by the HCV is faster in people with who also have HIV. Those infected with genotypes 2 or 3 and HIV may benefit from 48 weeks of treatment instead of the standard 24 weeks offered to mono-infected individuals. (See Treatment Regimen for more information.)
Drug Interactions
Ribavirin may increase the toxic effect of some anti-HIV meds, including ddI (didanosine, Videx EC) and d4T (stavudine, Zerit), by causing higher-than-normal levels of lactic acid in their blood. This complication, called lactic acidosis, leads to fatigue and in some cases can cause damage to organs such as the pancreas and liver. In extreme situations, lactic acidosis can be life-threatening.
AZT (zidovudine, Retrovir) and Hep C meds (interferon and ribavirin) can cause drops in certain blood cells. This is most concerning in terms of low levels of red blood cells (anemia) and the patient should be monitored closely if these meds are taken together. Current treatment guidelines suggest that AZT should be switched for a different medication to prevent these possible effects.
Recently, one study showed that abacavir (Ziagen) may reduce the effectiveness of ribavirin. This has not been verified by other evaluations so most physicians will not recommend stopping abacavir before starting HCV treatment.
Regardless of the HIV medications used, monitoring liver blood tests is important to identify possible liver complications.
High-dose ritonavir (Norvir), which is no longer used in HIV treatment, has been associated with increased liver complications. Low-dose ritonavir, which is currently used to boost levels of other HIV medications, is as safe for the liver as other anti-HIV meds that make up the standard of care. Nevirapine (Viramune) is also processed by the liver and has been associated with increased liver toxicity and liver damage in the first 16 weeks of therapy. Thereafter, the risk of liver complications is the same as other standard HIV meds. Regardless of the HIV medications used, monitoring liver blood tests is important to identify possible liver complications.
Side effects of anti-HIV or HCV meds can be compounded when both treatments are taken together and they should be monitored closely by a healthcare team.
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