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TreatmentUpdate 176

Volume 22 Issue 1

2010 January

I ANTI-HIV AGENTS - I. Hepatitis C virus co-infection

Long-term studies have found that about 33% of people with HCV mono-infection develop severe liver damage in about 20 years after infection. However, the following factors can accelerate the course of liver disease:

• older age
• alcohol abuse
• being male
• having HIV infection

Analysis of several studies in people co-infected with HCV and HIV suggest that the speed at which severe liver damage occurs is about three times greater in cases of co-infection, particularly when CD4+ counts are low.

Before beginning HIV therapy, the panel encourages doctors to test their HIV-positive patients for HCV infection.

Here are some critical points about care that the panel mentions:

• “Co-infected patients should be advised to avoid alcohol consumption, use appropriate precautions to prevent the transmission of both viruses to others, and should be given hepatitis A and B vaccines if [they do not have immunity to these germs].”
• All co-infected patients should be evaluated for HCV therapy.
• The panel recommends treatment for co-infected patients, particularly those with high CD4+ cell counts, according to standard HCV guidelines.
• In patients with less than 200 CD4+ cells, the panel suggests initiating anti-HIV therapy and waiting until cell counts increase before starting HCV therapy.
• Bone marrow stimulants may be needed to reduce the impact of side effects from HCV medicines.

HIV treatment considerations for people with HCV co-infection:

• ddI should not be used with the antiviral drug ribavirin because of the potential for severe toxicity.
• AZT should not be used by people taking ribavirin because of the potential for increased toxicity.
• Although some retrospective studies suggest that the drug abacavir (Ziagen and in Kivexa) may not work well in people taking HCV therapy, there is no robust data from well-designed trials to confirm this. Therefore, the panel does not discourage the use of abacavir in cases of co-infection.

Liver injury

Exposure to anti-HIV drugs may cause liver injury, particularly in people co-infected with HCV and HIV. The greatest risk for this toxicity occurs in people with severe liver damage, cirrhosis or end-stage liver disease. Successful treatment of HCV infection may decrease the chance of liver injury caused by anti-HIV therapy.

Starting anti-HIV therapy

The panel recommends that co-infected people begin therapy once CD4+ counts fall below the 500-cell mark. It recommends the same combinations for co-infected people as for HIV-mono-infected people.

Anti-HIV drugs to avoid

The panel recommends that patients considering or receiving ribavirin should avoid the use of these anti-HIV drugs:

• AZT (zidovudine, Retrovir and in Combivir)
• d4T (stavudine, Zerit)
• ddI (Videx EC)

Created on: 2010 January 25

Author: Hosein SR

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