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G&H What is the prevalence of liver disease among patients currently infected with HIV?
DD Liver disease is now the number one killer in most clinics among patients with HIV, primarily from hepatitis C virus (HCV) infection. Rates of co-infection with HIV/HCV range anywhere from over 90 % in hemophiliacs and IV drug users to approximately 10% in men who contract HIV through sex with men. Hepatitis C has also been reported at epidemic levels in major US cities, among men who have sex with men and engage in specific sexual practices that can potentially break the colonic mucosal barrier.
G&H How has the introduction of highly active antiretroviral therapies changed the prognosis and treatment priorities for co-infected patients?
DD Before the use of effective antiretroviral therapy, the median survival of people with HIV infection was approximately 3 weeks. Obviously, in that scenario, HCV co-infection would not be a critical issue. However, HIV survival rapidly extended from months to years with early antiretroviral therapy. Since 1996 and the introduction of antiretroviral therapy (ART) combinations, the survival of HIV patients in the United States has proven comparable to age- and sex-matched controls with diabetes or hypertension. HIV has simply become another controllable, chronic disease for patients with access to the proper medication. However, HIV infection can change and sometimes heighten, the mortality risk of other chronic diseases, including HCV infection, making HCV therapy and viral eradication of primary importance in co-infected patients.
G&H How does the treatment course differ for co-infected patients as opposed to those with only HCV?
DD The basic decision making is essentially the same, with the exception that HCV infection progresses more rapidly in HIV-positive patients than it does in those who are HIV-negative, in terms of the development of liver fibrosis and cirrhosis, warranting an earlier and more aggressive schedule of treatment.
In addition, HIV medications can cause liver toxicity, which is heightened by HCV co-infection. It is therefore important to have the HCV enzymes under control to improve tolerance of HIV drug therapies.
G&H Are there contraindications to simultaneous therapy for the two viruses?
DD We never start therapy for both viruses at the same time. If patients have a side effect or an intolerance issue, we need to pinpoint which therapy is causing it and make an adjustment. Causes of side effects are much easier to identify if patients are established on one therapy with no problems before starting the other regimen. In addition, with regard to co-infection, ddI stands for “don’t do it.” Didanosine (ddI; Videx, Bristol-Myers Squibb) should not be used with ribavirin as the combination is associated with severe hepatotoxicity. Patients on standard HCV therapy with pegylated interferon plus ribavirin should have their HIV regimen adjusted accordingly. Generally, AZT can be used in co-infected patients though we tend to avoid it in those with baseline anemia.
G&H Is it feasible to utilize maintenance therapy to control HCV as a treatment goal in co-infected patients?
DD Maintenance approaches in co-infected patients who are perhaps nonresponders to HCV eradication therapy are a viable option. Several trials are underway with designs similar to the HALT-C (Hepatitis C Antiviral Long-Term Treatment Against Cirrhosis) trial that are looking at HIV/HCV co-infected patients.
G&H How does the HCV eradication rate in co-infected patients compare to that among patients with HCV only?
DD The major misconception among clinicians is that co-infection is an untreatable problem. In reality, our practice has achieved sustained response rate or cure rate for HCV that are only slightly lower than those seen in patients who don’t have HIV.
We invite our readers to submit case studies for publication. For cases, please send a description of the case followed by your treatment question(s). Case studies are published alongside an expert commentary. Case studies should include a description of the case and a brief literature review. Specific inquiries for the reviewer should also be stated. Inclusion of tables and/or figures is encouraged. All submissions are peer reviewed.
To submit your case study or manuscript, please send an electronic file to moc.secnavdalacinilc@rotide and mail a single printed copy to the address provided.
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