HIV and Hepatitis C The Complications of Being Infected with Both
Posted by pozlife on March 2, 2008
By Mark Cichocki, R.N., About.com
Updated: July 4, 2007
About.com Health’s Disease and Condition content is reviewed by Susan Olender, MD
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Concerns with HIV and Hepatitis C Coinfection?
Hepatitis C (HCV) infection is difficult. HIV will change your life. Infection with HIV and HCV together makes the treatment of both much more difficult. HCV alone is a public health concern. Coinfection with HIV only makes the HCV problem worse.
- About one quarter of all HIV positive people in the United States is also infected with HCV
- HCV is a major cause of chronic liver disease in the United States
- HCV infection progresses more rapidly to liver damage in HIV-infected persons
- HCV infection impacts the course and management of HIV infection.
The U.S. Public Health Service/Infectious Diseases Society of America (USPHS/IDSA) guidelines recommend that all HIV infected people should be screened for HCV infection. Prevention of HCV infection for those not already infected and reducing chronic liver disease in those who are infected are important concerns for HIV infected people and their health care providers.
Who is Likely to Be Coinfected with HIV and HCV?
HCV is transmitted primarily by large or repeated exposures to contaminated blood (usually through the skin by a needle puncture). Therefore, coinfection with HIV and HCV is common among:
- HIV infected injection drug users(IDUs)
- among people with hemophilia who received blood products before 1987
HCV Infection Through Sexual Exposure or Mother to Child
The risk for acquiring infection through sexual exposures or from mother to child is much lower for HCV than it is for HIV. In fact for persons infected with HIV through sexual exposure (e.g., men who have sex with men), coinfection with HCV is no more common than among similarly aged adults in the general population.
What are the Effects of Coinfection
Coinfection with HIV and HCV can change the prognosis and disease progression of both.
- Chronic HCV infection develops in 75 to 85 percent of infected persons and leads to chronic liver disease in 70 percent of these chronically infected people.
- HIV and HCV coinfection has been associated with higher blood levels of HCV, more rapid progression to HCV-related liver disease, and an increased risk for HCV-related cirrhosis (scarring) of the liver.
- HCV infection has been viewed as an opportunistic infection in HIV infected people since 1999. It is not, however, considered an AIDS-defining illness.
- As HIV medications and prophylaxis of opportunistic infections increase the life span of persons living with HIV, HCV-related liver disease has become a major cause of hospital admissions and deaths among HIV-infected persons.
The effects of HCV coinfection on HIV disease progression are less certain. Some studies have suggested that infection with certain HCV genotypes is associated with more rapid progression to AIDS or death. However, the subject remains controversial. Since coinfected patients are living longer on HIV medications, more data are needed to determine if HCV infection influences the long-term natural history of HIV infection.
How Can Coinfection with HCV Be Prevented?
Persons living with HIV who are not already coinfected with HCV can adopt measures to prevent acquiring HCV. Such measures will also reduce the chance of transmitting their HIV infection to others. HCV prevention methods include:
- stopping injection drug use by employing substance abuse treatment and prevention programs.
- if patients continue to inject drugs, they should be counseled about safer injection practices such as using new, sterile syringes every time they inject drugs and never reusing or sharing syringes, needles, water, or drug preparation equipment (“works”).
- Toothbrushes, razors, and other personal care items that might be contaminated with blood should not be shared.
- Although there is no data indicating that tattooing and body piercing place persons at increased risk for HCV infection, these procedures may be a source for infection with any bloodborne illness if proper infection control practices are not followed.
- Although consistent data is lacking regarding the extent to which sexual activity contributes to HCV transmission, persons having multiple sex partners are at risk for other sexually transmitted diseases (STDs) as well as for transmitting HIV to others. Therefore, safer sex practions should be employed.
Treatment of HIV and Hepatitis C Coinfection
General Treatment Guidelines
- Patients coinfected with HIV and HCV should be encouraged to adopt safe behaviors (as described in the previous section) to prevent transmission of HIV and HCV to others.
- Individuals with evidence of HCV infection should be given information about prevention of liver damage, undergo evaluation for chronic liver disease and, if indicated, be considered for HCV treatment.
- Persons coinfected with HIV and HCV should be advised not to drink excessive amounts of alcohol. Avoiding alcohol altogether might be wise because the effects of even moderate or low amounts of alcohol (e.g., 12 oz. of beer, 5 oz. of wine or 1.5 oz. hard liquor per day) on disease progression are unknown. When appropriate, referral should be made to alcohol treatment programs.
- Because of possible effects on the liver, HCV infected patients should consult with their health care professional before taking any new medicines, including over-the-counter, alternative or herbal medicines.
- Susceptible coinfected patients should receive hepatitis A vaccine because the risk for fatal hepatitis associated with hepatitis A is increased in persons with chronic liver disease.
- Susceptible patients should receive hepatitis B vaccine because most HIV-infected persons are at risk for HBV infection. The vaccines appear safe for these patients and more than two-thirds of those vaccinated develop antibody responses. Prevaccination screening for antibodies against hepatitis A and hepatitis B in this high-prevalence population is generally cost-effective. Postvaccination testing for hepatitis A is not recommended, but testing for antibody to hepatitis B surface antigen (anti-HBs) should be performed 1-2 months after completion of the primary series of hepatitis B vaccine. Persons who fail to respond should be revaccinated with up to three additional doses.
- HIV medications (HAART) has no significant effect on HCV. However, coinfected persons may be at increased risk for HAART-associated liver toxicity and should be closely monitored during antiretroviral therapy. Data suggest that the majority of these persons do not appear to develop significant and/or symptomatic hepatitis after initiation of antiretroviral therapy.
Treatment for HCV Infection
A Consensus Development Conference Panel convened by The National Institutes of Health in 1997 recommended antiviral therapy for patients with chronic hepatitis C who are at the greatest risk for progression to cirrhosis. These persons include anti-HCV positive patients with persistently elevated liver enzymes, detectable HCV RNA, and a liver biopsy that indicates either liver scarring or inflammation and necrosis (tissue death). Patients with less severe liver disease should be managed on an individual basis.
In the United States, two different medication regimens have been approved as therapy for chronic hepatitis C:
- monotherapy with alpha interferon
- combination therapy with alpha interferon and ribavirin. Among HIV-negative persons with chronic hepatitis C, combination therapy consistently yields higher rates of sustained response than monotherapy. Combination therapy is more effective against certain types of HCV and requires a shorter course of treatment. Combination therapy is associated with more side effects than monotherapy, but, in most situations, it is preferable. At present, interferon monotherapy is reserved for patients who have contraindications to the use of ribavirin.
Studies thus far, although not extensive, have indicated that response rates in HIV-infected patients to alpha interferon monotherapy for HCV were lower than in non-HIV-infected patients, but the differences were not statistically significant. Monotherapy appears to be reasonably well tolerated in coinfected patients. There are no published articles on the long-term effect of combination therapy in coinfected patients, but studies currently underway suggest it is superior to monotherapy. However, the side effects of combination therapy are greater in coinfected patients. Thus, combination therapy should be used with caution until more data are available.
The decision to treat people coinfected with HIV and HCV must also take into consideration their current medications and medical conditions. If CD4 counts are normal or near normal there is little difference in treatment success rates between those who are coinfected and those who are infected with HCV alone.
Other Treatment Considerations
Persons with chronic HCV who continue to abuse alcohol are at risk for ongoing liver injury, and antiviral therapy may be ineffective. Therefore, strict abstinence from alcohol is recommended during antiviral therapy, and interferon should be given with caution to a patient who has only recently stopped alcohol abuse. Typically, a 6-month abstinence is recommended for alcohol abusers before starting therapy; such patients should be treated with the support and collaboration of alcohol abuse treatment programs.
Although there is limited experience with antiviral treatment for chronic hepatitis C in people recovering from long-term injection drug use, there are concerns that interferon therapy could be associated with relapse into drug use, both because of its side effects and because it is administered by injection. There is even less experience with treatment of persons who are active injection drug users, and an additional concern for this group is the risk for reinfection with HCV. Although a 6-month abstinence before starting therapy also has been recommended for injection drug users, additional research is needed on the benefits and drawbacks of treating these patients. Regardless, when patients with past or continuing problems of substance abuse are being considered for treatment, such patients should be treated only in collaboration with substance abuse specialists or counselors. Patients can be successfully treated while on methadone maintenance treatment of addiction.
Because many coinfected patients have conditions or factors (such as major depression or active illicit drug or alcohol use) that may prevent or complicate antiviral therapy, treatment for chronic hepatitis C in HIV-infected patients should be coordinated by health care providers with experience in treating coinfected patients or in clinical trials.
It is not known if maintenance therapy is needed after successful HCV therapy, but patients should be counseled to avoid injection drug use and other behaviors that could lead to reinfection with HCV and should continue to abstain from alcohol.