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©2009 The WJG Press and Baishideng.
World J Gastroenterol. Aug 14, 2009; 15(30): 3713-3724
Published online Aug 14, 2009. doi: 10.3748/wjg.15.3713
Published online Aug 14, 2009. doi: 10.3748/wjg.15.3713
Table 1 Baseline assessment before starting treatment in HCV-HIV co-infected patients
Assessment of liver diseases status |
CTP staging |
HCV-RNA |
HCV genotype |
AFP and USG/CT scan for HCC |
HBV markers (HBsAg and anti-HBc) |
HBV-DNA for patients with isolated anti-HBc to detect low level viremia |
Anti-HAV IgG |
Assessment of HIV disease status |
Current and past opportunistic infections |
HIV-associated malignancy |
CD4 count |
HIV viral load |
Details of HAART |
Assessment for problems precluding therapy or requiring control before therapy |
TSH |
Screening for depression or other psychiatric diseases |
Complete blood count |
Blood sugar |
History of significant cardiac, renal, or pulmonary disease |
Fundus examination for retinopathy |
Beta HCG to exclude pregnancy in females |
Urine toxicology screening to exclude concurrent active substance abuse |
Social support and treatment compliance |
Table 2 Trials of anti-HCV treatment in HIV patients
Author (yr) | Country | n | Schedule | Duration | Overall response (%) | GT-2/3 | GT-1/4 | |||
ETR | SVR | ETR | SVR | ETR | SVR | |||||
Pérez-Olmeda et al[39] (2003) | Spain | 68 | PEG-IFN 150 μg/wk × 12 wk, then 100 μg/wk + RBV 400 mg bid | 6 mo for GT-1/4 and 12 mo for GT-3 | 30.3 | 24.2 | 811 | 52.3 | 30.3 | 24.2 |
Cargnel et al[40] (2005) | Italy Multi Center | 135 | PEG-IFN 1.5 μg/kg per week + RBV 400 bid | 48 wk | 28.9 | 21.7 | 43.7 | 34.4 | 18.7 | 9.4 |
PEG-IFN 1.5 μg/kg per week | 16.7 | 9.1 | 16.2 | 10.8 | 14.7 | 8.8 | ||||
Bräu et al[41] (2004) | United States | 107 | IFN α-2b 3 mu tiw + RBV 800 mg /d vs | 48 wk | 18.9 | 11.3 | 50 | 41.7 | 10 | 2.5 |
IFN α 2b 3 mu tiw + placebo × 16 wk, then RBV 800 mg/d | 7.4 | 5.6 | ||||||||
Laguno et al[42] (2004) | Spain | 95 | IFN α 2b 3 mu tiw + RBV 800-1200 mg/d vs | 48 wk for GT-¼ and 24 wk for HT-2/3 | 301 | 211 | 67 | 47 | 11 | 7 |
PEG-IFN 100-150 μg/wk + RBV 800-1200 mg/d | 52 | 44 | 68 | 53 | 41 | 38 | ||||
Myers et al[43] (2004) | Canada | 32 | PEG-IFN α 2b (1.5 μg/kg per week) + weight based RBV (1000 mg for 75 kg or less or 1200 mg for > 75 kg) in IFN non responders | 48 wk | 19 | 16 | 29 | 9 | ||
Chung et al[44] (2004) ACTG | United States | 133 | PEG-IFN α 2a 180 μg/wk + RBV (400 mg/d × 4 wk- 600 mg/d × 4 wk - 1000 mg/d vs | 48 wk | 411 | 271 | 801 | 731 | 331 | 29 |
IFN α 2a 6 mu tiw × 12 wk, then 3 mu tiw +RBV as above | 12 | 12 | 33 | 33 | 6 | 6 | ||||
Moreno et al[45] (2004) | Spain | 35 | PEG-IFN 50 μg/wk + RBV 800 mg/d | 48 wk | 31 | 70 | 25 | |||
Torriani et al[46] (2004) | APRICOT | 868 | PEG-IFN α 2a 180 μg/wk + RBV 800 mg/d vs | 48 wk | 47 | 401 | 64 | 621 | 38 | 29 |
PEG-IFN α 2a + Placebo vs | 31 | 20 | 57 | 36 | 21 | 14 | ||||
IFN α 2a 3 mu tiw + RBV | 14 | 12 | 27 | 20 | 8 | 7 | ||||
Carrat et al[47] (2004) RIBAVIC | France Multi Center | 412 | PEG-IFN α 2b 1.5 μg/kg per week + RBV 800 mg/d vs | 48 wk | 351 | 271 | 50 | 43.7 | 25.6 | 16.81 |
IFN α 2b 3 mu tiw + RBV 800 mg/d | 21 | 20 | 47.4 | 43.4 | 6.2 | 6.2 | ||||
Khalili et al[48] (2005) | United States | 154 | PEG-IFN α 2a 180 μg/wk | 48 wk | 55 | 35 | NA | |||
PEG-IFN + Placebo | 3 | 0 | ||||||||
PEG-IFN + RBV 800 mg/d | 11 | 5 | ||||||||
Hopkins et al[49] (2006) | United Kingdom | 45 | PEG-IFN α 2b 1.5 μg/kg per week + RBV (1000-1200 mg/d) | 24 wk for GT- 2/3 and 48 wk for GT-1 | 62 | 53 | 82 | 751 | 25 | 19 |
Moreno et al[50] (2006) | Spain | 70 (HCV) | PEG-IFN α 2b 1.5 μg/kg per week + RBV 10.6 mg/kg per day | 48 wk | 46 | 371 | All patients had GT-1 or 4 infection and the overall ETR and SVR were 39 and 30% respectively | |||
36 (HCV +HIV) | 25 | 171 | ||||||||
Santin et al[51] (2006) | Spain Multi Center | 60 | PEG-IFN α 2b 80-150 μg/wk + RBV 800-1200 mg/d | 24 wk for GT 2/3 and 48 wk for GT ¼ | 33 | 27 | 53 | 42 | 24 | 201 |
Voigt et al[52] (2006) | Germany Multi Center | 122 | PEG-IFN α 2b 1.5 μg/kg per week + RBV 800 mg/d | 24 wk for GT 2/3 and 48 wk for GT ¼ | 52 | 25 | 72 | 44 | 41 | 181 |
Fuster et al[53] (2006) | Spain Multi Center | 110 | PEG-IFN 180 μg/wk + RBV 800 mg/d | 24 wk for GT 2/3 and 48 wk for GT ¼ | 53 | 42 | 68 | 55 | 47 | 33 |
Righi et al[54] (2008) | Italy | 43 | PEG-IFN 2a 180 μg/wk or 2b 1.5 μg/kg per week + RBV (10.6 mg/kg per day) | 24 wk for GT 3 and 48 wk for GT-1a | 51 | 30 | 38 | 24 |
Table 3 Barriers against anti-HCV therapy in co-infected patients
Patient-related factors |
Active substance abuse |
Concern regarding adverse effects |
Cost of treatment |
Lack of social support |
Lack of transport |
Number of pills and dosing frequency (including HAART) |
Physician-related factors |
Lack of experience |
Lack of awareness |
Lack of motivation for referral |
Fear of adverse effects |
Table 4 Morbidity and mortality with PEG-IFN + RBV: results of three large trials
Parameter | Sub-parameter | ACTG (n = 66) | APRICOT (n = 286) | RIBAVIC (n = 194) |
Treatment related adverse events | Influenza like symptoms | 31 (47) | 172 (89) | |
Fatigue | 128 (44) | |||
Pyrexia | 128 (44) | |||
Headache | 111 (39) | |||
Myalgia | 103 (36) | |||
Nausea | 85 (30) | |||
Diarrhea | 81 (28) | |||
Depression | 7 (11) | 76 (26) | 46 (24) | |
Weight loss | 82 (28 | 46 (24) | ||
Injection site reaction | 44 (21) | |||
Anorexia | 38 (20) | |||
Irritability | 32 (16) | |||
Bronchitis/cough | 26 (13) | |||
Insomnia | 76 (26) | 19 (10) | ||
Elevated lipase/amylase | 9 (14) | |||
Glucose: high or low | 19 (28) | |||
HIV-related adverse events | Lipodystrophy | 37 (19) | ||
Oral candidiasis | 2 (< 1) | 30 (15) | ||
AIDS defining event | 2 (< 1) | |||
Specific serious adverse events | Psychiatric disorders | 8 (4) | ||
Liver failure | 1 (< 1) | 4 (2) | ||
Liver decompensation | 5 (2) | |||
Pneumonia/sepsis | 2 (1) | 6 (3) | ||
Symptomatic increased lactate | 4 (1) | 9 (5) | ||
Pancreatitis | 2 (1) | |||
Lactic acidosis | 0 (0) | 2 (1) | ||
ELAT > 10 ULN | 20 (30) | 16 (8) | ||
Neutropenia < 500/μL | 5 (8) | 10 (5) | ||
Anemia | 2 (3) | 6 (2) | ||
Thrombocytopenia | 1 (2) | 1 (< 1) | ||
Drug abuse | 4 (1) | |||
Deep vein thrombosis | 3 (1) | |||
Bacterial infection | 3 (1) | |||
Gastroenteritis | 2 (1) | |||
Any serious event | Total | 50 (17) | 68 (35) | |
Treatment-related | 24 (8) | 30 (15) | ||
Deaths | Total | 1 (2) | 4 (1) | 5 (3) |
Table 5 Hepatotoxicity of highly active anti-retroviral therapy drugs and guidelines for their use in patients with liver disease
Group | Drug | Dose adjustment |
NRTI | Didanosine | Use cautiously |
NNRTI | Delavirdine, Efavirenz, Nevirapine | Caution with hepatic impairment |
PIs | Lopinavir, Nelfinavir, Ritonavir, Saquinavir | Caution with hepatic impairment |
Atazanavir | Reduce 25% of dose in patients with CTP stage B and C | |
Indinavir | Reduce dose by 25% in CTP stage B and C | |
Tipranavir | Avoid in patients with CTP stage B or C | |
Fosamprenavir | Avoid in patients with CTP stage C | |
Darunavir | Avoid in patients with CTP stage C |
Table 6 Recommendations for management of HCV in HIV patients
All HIV patients should be screened for concomitant HCV infection |
Effective management of HCV is crucial to improve the survival of HIV patients |
Patients with stage 2 or more disease are candidates for therapy provided their HIV disease is controlled |
Pegylated interferon and weight based ribavirin combination is recommended |
Liver transplantation is no longer a contra-indication in the presence of HIV and should be considered in appropriate patients |
Patients with cirrhosis should be screened for esophageal varices and for hepatocellular carcinoma |
- Citation: Singal AK, Anand BS. Management of hepatitis C virus infection in HIV/HCV co-infected patients: Clinical review. World J Gastroenterol 2009; 15(30): 3713-3724
- URL: https://www.wjgnet.com/1007-9327/full/v15/i30/3713.htm
- DOI: https://dx.doi.org/10.3748/wjg.15.3713