HIV/AIDS Related Conditions Treating Hepatitis C in People With HIV By James Myhre & Dennis Sifris, MD James Myhre & Dennis Sifris, MD Dennis Sifris, MD, is an HIV specialist and Medical Director of LifeSense Disease Management. James Myhre is an American journalist and HIV educator. Learn about our editorial process Updated on November 22, 2020 Medically reviewed by Latesha Elopre, MD, MSPH Medically reviewed by Latesha Elopre, MD, MSPH LinkedIn Latesha Elopre, MD, is a board-certified internist specializing in HIV. She is an assistant professor of infectious diseases at the University of Alabama at Birmingham. Learn about our Medical Expert Board Print Hepatitis C is an infectious disease affecting the liver, transmitted by the hepatitis C virus (HCV); globally, 37 million people are infected with HIV and 115 million people with antibodies to hepatitis C virus (HCV). The American Association for the Study of Liver Diseases (AASLD) reports that more than 350 million people globally are infected with viral hepatitis B and C, with one person dying every 30 seconds, while cancer rates from the diagnosis climb. There is currently no vaccine for hepatitis C. PeopleImages / Getty Images HIV/HCV Coinfection The reported prevalence of HIV/HCV coinfection tends to vary by study, 2016 research in the Midwest Region of Brazil showed a HIV-HCV coinfection rate of 6.9%Furthermore, a 2021 study showed a special cohort of persons who inject drugs and the prevalence of HIV and HVC co-infection is significantly high. While men who have sex with men (MSM) don’t inherently have an increased risk for HCV infection, according to the Centers for Disease Control and Prevention, MSM, including gay and bisexual, have an increased chance of contracting Hepatitis A, B, and C. Coinfected people generally have higher HCV viral loads than their mono-infected counterparts. Moreover, coinfected people have a threefold greater risk of antiretroviral-associated hepatotoxicity (liver toxicity) than those with HIV alone. These figures demonstrate the need for greater identification of HCV among people with HIV, as well as more effective treatments to either clear HCV infection or, at the very least, slow disease progression. When to Start Treatment When to start HCV can be a complicated issue. Generally speaking, HCV treatment is indicated in individuals with proven HCV-associated liver abnormalities. The CDC recommends at least a one-time hepatitis C test for all adults, "including those with HIV," additionally, the "CDC continues to recommend people with risk factors, like people who inject drugs, be tested regularly." Because of the significant potential for drug side effects—alongside the fact that treatment does not entirely guarantee HCV clearance—the decision to treat is based largely on patient readiness, as well as assessment the prognostic indicators for treatment success (e.g., HCV genotype, HCV viral load). However, it's important to note that ever-improving HCV drugs are fast reducing barriers to treatment, with the benefits of therapy far outweighing the potential consequences. The Department of Health and Human Services (DHHS) recommends using combination antiretroviral therapy (ART) for coinfected people with HIV/HCV coinfection. Some of those recommendations include: ART should be used in HCV/HIV coinfection, regardless of CD4 T lymphocyte cell count.HCV/HIV coinfection patients should be considered for HCV therapy that diagnoses the patients' liver fibrosis stage to predict possible hepatocellular carcinoma and liver disease.HCV/HIV patients receive screening prior or active hepatitis B virus (HBV). Overview of HCV Medication Options The backbone of HCV treatment has long been the combination of pegylated interferon alpha (or PEG-IFN) with or without ribavirin. PEG-IFN is a combination of three antivirals that elicits cells to produce a large amount of enzymes able to kill both the virus and infected host cells. Ribavirin, another antiviral agent, interferes with RNA metabolism necessary for viral replication. A 2018 medical study showed that newer direct acting antivirals (DAAs) are increasingly able to treat a variety of hepatitis C genotypes without the use of PEG-INF and, in many cases, ribavirin. By doing so, the side effects associated with HCV therapy is greatly reduced, as is the duration of treatment. Among the currently approved DAAs used in the treatment of chronic hepatitis C infection (by order of FDA approval): Drug Approved for Prescribed with Dosing Duration Epclusa (sofosbuvir + velpatasvir) genotypes 1, 2, 3, 4, 5, and 6 with our without cirrhosis ribavirin in cases of decompensated cirrhosis and without ribavirin in all other cases one tablet daily with or without food 12-16 weeks Zepatier (elbasvir + grazoprevir) genotypes 1 and 4 with or without cirrhosis ribavirin or without ribavirin, depending on genotype and treatment history one tablet daily with or without food 12-16 weeks Daklinza (daclatasvir) genotypes 3 without cirrhosis Sovaldi (sofosbuvir) one tablet daily with food 12 weeks Technivie (ombitasvir + paritaprevir + ritonavir) genotypes 4 without cirrhosis ribavirin two tablets daily with food 12 weeks Viekira Pak (ombitasvir + paritaprevir + ritonavir, co-packaged with dasabuvir) genotypes 1 with or without cirrhosis ribavirin or taken on its own, where indicated two tablets of ombitasvir + paritaprevir + ritonavir taken once daily with food, plus one tablet of dasabuvir taken twice daily with food 12-24 weeks Harvoni (sofosbuvir + ledipasvir) genotype 1 with or without cirrhosis taken on its own one tablet daily with or without food 12-24 weeks Sovaldi (sofosbuvir) genotypes 1, 2, 3 and 4 with cirrhosis, including those with cirrhosis or hepatocellular carcinoma (HCC) peginterferon + ribavirin, ribavirin alone, or Olysio (simeprevir) with or without ribavirin, where indicated one tablet daily with or without food 12-24 weeks Olysio (simeprevir) genotype 1 with or without cirrhosis peginterferon + ribavirin, or Sovaldi (sofosbuvir), where indicated one capsule daily with food 24-48 weeks Common Side Effects One of the main concerns about treating HIV/HCV coinfection is the potential side effects than may occur as a result of therapy. While the introduction of newer generation drugs has transformed the treatment of HCV infection, there’s no underplaying the challenges that some patients face. The Mayo Clinic reports common hepatitis C drug side effects that include fatigue, flu-like symptoms, lung problems, mood changes, and skin, sleep, and stomach problems. More serious side affects according to the Mayo Clinic include: A sharp reduction in red blood cells (anemia), which is particularly dangerous for people with heart disease or at high risk of heart disease Suicidal thoughts and impulses, particularly in people with a history of depression, addiction or both A low level of clotting cells in your blood (thrombocytopenia), potentially leading to serious bleeding problems, particularly in those with liver disease Eye problems — specifically, abnormalities in the light-sensitive lining at the back of the eye (retina), particularly in people with diabetes or high blood pressure Inflammation of tissue in the air sacs and lining of the lungs (interstitial pneumonitis), which can severely restrict breathing in a short time Increased or new signs and symptoms of thyroid disease (hypothyroidism), a condition that can be hard to distinguish from the most common treatment side effects, such as fatigue Flares of existing autoimmune conditions, such as rheumatoid arthritis, lupus and psoriasis Before Starting HCV Therapy Understanding and anticipating possible side effects are key to individualizing therapy and achieving optimal treatment goals. Pill burden, dosing schedules, and dietary changes (i.e., increasing fat intake for those on low-fat diets) are just some of the issues that need to be addressed to better ensure patient preparedness. And while drug selection may be considered key to treatment success, so, too, is drug adherence. It relates not only to better outcomes but in many instances reduces the incidence and severity of side effects. Suboptimal adherence is, in fact, as much a factor to the likelihood of treatment failure as are adverse treatment events. Liver Transplants Liver transplants are also a way to treat HIV/HVC coinfection. A 2015 medical study reports "liver transplant outcomes are poorer in HIV/HCV-coinfected recipients compared with those with HCV-monoinfection. The new HCV DAAs offer tremendous potential to improve outcomes in this challenging population." Newer generation HCV medications may likely advance these results, while allaying the high level of drug side effects associated with treatment. 8 Sources Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy. Platt L, Easterbrook P, Gower E, et al. Prevalence and burden of HCV co-infection in people living with HIV: a global systematic review and meta-analysis. The Lancet Infectious Diseases. 2016;16(7):797-808. doi. 10.1016/S1473-3099(15)00485-5. Freitas SZ, Teles SA, Lorenzo PC, et al. Hiv and hcv coinfection: prevalence, associated factors and genotype characterization in the midwest region of brazil. Rev Inst Med trop S Paulo. 2014;56(6):517-524. doi. 10.1590/S0036-46652014000600011. Jamalidoust M, Namayandeh M, Moghadami M, Ziyaeyan M. Comparison of HCV viral load and its genotype distributions in HCV mono- and HIV/HCV co-infected illicit drug users. Virology Journal. 2017;14(1):127. doi. 10.1186/s12985-017-0797-2. Huang X, Liang H, Fan X, Zhu L, Shen T. Liver damage in patients with hcv/hiv coinfection is linked to hiv-related oxidative stress. Oxidative Medicine and Cellular Longevity. 2016;2016:1-11. doi. 10.1155/2016/8142431. Beaucourt S, Vignuzzi M. Ribavirin: a drug active against many viruses with multiple effects on virus replication and propagation. Molecular basis of ribavirin resistance. Current Opinion in Virology. 2014;8:10-15. doi. 10.1016/j.coviro.2014.04.011. Khaliq S, Raza S. Current status of direct acting antiviral agents against hepatitis c virus infection in pakistan. Medicina. 2018;54(5):80. doi. : 10.3390/medicina54050080. Kay AW, Thivalapill N, Skinner D, et al. Predictors of suboptimal adherence to isoniazid preventive therapy among adolescents and children living with HIV. Palinkas L, ed. PLoS ONE. 2020;15(12):e0243713. doi. 10.1371/journal.pone.0243713. Kardashian AA, Price JC. Hepatitis C virus–HIV-coinfected patients and liver transplantation. Current Opinion in Organ Transplantation. 2015;20(3):276-285. 10.1097/MOT.0000000000000199. Additional Reading Alcorn, K. “Triple-drug HCV therapy comes with high risk of serious adverse events for people with cirrhosis.”NAM/AIDSMAP. American Association for the Study of Liver Disease (AASLD). "Assessing the Global and Regional Burden of Liver Disease." Washington, D.C. U.S. Department of Health and Human Services. "Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents." Washington, D.C. U.S. Food and Drug Administration (FDA). "FDA approves first combination drug to treat hepatitis C." Silver Spring, Maryland. U.S. Food and Drug Administration (FDA). "FDA approves new treatment for hepatitis C virus." Silver Springs, Maryland. U.S. Food and Drug Administration (FDA). "FDA approves Technivie for treatment of chronic hepatitis C genotype 4." Silver Spring, Maryland. U.S. Food and Drug Administration (FDA). "FDA approves Viekira Pak to treat hepatitis C." Silver Spring, Maryland. U.S. Food and Drug Administration (FDA). "Olysio (simeprevir) for the treatment of chronic HCV in combination antiviral therapy." Silver Springs, Maryland. Sources: Danta, M.; Brown, D.; Bhagani, S.; et al. "Recent epidemic of acute hepatitis C virus in HIV-positive men who have sex with men linked to high-risk sexual behaviours." AIDS. May 11, 2007; 21(8):983-991. Ghany, M.; Strader, D.; Thomas, D; and Seeff, L. "Diagnosis, Management, and Treatment of Hepatitis C: An Update." Hepatology. 2009; 49(4):1335-1374. Manns, M. and Cornberg, M. "Sofosbuvir: the final nail in the coffin for hepatitis C?" Lancet. March 15, 2013; 13(5):378-379. Rotman, Y. and Liang, T. "Coinfection with Hepatitis C Virus and Human Immunodeficiency Virus: Virological, Immunological, and Clinical Outcomes." Journal of Virology. August 2009; 83(15): 7366-7374. Sulkowski, M.; Naggie, S.; Lalezari, J.; et al. "Sovaldi and Ribivirin for Hepatitis C in Patients with Hepatitis C Coinfection." Sulkowski, M. and Benhamou, Y. "Therapeutic issues in HIV/HCV-coinfected patients." Journal of Viral Hepatitis. June 1, 2007; 14(6):371-388. Tsoulfas, G.; Goulis, I; Papanikolaou, V.; et al. "HIV and Liver Transplantation." Hippokratia. October-December 2009; 13(4):211-215. By James Myhre & Dennis Sifris, MD Dennis Sifris, MD, is an HIV specialist and Medical Director of LifeSense Disease Management. James Myhre is an American journalist and HIV educator. See Our Editorial Process Meet Our Medical Expert Board Share Feedback Was this page helpful? Thanks for your feedback! What is your feedback? 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