Treating Hepatitis C in People With HIV

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.

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):

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.