Module 9: Co-infection with HIV - section 3

In this document:

Treatment of HIV/HCV Co-infection

Activity: Presentation, group discussion
Section Time: Approximately 30 minutes

The purpose of this section is to give participants a basic understanding of how HIV/HCV co-infection affects treatment and care.

Initiate activity showing Slide 9.7 (HIV/HCV co-infection and treatment implications) and Slide 9.8 (Impact of HCV infections on HIV disease progression) and outline treatment implications and the impact on HIV disease progression:



Impact of HIV infection on HCV disease progression

  • People co-infected with HCV and HIV have more rapid fibrosis progression than mono-infected patients
  • People with HCV/HIV co-infection may have quantitative and/or qualitative deficiency in their immune responses to HCV. HIV accelerates the course of HCV-associated liver disease, particularly in patients who are more severely immune deficient.
  • Liver disease is the leading cause of morbidity and mortality in HCV/HIV co-infected people
  • Comorbidities with hepatic consequences (drug hepatotoxicity, HBV, steatosis, alcohol or drug abuse) are frequent in co-infected patients and may increase the rate of complications associated with HCV-related liver disease
  • Spontaneous clearance of HCV is significantly lower in HIV-infected patients than in immuno- competent patients with acute hepatitis.

Impact of HCV infection on HIV disease progression

  • HCV has little or no effect on the response to ART or on immunological, virological or HIV-related clinical disease progression
  • HCV antibodies per se do not influence progression although infection with certain multiple genotypes might do so
  • Patients on HAART do not have any major differences in HIV-related mortality from HCV/HIV-co-infected patients or those infected with HIV alone, particularly if ART is given
  • There is, however, an increased risk for liver disease-related morbidity and mortality in hepatitis-co-infected HIV, as well as more hepatotoxicity under ART regimens.

Show Slide 9.9 (Group work) :


Distribute:

to all participants before asking them to get into small groups as they will have done for the previous activity.

Allow the groups 10 minutes to review and discuss the hand-outs and ask participants to:

  • Consider the differences for those with mono-infection and those with co-infection
  • Note differences on flip chart paper

Convene large group to allow answers to the question and general feedback. Facilitate discussion by asking participants to consider:

  • How progression varies from those with mono-infection of HCV
  • How well treatment of HCV in people co-infected with HIV works?
  • How does it compare with treatment for mono-infection of HCV?
  • What other treatment strategies might be required for those who don’t clear the virus?
Supporting content:

The goal of hepatitis C treatment is to achieve a sustained virological response (SVR). This is defined as a negative HCV RNA test result six months after the end of treatment. The rate of treatment success is lower if a person is co-infected, with generally 25–50% of co-infected people responding to treatment, depending on the HCV genotype. The treatment regimens are similar in co-infection and mono-infection. Co-infected individuals may start treatment for Hep C earlier because the rate of liver damage caused by the HCV is faster in people with who also have HIV. Those infected with genotypes 2 or 3 and HIV may benefit from 48 weeks of treatment instead of the standard 24 weeks offered to mono-infected individuals (Canadian AIDS Treatment Information Exchange)

Present Slide 9.10 (Treatment options people co-infected with HCV/HIV (1) ) and 9.11 (Treatment options people co-infected with HCV/HIV (2) ) to support the summarising of this section:



Understanding the impact that HCV and HIV can have in a co-infected person is essential in informing any potential treatment plan. HIV/HCV co-infection is an increasingly important public health concern across the region and more research and education for both doctors and patients is needed to further inform how both these diseases work in the body and how they interact with each other.

Most studies indicate that HIV can worsen hepatitis C. HIV/HCV co-infection has been associated with a faster rate of hepatitis C disease progression, higher HCV viral loads, and a greater risk of developing severe liver damage. The impact of hepatitis C on HIV disease is less clear, but a majority of studies suggest that hepatitis C does not accelerate HIV disease progression.

Recent studies show, that with careful monitoring, combination drug regimens can be used to successfully treat both HIV and HCV in co-infected people. The decision whether to initiate HIV or HCV treatment first, or at all, will be determined by a number of factors.

Some experts believe it is better to begin HIV treatment first in order to control HIV replication and increase the CD4 count, since hepatitis C treatment works better in people with stronger immune systems. In people with early-stage HIV disease and advanced hepatitis C, it may be better to start hepatitis C treatment first, so the liver can more easily handle HIV drugs since many HIV medications are metabolized by the liver and some can cause liver toxicity (hepatotoxicity).

Application of good clinical management can evaluate options and determine the most appropriate treatment approach and is one that fully informs the co-infected person of options and likely outcomes, pros and cons of any proposed treatment plan. It is important to recognize that HCV can be treated, regardless of HIV status, although co-infected people are less likely to achieve SVR. However, not all co-infected people need treatment immediately.(Management of hepatitis C and HIV co-infection: Clinical protocol for the WHO European Region, WHO, 2006).

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