Ask the Experts - Treat HIV or HCV in Asymptomatic Coinfected Patient?
Ask the Experts - Treat HIV or HCV in Asymptomatic Coinfected Patient?
I have a 40-year-old male patient who has HIV and hepatitis C. His CD4+ count has been stable at around 450 to 600 cells/mm over the past few years, and his viral load is currently stable at around 1500 copies/mL, with a nadir of <400 copies/mL 2 years ago and a peak of around 2500 copies/mL late last year. His serum ALT is stable at around 70, his HCV viral load is around 130,000 copies/mL, and his biopsy shows inflammation and early portal fibrosis consistent with HCV infection. He is asymptomatic and has never received antiretroviral medications. Should such a patient be treated for either HIV, HCV, or both?
Robert Wolverton, MD
This is a fascinating question because it concerns two key issues for which there are no good data from available clinical trials, and therefore we need to come up with a recommendation for the patient by synthesizing available data and using our best judgment.
The issue for this patient is that he has two potentially life-threatening, chronic viral infections and he would like to know which, if any, needs treatment now. The first question to address is whether treatment of one will affect the other. Although there have been conflicting data on this subject, it does not appear that antiretroviral therapy affects HCV viral load or the progression of HCV disease. On the other hand, chronic hepatitis from HCV does increase the risk for hepatotoxicity with antiretroviral therapy (particularly protease inhibitors). Thus, control of hepatitis C might be helpful if aggressive therapy for HIV is needed, and might sway one to treat HCV first.
Before finalizing the decision, it is useful to examine what benefit this particular patient might gain from therapy. At the moment, without any antiretroviral therapy, the patient has a very low plasma HIV viral load (1500 copies/mL) and a stable CD4+ count in a range that does not put him at great risk for opportunistic infections. This patient is at low risk of progressing to AIDS over the next few years, and given the toxicities of antiretroviral therapy, I would defer the initiation of HIV treatment for as long as possible.
Thus the ultimate decision is whether his HCV should be treated now. Although the HCV viral load is relatively low for this virus, he does have persistent elevation of ALT and a liver biopsy that shows some evidence of inflammation and early portal fibrosis. Thus he is a candidate for therapy. In contrast to the current state-of-the-art with HIV, it does appear that therapy for hepatitis C can result in long-term remission, and thus possibly eradication. In randomized controlled clinical trials, the combination of interferon-alpha and ribavirin was associated with a sustained virologic response (after treatment was stopped) in 40%-50% of patients. Although HIV-positive patients were excluded from these trials, preliminary data from studies of the combination of interferon-alpha and ribavirin in HIV-infected persons suggest that this regimen remains effective. Thus, in the absence of any known contraindication, especially current or prior severe depression, I would discuss treating HCV with this patient.
I have a 40-year-old male patient who has HIV and hepatitis C. His CD4+ count has been stable at around 450 to 600 cells/mm over the past few years, and his viral load is currently stable at around 1500 copies/mL, with a nadir of <400 copies/mL 2 years ago and a peak of around 2500 copies/mL late last year. His serum ALT is stable at around 70, his HCV viral load is around 130,000 copies/mL, and his biopsy shows inflammation and early portal fibrosis consistent with HCV infection. He is asymptomatic and has never received antiretroviral medications. Should such a patient be treated for either HIV, HCV, or both?
Robert Wolverton, MD
This is a fascinating question because it concerns two key issues for which there are no good data from available clinical trials, and therefore we need to come up with a recommendation for the patient by synthesizing available data and using our best judgment.
The issue for this patient is that he has two potentially life-threatening, chronic viral infections and he would like to know which, if any, needs treatment now. The first question to address is whether treatment of one will affect the other. Although there have been conflicting data on this subject, it does not appear that antiretroviral therapy affects HCV viral load or the progression of HCV disease. On the other hand, chronic hepatitis from HCV does increase the risk for hepatotoxicity with antiretroviral therapy (particularly protease inhibitors). Thus, control of hepatitis C might be helpful if aggressive therapy for HIV is needed, and might sway one to treat HCV first.
Before finalizing the decision, it is useful to examine what benefit this particular patient might gain from therapy. At the moment, without any antiretroviral therapy, the patient has a very low plasma HIV viral load (1500 copies/mL) and a stable CD4+ count in a range that does not put him at great risk for opportunistic infections. This patient is at low risk of progressing to AIDS over the next few years, and given the toxicities of antiretroviral therapy, I would defer the initiation of HIV treatment for as long as possible.
Thus the ultimate decision is whether his HCV should be treated now. Although the HCV viral load is relatively low for this virus, he does have persistent elevation of ALT and a liver biopsy that shows some evidence of inflammation and early portal fibrosis. Thus he is a candidate for therapy. In contrast to the current state-of-the-art with HIV, it does appear that therapy for hepatitis C can result in long-term remission, and thus possibly eradication. In randomized controlled clinical trials, the combination of interferon-alpha and ribavirin was associated with a sustained virologic response (after treatment was stopped) in 40%-50% of patients. Although HIV-positive patients were excluded from these trials, preliminary data from studies of the combination of interferon-alpha and ribavirin in HIV-infected persons suggest that this regimen remains effective. Thus, in the absence of any known contraindication, especially current or prior severe depression, I would discuss treating HCV with this patient.
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