Management of chronic hepatitis C in HIV-infected patients

Viral hepatitis induces hepatocellular cancer: what can we learn from epidemiology comparing iran and worldwide findings?

CONTEXT

Several risk factors play the role in the development of hepatocellular carcinoma (HCC) from which chronic hepatitis B and C infections are the most important ones. DNA integration of hepatitis viruses alters the function of critical genes promoting malignant transformation of virus-infected liver cells.

EVIDENCE ACQUISITION

There are remarkable geographic differences in prevalence of chronic viral hepatitis and incidence of HCC. Middle Eastern countries are characterized by a moderate to high prevalence rate of chronic viral hepatitis in the population. This review discusses about epidemiologic findings of hepatitis B and C infections, and HCC, as well as focuses on Middle East countries, particularly Iran. We provide an overview about risk factors, prevention and treatment, and bring up the role of HCC induced by chronic viral hepatitis.

RESULTS

Vaccination against hepatitis B virus (HBV) in the early childhood is highly effective to lower infection rates, substantially. For hepatitis C, adequate hygiene when dealing with human blood and screening programs for blood donors can mainly reduce infection rates. As HCC is strongly associated with chronic viral hepatitis, prevention against the infection is crucial for preventing against HCC too.

CONCLUSIONS

Although prevention and treatment of chronic hepatitis B and C have improved within the last decades even in high-risk countries, effective and sustainable reduction of these infections still needs more actions.

Noninvasive procedures to evaluate liver involvement in HIV-1 vertically infected children

OBJECTIVES

: Progressive liver injury is a concern in HIV-infected children exposed to long-term antiretroviral drugs and to the cytopathic effect of HIV. Yet liver biopsy is usually considered too invasive to be repeated in these patients. The aims of this study are to evaluate the feasibility of noninvasive hepatic investigations in HIV-1-infected children, assess the prevalence of signs of liver affection, and analyse the influence of the HIV disease severity and the exposure to antiretroviral therapy.

MATERIALS AND METHODS

: A cross-sectional study conducted in 26 HIV-1 vertically infected children ages 8 to 18 years old. Liver function was assessed with standard serum biochemical markers, FibroTest, ActiTest, SteatoTest, Forns index, aspartate aminotransferase to platelet ratio index, ultrasound, and Fibroscan.

RESULTS

: Nineteen (>60%) children had signs of liver affection on at least 1 of the test results: 13 (50%) had elevated liver enzymes, 15 (63%), 8 (33%), 5 (21%), and 5 (21%) had abnormal FibroTest, ActiTest, Forns index, and aspartate aminotransferase to platelet ratio index results, respectively. Four children (17%) had mild liver steatosis on ultrasound. Fibroscan measures were significantly higher in patients than in age-matched healthy children. Patients with elevated Fibroscan measures also had significantly higher FibroTest results. Age, HIV stage N in the Centers for Disease Control and Prevention classification and exposure duration to nucleoside reverse transcriptase inhibitor and non-nucleoside reverse transcriptase inhibitor drugs were the main risk factors for hepatotoxicity.

CONCLUSIONS

: More than half of our population of HIV-infected children had biological and/or radiological signs of liver affection. Regular follow-up of liver function is necessary in these patients, which is now possible with noninvasive procedures.

Optimized cutoffs improve performance of the aspartate aminotransferase to platelet ratio index for predicting significant liver fibrosis in human immunodeficiency virus/hepatitis C virus co-infection

AIM

To assess the diagnostic value of modified cutoffs for aspartate aminotransferase to platelet ratio index (APRI) to predict significant liver fibrosis in human immunodeficiency virus (HIV)/hepatitis C virus (HCV) patients.

PATIENTS AND METHODS

This retrospective cross-sectional study included consecutive patients with HIV/HCV co-infection who underwent percutaneous liver biopsy. The accuracy of APRI for the diagnosis of significant fibrosis (F2/F3/F4 METAVIR) was evaluated by estimating the positive and negative predictive values (PPV and NPV respectively) and by measuring the area under the receiver operating characteristics curve (AUROC).

RESULTS

One hundred and eleven patients were included (73% men, mean age 40.2+/-7.8 years). Significant fibrosis was observed in 45 patients (41%). To discriminate these subjects, the AUROC of APRI was 0.774+/-0.045. An APRI > or = 1.8 showed a PPV of 75% for the presence of significant fibrosis, and an index < 0.6 excluded significant fibrosis with an NPV of 87%. If biopsy indication was based only on APRI and restricted to scores in the intermediate range (> or = 0.6 and < 1.8), 46% of liver biopsies could have been avoided as compared with 40% using the classical cutoffs.

CONCLUSION

APRI with adjusted cutoffs can predict significant liver fibrosis in patients with HIV/HCV co-infection and might obviate the need to perform a biopsy in a considerable percentage of those subjects.

There is no difference in hepatic fibrosis rates of patients infected with hepatitis C virus and those co-infected with HIV

Some studies have suggested that human immunodeficiency virus (HIV) infection modifies the natural history of hepatitis C virus (HCV) infection, accelerating the progression of fibrosis and the development of cirrhosis. Our objective was to evaluate the fibrosis progression rate (FPR) in HCV/HIV-co-infected patients, and to identify factors that may influence it. HCV-mono-infected and HCV/HIV-co-infected patients with a known date of HCV infection (transfusion or injection drug use) and a liver biopsy were included. The FPR was defined as the ratio between the fibrosis stage (Metavir score) and the estimated length of infection in years and the result was reported as fibrosis units per year. The factors studied were gender, age at infection, consumption of alcohol, aminotransferase levels, histological activity grade, HCV genotype and viral load, CD4 cell count, HIV viral load, and the use of antiretroviral therapy. Sixty-five HCV-infected (group 1) and 53 HCV/HIV-co-infected (group 2) patients were evaluated over a period of 19 months. The mean FPR of groups 1 and 2 was 0.086 +/- 0.074 and 0.109 +/- 0.098 fibrosis units per year, respectively (P = 0.276). There was a correlation between length of HCV infection and stage of fibrosis in both groups. The age at infection, the aspartate aminotransferase level (r = 0.36) and the inflammatory activity grade were correlated with the FPR (P < 0.001). No difference in FPR was found between HCV-mono-infected and HCV/HIV-co-infected patients.

[Ambulatorial prevalence of hepatitis B and C markers in patients with human immunodeficiency virus infection in a general hospital]

BACKGROUND

Hepatitis B and C viruses and human immunodeficiency virus share the same route of transmission, and the prevalence of HBV and HCV infection in patients infected with HIV is greater than it is in the general population.

AIM

To determine the prevalence of hepatitis B and C markers in a population of patients with HIV as well as the risk factors involved.

PATIENTS AND METHODS

From 5,870 registration forms of patients with HIV of an Infectology Unit, 587 were randomly selected. From these, the 343 which had investigated the presence of any hepatitis B (HBsAg, anti-HBc or anti-HBs) or C (anti-HCV) marker were retrospectively analyzed.

RESULTS

HBsAg was positive in 14/306 (4.6%), anti-HBs was positive in 40/154(26.0%), and anti-HBc in 79/205 (38.5%). The anti-HCV test was reactive in 126/330 (38.2%). HBV and HCV co-infection was observed in 7 of the 296 patients who had both HBsAg and anti-HCV tests (2.4%). For those who were HBsAg positive, the main exposure factor was homosexual intercourse (50.0%). For those who were anti-HCV reactive, the main risk factor was intravenous drug use (75.3%). In the HIV mono-infected (185 patients), the most prevalent exposure risk factor was promiscuous heterosexual practices or sexual intercourse with a spouse infected with HIV (83 patients - 44.9%).

CONCLUSION

In our environment HBV-HIV and HCV-HIV co-infections are frequent, a greater relevance being observed in the association between HCV and HIV.

[Evaluation of the cellular immunity in patients coinfected by the hepatitis C virus and the human immunodeficiency virus]

BACKGROUND

The immune activation provoked by the hepatitis C virus can be deleterious in patients with human immunodeficiency virus, favouring the destruction of CD4 cells. By the other side, the immune restoration observed after the onset of antiretroviral therapy can be partially obscured in patients with the hepatitis C virus.

AIM

The objective of the present study was to evaluate the impact of coinfection by hepatitis C virus and the human immunodeficiency virus in the cellular immunity.

METHODS

Two groups of patients were considered: coinfected patients were prospectively evaluated in the gastroenterology clinic at "Hospital Nossa Senhora da Conceição", Porto Alegre, RS, Brazil (group 1 - 385 patients), and monoinfected patients by human immunodeficiency virus based on the review of the charts from the infectious diseases clinic (group 2 - 198 patients). Demographic (gender, race, age) CD4 and CD8 cell count, CD4/CD8 index and human immunodeficiency virus viral load were evaluated. A 5% significance level was adopted.

RESULTS

There were no difference between the parameters evaluated: mean CD4 count (374,7 +/- 215,7 x 357,5 +/- 266,0), CD8 (1.512,4 +/- 7.274,6 x 986,7 +/- 436,4) and HIV viral load (83.744,2 +/- 190.292,0 x 104.464,0 +/- 486.880,5) respectively in both groups evaluated, as well as the proportion of patients with CD4/CD8 rate below 1.

CONCLUSION

Coinfection by both viruses did not have a negative impact in relation to monoinfection by human immunodeficiency virus, and the immune profile was similar in all groups.

Is time to treat for HCV all the HIV/HCV co-infected hemophiliacs?

Hepatitis C virus (HCV) and human immunodeficiency virus (HIV) co-infection is a major problem for hemophiliacs treated before 1985 with non-virally inactivated factor concentrates. However, as HIV infection has been effectively controlled by highly active antiretroviral therapy (HAART), HCV eradication has become a primary goal in co-infected individuals in order to prevent the progression to cirrhosis and end-stage liver failure and the development of hepatocellular carcinoma. In this concise review, the current knowledge as regards the management of HCV infection in HIV co-infected hemophiliacs is analyzed.

Impact of human immunodeficiency virus infection in patients infected with the hepatitis C virus

BACKGROUND/AIMS

The objective of the present study is to evaluate the impact of human immunodeficiency virus (HIV) in patients with hepatitis C virus (HCV) infection.

METHODS

Three different groups of patients were considered: group 1, 385 HCV/HIV coinfected; group 2, 198 HIV monoinfected; and group 3, 311 HCV monoinfected. Demographic and epidemiological data were collected. Blood tests included anti-HCV, HCV-RNA test, genotyping, CD4 cell count, anti-HIV, and HIV viral load. Treatment with interferon and ribavirin was proposed. The fibrosis progression rate was assessed.

RESULTS

The most prevalent risk factor in the group of coinfected was the use of intravenous drugs; in the HIV monoinfection group, heterosexual relations at risk; in the HCV monoinfection group, the transfusion of blood. There was no difference concerning the distribution of genotypes or HCV viral load between groups 1 and 3. Although the mean time of duration of HCV infection was greater in group 3 than in group 1, there was no difference when the fibrosis progression rate was evaluated. The response to treatment was similar.

CONCLUSION

In the present series there was no relevant impact of HCV infection in patients with HIV.

Treatment of hepatitis C in hemophiliacs

Hepatitis C virus (HCV) infection is a major cause of morbidity and mortality in hemophiliacs who received nonvirucidally treated large-pool clotting factor concentrates before 1986. In fact, although many hemophiliacs infected with HCV have a slow progression of liver disease, in a minority of them hepatitis evolves toward end-stage liver disease and hepatocarcinoma. Moreover, a significant percentage of HCV-infected hemophiliacs were also coinfected with human immunodeficiency virus (HIV), which can accelerate the progression of liver disease. Thus, the aim of anti-HCV therapy is to interrupt the chronic infection in order to prevent the progression of hepatitis to cirrhosis, liver decompensation, cancer and, ultimately, death. In this review we present the literature data on anti-HCV treatment in hemophiliacs. Combination therapy with interferon (IFN) and ribavirin has improved the poor results obtained with IFN monotherapy and has become the standard treatment of chronic hepatitis C. Given the positive results obtained with pegylated interferon plus ribavirin in nonhemophiliacs, ongoing trials are evaluating this promising therapy in HCV-chronically infected hemophilic patients; preliminary results show a sustained response rate similar to that in patients without coagulopathy. Finally, based on the encouraging results in coinfected nonhemophiliacs, anti-HCV treatment should also be considered for those HIV-positive hemophiliacs in whom anti-retroviral treatment has stabilized the HIV infection.

Study of a novel hypervariable region in hepatitis C virus (HCV) E2 envelope glycoprotein

A large share of hepatitis C virus amino acid sequence variation is concentrated within two hypervariable regions located at the N-terminus of the E2 envelope glycoprotein (HVR1 and HVR2). Interhost and intrahost comparison of 391 E2 sequences derived from 17 subjects infected with HCV using amino acid entropy revealed clustering of amino acid variability at a third site (residues 431-466), which was termed HVR3. Genetic distance analysis supported the division of HVR3 into three subdomains (HVR3a, HVR3b, and HVR3c). Study of synonymous and nonsynonymous nucleic acid substitutions confirmed that HVR3a was subjected to strong intrahost-selective pressure. Physicochemical and antigenicity predictions, conservation of key residues, and molecular modeling were concordant with one another and further validated the proposed organization of HVR3. Taken together, these results are suggestive of a role for HVR3 in cell surface receptor binding and viral entry akin to that proposed for HVR1 and HVR2.

Epidemiology of human immunodeficiency virus, viral hepatitis (B and C), treponema pallidum, and human T-cell lymphotropic I/II virus among men who have sex with men in Buenos Aires, Argentina

BACKGROUND

Human immunodeficiency virus (HIV) and sexually transmitted infections (STI) are prevalent among men who have sex with men (MSM).

GOAL

To estimate the prevalence of HIV and STIs in this group.

STUDY

A total of 694 MSM were tested for HIV, hepatitis B (HBV), hepatitis C (HCV), human T-cell lymphotropic (HTLV-I/II) viruses and Treponema pallidum infection.

RESULTS

HIV, HBV, and T pallidum were detected in 13.8%, 37.7%, and 16.9% of subjects, respectively. Prevalences of 1.9% and 0.3% were detected for HCV and HTLV-I/II. A prior history of STI was the most predictor for HIV, HBV, and T pallidum. Use of illegal drugs, blood transfusion history, and multiple sexual partners were associated with HCV. The 2 most common co-infections were HBV/T pallidum and HIV/HBV.

CONCLUSIONS

Infection with HIV, HBV, and T pallidum was elevated among MSM. Routine testing, education, vaccine-based prevention, and control programs need to be implemented in this high-risk population.

Natural history and predictors of severity of chronic hepatitis C virus (HCV) and human immunodeficiency virus (HIV) co-infection

Co-infection by the hepatitis C virus (HCV) is observed in up to 30% of HIV-infected individuals. In studies conducted in the 'pre-HAART era', the late consequences of HCV-related chronic liver disease were overshadowed by extra-hepatic causes of deaths, related to severe immune deficiency, and the impact of HCV infection on mortality of HIV-infected patients was low. While the development of HAART has resulted in a significant decrease in morbidity and mortality amongst HIV-infected patients, this clear benefit allowed the expression of liver-related complications associated with HCV chronic infection. The impact of HCV on HIV remains debated but HIV infection significantly modifies the natural history of HCV infection. HIV infection increases levels of HCV viraemia by 2- to 8-fold, resulting in a significant decrease in spontaneous recovery of acute hepatitis. HIV co-infection also worsens the histological course of HCV infection by increasing and accelerating the risk of cirrhosis or leading to rare but lethal fibrosing cholestatic hepatitis. Liver disease is now one of the leading causes of morbidity and mortality in co-infected patients, even if HAART and especially protease inhibitors, may decrease the severity of the liver disease and the liver-related mortality. Several non-exclusive pathogenic processes explain the increasing rate of liver complications associated with HCV-related liver disease.

Influence of HCV or HBV coinfection on adverse drug reactions to antiretroviral drugs in HIV patients

OBJECTIVE

To compare the profile of adverse drug reactions (ADRs) to antiretroviral (ARV) drugs in patients coinfected with hepatitis C virus (HCV) or hepatitis B virus (HBV) versus non-coinfected patients with human immunodeficiency virus (HIV) infection.

METHODS

We used the French Pharmacovigilance Database from 2000 to 2002. Selected patients were classified into four groups: HIV+HCV, HIV+HBV, HIV+HBV+HCV and HIV patients. We compared patients' characteristics and profiles of ADRs to ARV drugs between the four groups.

RESULTS

We identified 1,068 HIV, 172 HIV+HCV, 72 HIV+HBV and 26 HIV+HBV+HCV patients with 2,398, 446, 183 and 70 ADRs related to ARV drugs, respectively. The "seriousness" of these ADRs was similar in HIV and coinfected patients but death related to the ADRs was more frequent in HIV+HCV (9.4%) than in HIV (3.6%) patients (p<0.001). "Liver and bile system disorders" were more frequently reported in HIV+HCV and HIV+HBV patients than in HIV patients (17.3% and 20.8%, respectively, versus 8.9%, p<0.001). In HIV+HBV patients, the occurrence of these ADRs was independently associated in a logistic regression model to male gender [odds ratio (OR): 9.28, 95% confidence interval (CI): 2.74-31.36], exposure to zalcitabine (OR: 17.82, 95% CI: 1.49-212.95) or efavirenz (OR: 5, 95% CI: 1.44-17.33). "Red blood cell disorders" were also more frequent in HIV+HCV (7.4%) than in HIV (4.4%) patients (p<0.01).

CONCLUSION

Hepatic or haematological (mainly anaemia) ADRs to ARV drugs are more frequent in coinfected patients than in HIV patients. This study underlines the importance of hepatitis B or C in the occurrence of ADRs in HIV patients on ARV drugs.

Hepatitis C virus treatment decision-making in the context of HIV co-infection: the role of medical, behavioral and mental health factors in assessing treatment readiness

Hepatitis C virus (HCV)-related liver disease is among the leading causes of mortality among HIV patients, yet very few co-infected patients receive pegylated-interferon and ribavirin combination therapy, the standard of care for chronic HCV. Whereas factors related to the provider, patient and clinic setting all contribute to HCV treatment decision-making, the decision of the provider to recommend or defer treatment is perhaps the most critical determinant of whether a patient receives treatment. This paper reviews the literature related to the medical, behavioral and mental health variables that contribute to providers' assessment of treatment readiness, and associations with treatment response, adherence and retention. A greater understanding of the multilevel factors contributing to HCV treatment decision-making, as well as patient characteristics that predict treatment outcome and adherence, can inform the development of interventions aimed at improving HCV care for HIV patients.

The effects of hepatitis C, HIV, and methamphetamine dependence on neuropsychological performance: biological correlates of disease

OBJECTIVE

To determine the effects of hepatitis C virus (HCV) infection on neuropsychological (NP) performance.

DESIGN

Cross-sectional analysis of a prospectively enrolled cohort.

METHODS

A total of 239 HIV-seropositive and 287 HIV-seronegative subjects enrolled in prospective cohort studies at a single center. Subjects underwent standardized assessments, including comprehensive neuropsychological testing, substance use inventory neuromedical examination, venipuncture, and lumbar puncture. HCV antibody was measured in serum. In seropositive individuals, HCV RNA was measured in plasma and cerebrospinal fluid (CSF).

RESULTS

HCV-seropositive subjects performed worse on neuropsychological testing and were almost twice as likely to be diagnosed as globally impaired, compared with those who were HCV seronegative. In a multivariate analysis, HCV, HIV, and methamphetamine dependence were independently associated with worse performance, even after adjusting for Centers for Disease Control stage and antiretroviral use. HCV-RNA levels in plasma were higher in those with memory, but not global, impairment. In cerebrospinal fluid, HCV RNA was below 100 copies/ml in all specimens. In HIV-infected subjects, HCV was associated with higher levels of HIV RNA in CSF, but not in plasma. HCV was also associated with higher levels of monocyte chemotactic protein 1, TNF-alpha, and soluble TNF receptor II. HCV-seropositive subjects did not appear to have advanced liver disease.

CONCLUSIONS

HIV, HCV, and methamphetamine independently injure the central nervous system, leading to global neuropsychological impairment. HCV may injure the brain by viral or immune-mediated mechanisms. HCV-associated brain injury may be preventable or reversible because HCV infection is potentially curable.

Relative prevalence of comorbidities and treatment contraindications in HIV-mono-infected and HIV/HCV-co-infected veterans

OBJECTIVES

To determine the prevalence of hepatitis C virus (HCV) co-infection among HIV-infected veterans, assess the prevalence of comorbid conditions that may complicate or limit treatment options, and ascertain whether comorbid conditions were more common in co-infected veterans.

DESIGN AND METHODS

We used the Veterans Administration electronic medical records system to identify all veterans receiving care for HIV during fiscal years 1997-2002. Demographic data and diagnostic codes for HIV, HCV, and comorbid conditions were extracted. The validity of using diagnostic codes was assessed by calculating the agreement between chart extraction and electronic data on a separate sample of veterans. Factor analysis was used to identify the structure underlying the intercorrelation between comorbid conditions. Logistic regression was used to compare the prevalence of comorbid conditions and factors between HIV/HCV-co-infected and HIV-mono-infected veterans, adjusting for age and race.

RESULTS

We identified 25,116 HIV-infected veterans in care, of whom 4489 (18%) were HCV co-infected. A validity assessment revealed moderate agreement between chart extraction and electronic data for each of the comorbid conditions assessed. HIV/HCV-co-infected veterans were significantly more likely to have each of the comorbid conditions, and to have significantly more comorbid conditions. Factor analysis revealed three dimensions of comorbidity: mental disorders, medical disorders, and alcohol-related complications. Veterans with co-infection were significantly more likely to have mental disorders and alcohol-related complications.

CONCLUSIONS

HIV/HCV-co-infected veterans had a higher prevalence of comorbid conditions that may complicate and limit treatment options for HIV and for HCV co-infection. Strategies to improve treatment options for co-infected patients with comorbidities must be developed.

Modifications of haematological series in patients co-infected with human immunodeficiency virus and hepatitis C virus during treatment with interferon and ribavirin: differences between pegylated and standard interferon

Therapy with interferon and ribavirin for hepatitis C virus (HCV) infection induces a decrease in several haematological population counts. It is unclear whether haematological toxicity is more severe in patients co-infected with HCV and human immunodeficiency virus (HIV). This study analysed the evolution of haematological population counts during and after interferon and ribavirin therapy for chronic HCV infection. Eleven patients co-infected with HIV and HCV and treated with pegylated interferon plus ribavirin, and ten treated with standard interferon plus ribavirin, were analysed. With reference to baseline values, neutrophil counts decreased by an average of 45% (range 18-67%), total lymphocytes by 50% (16-63%), CD4 lymphocytes by 54% (16-61%), haemoglobin by 9% (5-16%) and platelets by 31% (16-45%). The nadir of the decrease was reached in the first weeks of therapy and was maintained while patients were receiving treatment. The reduction in all series was higher with pegylated interferon. Patients recovered their baseline counts after finishing the treatment. No cases of haemorrhage or outstanding infection were detected during follow-up.

Dissociation of serum and liver hepatitis C virus RNA levels in patients coinfected with human immunodeficiency virus and treated with antiretroviral drugs

We examined hepatitis C virus (HCV) RNA levels in serum, peripheral blood mononuclear cells (PBMC), and the liver for 135 patients with chronic HCV infections, 44 of whom were human immunodeficiency virus (HIV) positive and treated with highly active antiretroviral therapy (group A), 66 of whom were HIV negative (group B), with abnormal serum alanine aminotransferase (ALT) values, and 25 of whom were HIV negative, with ALT values of </=1.5 times the normal value (group C). Patients had not been treated with interferon, with or without ribavirin, at the time of the study. A statistically significant correlation between HCV RNA levels in the liver and serum was reproducibly documented, whereas this was inconsistent for serum and PBMC. A comparative evaluation of HCV RNA levels in the liver and PBMC showed significantly lower values for group A than for groups B and C (P < 0.01 and P < 0.0001, respectively). In contrast, HCV RNA levels in serum were significantly higher for group A than for group B (P < 0.001). A dissociation between HCV RNA levels in serum and the liver was found for patients with HIV-HCV coinfections. Although the relative contribution of extrahepatic reservoirs, including lymphoid cells, to HCV RNA levels in serum is unclear, it may be speculated that a low intrahepatic HCV burden is caused by restored immunocompetence after successful antiretroviral therapy in coinfected patients.

Pegylated interferon alpha-2b plus ribavirin in the treatment of post-liver transplant recurrent hepatitis C

BACKGROUND

Histological recurrence of the hepatitis C virus (HCV) occurs in the majority of persons transplanted for cirrhosis as a result of HCV. Herein we analyze our experience with the use of both conventional and pegylated (PEG) interferon (IFN) in combination with ribavirin (RBV) in liver transplant recipients with recurrent HCV.

METHODS

Patients transplanted between 1992 and 2001 with post-orthotopic liver transplantation (OLT) histological recurrence of HCV, and who were treated with at least 6 months of IFN or PEG-IFN in combination with RBV were included in this analysis. A retrospective chart review was performed.

RESULTS

A total of 31 patients were included. Fifteen were treated with IFN/RBV and 16 with PEG-IFN/RBV. Of these 16, 11 had been begun on IFN/RBV and were changed to PEG-IFN/RBV because of persistent viremia. Three patients (20%) in the IFN/RBV group and six patients (37.5%) in the PEG-IFN/RBV group experienced a virologic response (VR) on therapy. Of the six patients experiencing VR in the PEG-IFN/RBV group, three (50%) were IFN/RBV non-responders. There were two sustained VRs (SVR). The 65.6% of all patients experienced a biochemical response (BR) on therapy. Seven deaths were observed. Dose modifications of IFN or PEG-IFN (87.1%) and RBV (80.6%) and the requirement for hematopoietic growth factors were frequent.

CONCLUSIONS

Treatment of recurrent HCV infection with combination of IFN or PEG-IFN and RBV produced an on-therapy VR in 29% and BR in 65% of patients. Hematologic toxicity and dose modifications were frequent. Our experience with antiviral therapy for HCV post-OLT remains disappointing but PEG-IFN + RBV appears to produce VR in a sizable portion of IFN + RBV non-responders.

HIV infection and hepatic enzyme abnormalities: intricacies of the pathogenic mechanisms

Liver enzyme elevations are common in human immunodeficiency virus (HIV)-infected patients, and their diagnosis or management may be difficult because of the intricacies of the pathogenic mechanisms involved. These include hepatotoxicity related to the highly active antiretroviral therapy (HAART) regimen, idiosyncratic or immunoallergic mechanisms, and direct cytotoxicity enhanced by an underlying liver disease. Liver enzyme abnormalities may also reflect hepatitis B (HBV) or hepatitis C (HCV) infection, which each have their own risks for chronic immune-mediated liver disease (including hepatitis flare after immune reconstitution) and of direct cytotoxicity. Finally, other factors may affect liver deterioration, including alcohol-related liver disease, nonalcoholic steatohepatitis associated with metabolic syndromes (e.g., hyperlipidemia, diabetes, or being overweight) that are potentially HAART related, and use of medication or illicit drugs (e.g., methamphetamine). A better understanding of these complex interactions, including adjustments of dosages of antiretroviral drugs, will probably help in the management of HIV-infected patients with liver enzyme abnormalities.

Pegylated interferon alpha2b plus ribavirin for the treatment of chronic hepatitis C in HIV-infected patients

BACKGROUND

Hepatitis C virus (HCV) and HIV coinfection constitutes an important epidemiological and clinical problem. We evaluated the safety and efficacy of Pegylated interferon alpha2b (Peg-IFN) and a fixed dose of ribavirin in the treatment of chronic hepatitis C in HIV coinfection.

METHODS

Open, prospective study in HCV-HIV coinfected patients with persistently elevated alanine aminotransferase (ALT) levels and a liver biopsy showing either portal or bridging fibrosis. Therapy included Peg-IFN (50 micro g weekly) with ribavirin 800 mg for 48 weeks. The primary end point was sustained virological response (SVR). Univariate and multivariate analyses were performed to determine factors associated with response.

RESULTS

By intent-to-treat analysis, 11 of 35 patients (31%) reached SVR. SVR was significantly better for genotypes 2/3 than for genotype 1 (54% versus 21%; P < 0.05). By multivariate logistic regression analysis, only a non-1 genotype was an independent factor for SVR [odds ratio (OR), 6; 95% confidence interval (CI), 1.1-31.7; P < 0.005]. A decrease of at least 1.5 log10 HCV RNA at week 12 of therapy was highly predictive of SVR (OR, 49.9; 95% CI, 4.9-508.2; P < 0.001). Most patients developed adverse events, although only six patients (17%) discontinued treatment due to toxicity.

CONCLUSIONS

The combination of low doses of Peg-IFN plus a fixed dose of ribavirin resulted in a rate of SVR similar to that obtained with higher doses of the drugs in HIV-infected patients and lower than those obtained in non-HIV patients. Response at week 12 may be useful to help guide therapy in HCV-HIV co-infected patients.

HIV and HCV coinfection in haemophilia

A substantial number of haemophilic patients are infected with both human immunodeficiency virus (HIV) and hepatitis C (HCV). HIV has been shown to accelerate the course of HCV chronic liver disease and there is evidence that HCV infection may worsen the prognosis of HIV. As many HIV infected patients are stable on highly active antiretroviral therapy (HAART) HCV should be actively managed in coinfected individuals. Pegylated interferon (Peg-IFN)/ribavirin combination therapy is the treatment of choice for HCV infection and should be considered in patients with stable HIV on or off HAART with CD4 counts >200 x 10(6)/l. Results of on-going trials of combination therapy in coinfected individuals are awaited. For coinfected patients with end stage liver disease who are stable on HAART liver transplantation should be considered.

Prevalence of human immunodeficiency virus testing in patients with hepatitis B and C infection

OBJECTIVES

To determine the proportion of patients with hepatitis B virus (HBV) and hepatitis C virus (HCV) who are adequately assessed for human immunodeficiency virus (HIV) and to identify variables associated with absence of HIV testing.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of patients who had positive serologic test results for reactive HBV and/or HCV between January 1999 and December 1999 and were followed up at a general internal medicine clinic in East Harlem, NY. Data were collected on patient demographics, HIV risk factors, and other variables that might influence the physician's decision to test the patient for HIV. Primary outcomes were HIV tests performed and documented discussions of at-risk HIV behavior.

RESULTS

The HIV tests were performed in 40% (95% confidence interval [CI], 32%-49%) of the 141 patients with reactive HBV and/or HCV serologic test results. Predictors of HIV testing on multivariate logistic regression were age younger than 50 years (odds ratio [OR], 25; 95% CI, 13-3.8), male sex (OR, 1.6; 95% CI, 1.1-2.2), and having an established primary care provider (OR, 2.3; 95% CI, 1.2-3.9). Injection drug use was not significantly associated with HIV testing.

CONCLUSIONS

Although HBV and HCV have clear epidemiological links with HIV, this study shows that a high percentage of these patients are not being tested. Although some of the factors associated with lack of testing were identified, further studies on the barriers to HIV testing are needed to reveal potential approaches to increase rates of HIV testing in this high-risk population.

Management of Chronic Hepatitis C in Patients Co-Infected with HIV

Hepatitis C virus (HCV) infection is a significant public health problem and one of the most important causes of chronic liver disease worldwide. Co-infection with HCV and HIV occurs frequently, mainly because both viruses share the same transmission routes. In recent years, the life expectancy of patients with HIV disease has been increased due to the introduction of highly active antiretroviral therapy (HAART). Furthermore, several studies have established that HIV infection is associated with a major progression of the HCV-related liver disease. Thus, end-stage liver disease has become a leading cause of morbidity and mortality in this population, emphasising the importance of treatment of chronic hepatitis C in HIV-infected persons. The biological and histological benefit of interferon-alpha (IFNalpha) therapy in patients co-infected with HCV/HIV is not significantly different from that noted in similar patients without HIV when the HIV infection is adequately controlled. However, patients with low CD4+ cell counts tend to respond poorly to anti-HCV therapy.Given the relatively low sustained virological response rate to IFN alone, the use of IFNalpha monotherapy has been largely abandoned in favour of combination therapy with ribavirin. In the last 2 years, IFN plus ribavirin combination therapy has been the standard care for the treatment of chronic hepatitis C. Although information on the safety and efficacy of this dual therapy in HCV/HIV co-infected patients is scarce, recent trials have reported that the combination of IFN plus ribavirin is well tolerated and feasible in patients co-infected with HCV/HIV. However, the rates of sustained virological response seem to be worse than those observed in patients without HIV infection. New IFN formulations (e.g. pegylated interferon) plus ribavirin appear to be way of the future for the treatment of chronic hepatitis C in patients both with and without HIV co-infection.

Treatment of hepatitis C virus in the coinfected patient

Since hepatitis C virus (HCV) was first identified in 1989, the impact of HCV infection on the HIV-infected population has been steadily increasing. It is now known that HCV affects the course and treatment of HIV disease in coinfected individuals (those infected with both HCV and HIV). Although there are significant data regarding the treatment of HCV in non-coinfected individuals, there are numerous questions that still remain regarding how to monitor and treat HCV infection in the coinfected population. This article reviews the available data regarding treatment of HCV in the coinfected population as well as how these individuals should be monitored, before and during HCV therapy, as well as how to address the numerous side effects associated with HCV treatment. To meet the demands of the coinfected population. HIV nurses must be willing to expand their knowledge to support, educate, assess, and advocate for coinfected individuals.

Hepatitis C virus genetic variability in 52 human immunodeficiency virus-coinfected patients

The aim of this study was to examine whether hepatitis C virus (HCV) pretreatment quasispecies complexity was linked to virological response or other clinical and biological parameters, in human immunodeficiency virus (HIV)-coinfected patients undergoing anti-HCV treatment. In addition, HCV quasispecies composition is described longitudinally in these patients before, during, and after treatment. The 52 HIV-coinfected patients were included in a randomized therapeutic trial. At inclusion, they had CD4(+) counts of >250/micro l, HIV plasma load of <10,000 copies/ml, and chronic HCV infection with genotype 1 (n = 27), 2 (n = 2) or 3 (n = 23). These values were compared at baseline with 32 HCV-only-infected, interferon-naive patients who were infected with genotype 1, 2, or 3 (n = 16, 1, or 15, respectively). HCV complexity was studied by single-strand conformation polymorphism (SSCP) in E2 hypervariable region 1 (HVR1), and diversity was evaluated at inclusion in 20 coinfected patients by sequencing four major SSCP bands. The baseline number of SSCP bands was identical in HIV-infected and control patients. In HIV-infected patients, HCV complexity was not predictive of sustained virological response to anti-HCV treatment and was unrelated to epidemiological factors, immunological parameters linked to HIV infection (CD4(+) counts, T CD4(+) proliferative responses to HIV-1 p24), protease inhibitor treatment, HCV plasma load, or genotype. HCV diversity was lower in genotype 2- and 3-infected patients. Six months after completion of the anti-HCV treatment, in comparison with baseline, SSCP profiles were modified in 13 of the 21 nonresponding coinfected patients with analyzable samples. In conclusion, in HIV-infected patients, HCV variability had no significant influence on virological response to anti-HCV treatment.

Efficacy and tolerance of HCV treatment in HIV-HCV coinfected patients: the potential interaction of PI treatment

PURPOSE

To evaluate tolerance and efficacy of an open-label interferon-ribavirin treatment and their determinants in 62 HCV-HIV coinfected patients in routine followup.

METHOD

Patients received at least 6 and up to 12 months of combination interferon alpha-2b (peg or not) plus ribavirin. Determinants of therapeutic success were estimated by a multivariate logistic regression.

RESULTS

Five patients stopped the study, 4 were lost to follow-up, and 53 participated in the entire therapeutic protocol. Among these 53, the end-of-treatment results showed complete clearance of HCV-RNA in 17 (32%). A sustained virologic response (SVR) after 6 or 9 months was observed in 9 (17%) patients, 3 relapsed, and data were not available for 5. Genotype 3a (odds ratio [OR] = 14.4; confidence interval [CI] = 1.84-110.3) favored SVR and treatment with protease inhibitor (PI) therapeutic resistance (OR = 14.4; CI = 1.01-200); as well, a higher fibrosis score tended to increase resistance (p =.11). Adverse events were reported by 24/53 patients (45.3%).

CONCLUSION

HCV therapy associating interferon and ribavirin in HCV-HIV coinfected patients is well accepted even if tolerance is moderate. Treatment permitted SVR in at least 17% of the cases. This is likely when patients initiate treatment at the early fibrosis stage and are infected with genotype 3a. The potential interaction with PI therapy should be explored.

Comparison of 2 regimens that include interferon-alpha-2a plus ribavirin for treatment of chronic hepatitis C in human immunodeficiency virus-coinfected patients

An open-label, randomized trial was conducted to compare the efficacy and safety of 2 regimens of interferon-alpha-2a (IFN-alpha-2a) plus ribavirin for management of chronic hepatitis C virus (HCV) infection in human immunodeficiency virus (HIV)-coinfected patients. Sixty-eight patients were randomized to receive IFN-alpha-2a at a dosage of either (1) 6 MU given 3 times per week for 24 weeks, followed by 3 MU 3 times per week for an additional 24 weeks (group A; 31 patients); or (2) 9 MU per day for 2 weeks, followed by 3 MU per day for 22 weeks, followed by 3 MU 3 times per week for 24 weeks (group B; 37 patients). Ribavirin was added at week 16 of therapy if HCV RNA remained detectable at week 12. Sustained virological response was achieved in 10 patients (15%; 6 in group A and 4 in group B). HCV genotypes 2 or 3 and a decrease in the HCV load of >or=3 log(10) copies/mL between inclusion and week 4 were associated with virological response. In conclusion, the combination of conventional IFN-alpha-2a and ribavirin has poor virological efficacy in HCV-HIV-coinfected patients.

Reciprocal influence of HIV and HCV infections in co-infected patients and the involvement of HAART

The reciprocal influence of HIV-HCV co-infection was established prior to the era of highly active retroviral therapy (HAART) and continues to be a topic of debate, including the question of which infection to treat first.

Hepatitis C virus infection in children coinfected with HIV: epidemiology and management

Mothers with hepatitis C virus (HCV) and HIV coinfection are the major source of HCV/HIV coinfection in infancy and childhood. There is no known intervention capable of interrupting HCV spread from mother to child, while the majority of infant HIV infections occurring in the developed world can be prevented by antiretroviral prophylaxis in the mother and child, elective caesarean section, and formula-feeding. In the era preceding treatment of HIV infection with highly active antiretroviral therapy, HCV coinfection was of little concern because the short-term survival of patients with HIV infection prevented the slowly developing consequences of chronic hepatitis C. As the life expectancy of patients with HIV infection increased with therapy, HCV has emerged as a significant pathogen. Several lines of evidence in adult patients suggest that liver disease may be more severe in patients coinfected with HIV and that progression of HIV disease may be accelerated by HCV coinfection. Whether coinfected children may share these clinical patterns remains a matter of speculation. Chronic hepatitis C in otherwise healthy children is usually a mild disease; liver damage may be sustained and fibrosis may increase over the years, suggesting slow progression of the disease. Interferon-alpha has been the only drug used in the past decade to treat hepatitis C in children and adolescents, with average response rates of 20%. Preliminary results of treatment with interferon-alpha and ribavirin suggest that the efficacy would be greater with combined therapy. These treatment protocols have not yet been applied to children coinfected with HIV, but the increasing number of long-term survivors will probably prompt further investigation in the near future. At present, treating HIV disease and monitoring HCV infection and hepatotoxicity induced by antiretroviral drugs seem to be the more reasonable approach to HCV/HIV coinfection in childhood.

HIV and HCV co-infection: situation at six French university hospitals in the year 2000

The aims of this study were to assess the sociodemographic, epidemiological, clinical, and biological characteristics of French patients co-infected with human immunodeficiency virus-hepatitis C virus (HIV-HCV), as well as the management of their HCV infection. Data on 509 HIV-HCV co-infected patients, followed up at six French University Hospitals, were collected using a questionnaire. Student's t-test, Pearson's chi-square, Fisher's exact, and Fisher-Freeman-Halton's exact tests were used. The mean age of the patients was 38.3 years, and the male to female sex ratio 2.08; 88% of patients were born in Metropolitan France, and 20% were dependent on health benefits; 74% were intravenous drug users and 14% blood or blood product recipients. Forty-seven percent were in CDC classification stage A, 18% had a CD4+ count of <200, and 79% were undergoing current antiretroviral treatment. HCV RNA was positive in 84% (50% type 1, 13% untypable). Forty-four percent had normal alanine aminotransferase (ALT) levels, 24% alcohol consumption >15 g/day, and 51% had undergone liver biopsy (10% of which had cirrhosis). Histological grade was not related to ALT level or CD4+ count. Overall, 40% of patients had been treated for HCV infection. HCV treatment was significantly associated with performance of liver biopsy, histological grade, ALT level, CD4+ count, Centers for Disease Control (CDC) classification, but not with age or alcohol consumption. Rate of early response to treatment was fifty percent among patients treated with bitherapy. Eighty-nine percent of all patients with previous or current anti-HCV treatment had undergone liver biopsy. In conclusion, despite the difficulties in managing hepatitis C in HIV-infected patients, almost one-half of all patients in this study had received anti-HCV treatment.

[Report of three cases of hyperlactacidemiae/lactic acidosis after treatment of hepatitis C with pegylated interferon and ribavirin in HIV coinfected patients]

The hepatitis C infection is highly prevalent among HIV-infected patients. As a direct consequence of the increased survival of these patients in the HAART era, liver disease and its long-term complications have became a genuine health problem in these patients. The treatment of chronic HCV hepatitis is associated with several secondary effects, hiperlactacidemiae/lactic acidosis is one of the most dangerous. It appears to be related with the association of ribavirin and ddI, d4T or AZT. These are three cases of hiperlactacidemiae/lactic acidosis collected during the first twelve months of treatment with pegylated interferon and ribavirin in University Hospital of Guadalajara.

High prevalence of a variant of SENV in intravenous drug user HIV-infected patients

The prevalence, route of transmission, and clinical significance of SEN virus (SENV) infection was evaluated in 715 samples obtained from 150 blood donors, 165 patients infected by HIV, 150 with HCV/HBV infection, 80 with autoimmune diseases, 40 with Primary Immunodeficiency, 40 with sexually transmitted diseases, 40 polytransfused, and from 50 unselected patients. The identification of SENV-DNA was performed by polymerase chain reaction and hybridization, followed by an immunoenzymatic method that identify different SENV strains. SENV-A variant is largely represented among HIV-infected patients, being found in 71% of HIV(+) intravenous drug users and in 26% of individuals that had acquired HIV through sex. A high prevalence of SENV-A was observed also in HIV- polytransfused (27%) or in patients with sexually transmitted diseases (30%). These percentages are significantly higher than those observed in an unselected population and in blood donors. Prevalence of SENV-A is, therefore, high among HIV(+) patients with parental risk of exposure, but this infection does not appear to influence the clinical or immune status of HIV(+) patients.

[Characteristics of bleeding from esophageal-gastric varices in patients with HIV infection]

AIMS

Coinfection with human immunodeficiency virus (HIV) and hepatotropic viruses (hepatitis B and C) is frequent because the routes of infection are similar. Liver disease appears earlier in these patients and progression to cirrhosis and its complications is faster. The aim of this study was to determine the incidence and clinical characteristics of bleeding from esophageal-gastric varices in patients with HIV.

METHODS

We retrospectively analyzed 258 consecutive episodes of bleeding from esophageal-gastric varices in cirrhotic patients between January 1996 and January 2001, of which 20 episodes occurred in patients with HIV (7.8%).

RESULTS

The mean age was significantly lower in patients with HIV infection and all presented hepatitis C infection. The hepatic venous pressure gradient was higher in patients with HIV (22.8 3.4 mmHg vs 19.6 5,4 mmHg; p = 0.05). No differences in the severity of liver disease (Child-Pugh), transfusion requirements, treatment performed, initial hemostasis, early recurrence, or rescue treatment with dipeptidyl peptidase I (DPPI) were found. The development of complications (bacterial infections, hepatic encephalopathy and ascites), hospital stay and mortality were also similar. Mortality was not influenced by HIV stage. Bleeding from esophageal-gastric varices in patients with HIV infection has a similar form of presentation and clinical course with treatment to that in non-cirrhotic patients, despite a higher degree of portal hypertension.

CONCLUSIONS

The presence of HIV infection should not modify diagnostic or therapeutic attitudes to bleeding from esophageal-gastric varices.

Is hepatitis C virus co-infection associated with survival in HIV-infected patients treated by combination antiretroviral therapy?

OBJECTIVE

To study whether hepatitis C virus (HCV) co-infection or the severe elevation of transaminases is associated with survival after the initiation of antiretroviral combination therapy.

DESIGN

Prospective hospital-based cohort (Aquitaine Cohort).

METHODS

HIV-infected adults started on an antiretroviral combination before 30 June 1999. HCV infection was defined as antibody detection or positive HCV RNA. Severe elevation of transaminases was defined as a value of aspartate or alanine aminotransferase (AST, ALT) above five times the upper limit of normal values. Survival was studied using a Cox model, including at least baseline HCV status and transaminases as a time-dependent covariate.

RESULTS

Overall, 995 patients were analysed, including 576 HCV-positive individuals (58%). At baseline, HCV-positive patients were younger, more often injecting drug users and women, and had more frequently elevated transaminases. A shorter survival was associated with AIDS stage [hazard ratio (HR) versus non-AIDS 1.67; 95% confidence interval (CI) 1.03; 2.68], lower CD4 cell count (HR for 50 cells/mm3 lower 1.33; CI 1.17; 1.51), lower haemoglobin (HR for 1 g/dl lower 1.20; CI 1.07; 1.35), lower platelet count (HR for 10 000 cells/mm3 lower 1.04; CI 1.01; 1.07), and AST during follow-up (HR for > or = 200 IU/l 2.30; CI 1.32; 4.03). HCV co-infection (HR 1.20; CI 0.75; 1.92) was not statistically associated with survival.

CONCLUSION

The occurrence of a severe elevation of transaminases was associated with poorer survival, although HCV was not. If liver toxicity may be treatment induced, plasma drug concentrations could guide dosage adjustments of antiretroviral treatments currently prescribed to optimize their use.

Interferon-alpha-2b plus ribavirin: a review of its use in the management of chronic hepatitis C

Relatively few patients (< or =20%) with chronic hepatitis C achieve a sustained virological response after interferon-alpha monotherapy. Hence, alternative treatment strategies such as the addition of the broad spectrum antiviral agent ribavirin to interferon-alpha-2b have been investigated. Combination therapy with subcutaneous interferon-alpha-2b [3 million units (MU) three times per week] plus oral ribavirin (1000 to 1200 mg/day) has proven effective in several well designed trials of 24 to 48 weeks' duration in adult patients with compensated chronic hepatitis C. Compared with interferon-alpha-2b (3 or 6 MU three times per week) with or without placebo, combination treatment with interferon-alpha-2b plus ribavirin significantly enhanced end-of-treatment and sustained virological and biochemical response rates in treatment-naive and treatment-experienced patients [sustained virological response rates in treatment-naive recipients (6 to 19% vs 31 to 43% of patients); sustained overall (virological plus biochemical) response rates in nonresponders to (1 vs 14%) or relapsers (4 to 5% vs 30 to 44%) after previous interferon-alpha monotherapy]. Forty-eight weeks of combination therapy was superior to 24 weeks in treatment-naive patients infected with hepatitis virus C (HCV) genotype 1, whereas response rates were similar at 24 and 48 weeks in those infected with other HCV genotypes. Furthermore, there were marked improvements in histological inflammatory scores in patients who responded to treatment with either interferon-alpha-2b plus ribavirin or interferon-alpha-2b alone. Although adverse events associated with either drug during combination therapy occurred frequently, these were generally mild to moderate in intensity and were consistent with those reported for each individual agent. Twenty-six percent of patients required dosage modifications of one or both drugs during combination therapy.

CONCLUSIONS

Interferon-alpha-2b plus ribavirin is an efficacious first- and second-line therapy in adult patients with compensated chronic hepatitis C, significantly improving sustained virological and biochemical responses versus interferon-alpha-2b monotherapy. The tolerability profile of interferon-alpha-2b plus ribavirin therapy is consistent with the individual profiles of these agents with no evidence of additive effects. The place of interferon-alpha-2b plus ribavirin combination therapy in relation to newer agents, including pegylated interferons-alpha and other multidrug regimens, remains to be determined in this rapidly evolving area of therapeutic management. Currently, combination therapy with interferon-alpha-2b plus ribavirin is recommended as first-line therapy for patients with chronic hepatitis C and compensated liver disease, and is an option for use as second-line therapy in those who have relapsed after, or failed to respond to, previous treatment with interferon-alpha.

Management of chronic viral hepatitis in HIV-infected patients: Spanish Consensus Conference. October 2000

Co-infection by human immunodeficiency virus and hepatitis B and C viruses is quite common because they share similar routes of transmission. The introduction of highly active antiretroviral therapy has significantly improved the life expectancy of HIV-infected patients in the last few years. However, chronic viral hepatitis represents an emerging cause of morbidity and mortality in this population, either as a result of end-stage liver disease or as a consequence of hepatotoxicity induced by antiretroviral drugs. The main goal of the Consensus Conference was to establish specific recommendations for the management of chronic viral hepatitis B and C in HIV-infected patients. The role of orthotopic liver transplantation for co-infected individuals with end-stage liver disease was also assessed.

HIV coinfection does not compromise liver histological response to interferon therapy in patients with chronic hepatitis C

OBJECTIVE

Although discrepancies between histological and virological responses to anti-hepatitis C virus (HCV) therapy are well-established in HIV-negative patients, the liver histological outcome has never been assessed in HIV-HCV co-infected patients receiving anti-HCV therapy. We compared histological responses to interferon (IFN) alpha therapy between HIV-positive and HIV-negative injecting drug users (IDU) and determined factors associated with histological response.

DESIGN

Retrospective cohort study.

SETTING

Hepatology unit of a tertiary referral hospital.

PATIENTS/INTERVENTIONS

Seventy-nine HCV-infected IDU (32 HIV-positive) receiving a 6-month course of IFN-alpha2b therapy, 3 x 106 U three times a week.

PRIMARY OUTCOME MEASURE

Histological response, defined by a > or =2 point decrease in total Knodell score measured on paired liver biopsies over a 2-year follow-up period.

RESULTS

The sustained response rate to IFN therapy was lower in HIV-positive patients than in HIV-negative patients (6.2% versus 29.8%;P = 0.012). Conversely, the rates of histological response (40.6% versus 36.2%) were not different between HIV-positive and HIV-negative patients. Independent factors associated with histological response were first total Knodell score (P = 0.0007) and sustained response to IFN therapy (odds ratio, 12.34; P = 0.005). Histological response was observed in 25% of IFN non-responders whatever their HIV status. In HIV-positive patients, the CD4 cell count did not influence the histological response.

CONCLUSIONS

in HIV-HCV co-infected patients treated with IFN, liver histological improvement is frequently observed, similarly to that observed in HIV-negative patients. Such beneficial effect of interferon therapy supports early treatment of chronic hepatitis C in HIV-infected patients.

Hepatitis C and human immune deficiency coinfection at the era of highly active antiretroviral therapy

Interactions between human immunodeficiency virus (HIV) and hepatitis C virus (HCV) have been widely studied before the introduction of highly active antiretroviral therapies (HAART). We reviewed the potential impact of HAART on hepatitis C as well as the interactions between HIV and HCV therapies. Physicians should be aware of the potential risk of: (i) symptomatic liver disease in HCV-HIV-coinfected patients at the era of triple antiretroviral therapy; (ii) potential liver deterioration paralleling immune restoration; (iii) lack of impact of triple antiretroviral therapy on HCV load; and (iv) potential drug-related hepatitis which may modify the natural history of HCV-related liver disease. Liver biopsies should be performed regularly in these patients in order to identify patients with severe liver disease who require early initiation of anti-HCV therapy under close monitoring of their immune status. Treatment is, to date, based on the combination of ribavirin and interferon with an expected sustained response rate around 25%. An important unresolved issue is to better delineate the temporal place of anti-HCV and anti-HIV antiviral therapies. At least in coinfected patients with significant liver disease, namely necro-inflammatory activity and/or fibrosis >or= 2, we believe that anti-HCV therapy is the priority since it lessens the risk of drug-induced hepatitis and of hepatitis due to immune restoration.