Optimizing hepatitis C therapy in HIV/hepatitis C virus (HCV) coinfected patients: Analysis of HCV viral kinetics on treatment

Response-guided therapy for hepatitis C genotype 2 and 3 in those with HIV coinfection

BACKGROUND

Current guidelines recommend that interferon-based treatment of hepatitis C (HCV) genotype 2 or 3 in those with HIV coinfection should be for 48 weeks, especially if HCV PCR remains positive after 4 weeks of treatment.

AIM

To examine a single-center experience using response-guided therapy (RGT) using pegylated interferon (PegIFN) and weight-based ribavirin (RBV) for treating HCV genotype 2 or 3 in those with HIV coinfection.

METHODS

Electronic medical records were used to identify patients with HCV genotype 2 or 3 HIV coinfection seen at the Toronto General Hospital Immunodeficiency Clinic from February 2003 to December 2012. HCV PCR was tested after every 4 weeks of treatment until it was negative (<50 IU/mL). RGT protocol was as follows: Those with HCV PCR first negative after 4 weeks (VR4) were treated 24 weeks; first negative after 8 weeks (VR8) treated 36 weeks and VR12 treated 48 weeks.

RESULT

Database search identified 35 individuals with HCV genotype 2 or 3. Twelve were excluded. Total 23 patients completed the treatment and were included for data analysis. Eleven of 23 (48 %) achieved VR4 and eleven of 23 (48 %) achieved VR8. Only one individual had detectable viremia to week 12 and required 48 weeks of treatment. The majority (96 %) were successfully treated with <48 weeks of PegIFN-RBV therapy. One hundred percent achieved SVR with a response-guided HCV therapy.

CONCLUSION

The use of response-guided therapy allows therapy to be shortened in the majority of individuals. HCV PCR testing should be performed every 4 weeks during the first 12 weeks of therapy until HCV PCR is negative.

Treatment decisions and contemporary versus pending treatments for hepatitis C

The primary aim of antiviral therapy for chronic hepatitis C (CHC) is the prevention of progressive disease. A response to interferon (IFN) treatment is associated with an improvement in all-cause mortality and liver-related mortality from hepatitis C. Unless contraindicated, patients with CHC are thus potential candidates for treatment. Improved response rates are observed in patients with HCV genotype 1 infection treated with first-generation protease inhibitors. However, treatment with current first-generation protease inhibitors and IFN is complex and can result in appreciable adverse effects. The advent of potent, pan-genotypic all-oral direct-acting antiviral (DAA) regimens necessitates a critical examination of the immediate application of PEG-IFN, ribavirin and DAA regimens in patients with CHC. Current guidelines and position statements do not make clear recommendations, and are behind the emerging data. Some aspects of the conundrums facing physicians and patients are summarized in this Review. Cirrhosis presents an immediate threat of disease, and ideally treatment should be targeted at those patients who have advancing or advanced disease; unfortunately, a disparity exists, as response rates are reduced in patients with cirrhosis and the risks of adverse events are increased. On balance, patients with mild disease could consider deferring treatment.

Treatment outcomes of treatment-naïve Hepatitis C patients co-infected with HIV: a systematic review and meta-analysis of observational cohorts

Introduction

Co-infection with Hepatitis C (HCV) and HIV is common and HIV accelerates hepatic disease progression due to HCV. However, access to HCV treatment is limited and success rates are generally poor.

Methods

We conducted a systematic review and meta-analysis to assess HCV treatment outcomes in observational cohorts. Two databases (Medline and EMBASE) were searched using a compound search strategy for cohort studies reporting HCV treatment outcomes (as determined by a sustained virological response, SVR) in HIV-positive patients initiating HCV treatment for the first time.

Results

40 studies were included for review, providing outcomes on 5339 patients from 17 countries. The pooled proportion of patients achieving SVR was 38%. Significantly poorer outcomes were observed for patients infected with HCV genotypes 1 or 4 (pooled SVR 24.5%), compared to genotypes 2 or 3 (pooled SVR 59.8%). The pooled proportion of patients who discontinued treatment due to drug toxicities (reported by 33 studies) was low, at 4.3% (3.3–5.3%). Defaulting from treatment, reported by 33 studies, was also low (5.1%, 3.5–6.6%), as was on-treatment mortality (35 studies, 0.1% (0–0.2%)).

Conclusions

These results, reported under programmatic conditions, are comparable to those reported in randomised clinical trials, and show that although HCV treatment outcomes are generally poor in HIV co-infected patients, those infected with HCV genotypes 2 or 3 have outcomes comparable to HIV-negative patients.