HIV/HCV Coinfection
HIV/HCV coinfection is extremely common in correctional settings. Since HIV and HCV frequently occur in the same individual and HCV exacerbates the progression of HIV, the United States Public Health Service and the Infectious Disease Society of America issued guidelines stating that HIV infected individuals should be screened for HCV23 and named HCV an "opportunistic infection" in 1999.24 

Analyses of the effect of HCV and HIV co-infection on progression of either disease are often confounded by coexisting risk factors (ie IDU, EtOH) for progression. However, available data seem to indicate that HIV infection accelerates HCV liver disease causing coinfected patients to have a shortened natural history of HCV infection.25-29  Furthermore, coinfected patients appear to have a 12 to 300 fold higher risk of developing hepatocellular carcinoma than non-carriers.30 Additionally, one study found that coinfected patients died earlier because of their more rapid progression to cirrhosis. In this study, patients died earlier due to liver failure and not due to the development of hepatocellular carcinoma.25 
Moreover, liver inflammation can be due to ART, and this may be more frequent in those who have underlying chronic hepatitis due to HCV or HBV. It is estimated that the risk of hepatic inflammation by antiretroviral agents is approximately 4-6% in coinfected patients.31, 32 Those agents that have been associated with Grade 3 or 4 transaminase abnormalities include ritonavir44 and nevirapine. In contrast, other data have shown that those persons who were on PI containing regimens had lower fibrosis and necroinflammatory scores than those who were on non-PI containing regimens.32 Many HCV treaters would avoid ritonavir as a PI in PI doses, but agree that the small amount        of ritonavir in boosted PI therapies (i.e., ritonavir/saquinavir 100/1000mg bid; ritonavir/indinavir 200/800 bid) probably poses a much smaller risk for liver inflammation in coinfected patients. Thus, for those coinfected persons in whom treatment has already been initiated, frequent evaluation including transaminases, total bilirubin, and CBC should be performed to monitor drug tolerance and safety. In those who are treatment naïve and HIV therapy is indicated, care should be used in choosing an initial regimen, avoiding the risk of added potential toxicity associated with certain agents.

Cellular immune response (T helper cells or CD4 T cells and Cytotoxic T lymphocytes or CD8 T cells) is involved in mounting an immune defense against HCV. During the acute phase of HCV infection, specific anti-HCV CD4 and CD8 responses are important determinants of self-limited infection.33 Clearly, HCV infected individuals who also have advanced HIV infection (and low CD4 T cell counts) may be less able to respond to HCV infection due to their compromised cellular immune response. Therefore, in those with advanced HIV disease, it is important to treat the HIV infection first. Bringing the HIV infection under control may, in some cases, subsequently lower the HCV RNA, slowing progression of HCV-associated pathogenesis. With more CD4 cells, a patient will be more likely to mount a specific response against HCV, which will then result in a more favorable outcome for the patient.  In the event that an individual is newly infected with HIV, has a good CD4 count, yet has advanced HCV infection with enough liver damage to be unable to tolerate ART, then the HCV must be treated first.

CONTINUE...
 

• HCV Epidemiology
• Inmates at Risk
• Targeted Screening
• Who Should Get Treated?
• Shifting Standards for Treatment of HCV
• Expect Delays
• Length of Treatment
• Expected Outcome
• Liver Biopsy
• HIV/HCV Coinfection
• HIV/HCV Response Therapy
• Cost of Treatment
• Management
• New Guidelines for Corrections
• Conclusion
• References
• Figures 1, 2 & 3
• Box 1 & 2
• Tables 1 & 2

HEPP News is published twelve times a year by the: HIV Education/Prison Project at the Brown University AIDS Program Box G-B426 Brown University Providence, Rhode Island 02912 401-863-2180 fax 401-863-1243 heppnews@brown.edu