Treatment of Hepatitis C in People Living with HIV

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What Is Hepatitis C?

Hepatitis C is a disease of the liver caused by the hepatitis C virus (HCV). Over time, HCV can cause serious liver damage including cirrhosis (scarring), liver cancer, and life-threatening liver failure. For more information on HCV, including how it is spread, tests for HCV, and co-infection with HIV and HCV, see our article on Hepatitis C.

Treatment of HCV/HIV Co-Infection

Treatment options for those infected with HIV and HCV have improved a great deal in recent years, and there are several promising new drugs. These new drugs are often referred to as direct-acting antivirals, or DAAs.

In the past, the standard backbone of treatment was a combination of pegylated interferon plus ribavirin. Both interferon and ribavirin can cause serious side effects, and together have not always been very successful in getting rid of HCV in the body. As a result, many people have not pursued this form of treatment, or stopped this treatment due to side effects.

For a list of medications used to treat hepatitis C, please look here.

Direct-acting antivirals

Many new direct-acting antivirals, or DAAs, are now available to treat HCV.  DAAs work in much the same way that HIV drugs work – they disrupt the ability of the hepatitis C virus to multiply and infect the body. There are several different classes of DAAs defined by where and how they act to stop HCV from multiplying.  

Each DAA works differently against each of the six different genetic types (called genotypes) of HCV that exist worldwide. Because different genotypes of HCV respond differently to different treatments, it is important to have a genotype test before you begin treatment.

The good news is that DAAs tend to have fewer and less serious side effects than the interferon and ribavirin treatments of the past. Treatment with DAAs has also proven to be generally more effective than interferon-based treatment, with success rates in real-world settings often over 90 percent (depending on genotype, existing liver damage, etc.).

Treatment regimens with DAAs are also shorter than HCV treatment in years past, with many of the newer DAAs or combinations of the newer DAAs requiring only 12 weeks of treatment. It is important to note that people co-infected with HIV and HCV often have to take HCV treatment, including DAAs, for longer than 12 weeks to become successfully cured of hepatitis C.

Which HCV treatment is right for you will be based on several factors, including: 

  • Your HCV genotype
  • The health of your liver, including how much scarring (cirrhosis) it has
  • Your overall health, including any other medical conditions you may have
  • Which HIV drugs you are taking (as some HCV drugs interact with HIV drugs)
  • What side effects you may experience from the HCV drugs and how your body is likely to handle them
  • If you have taken HCV treatment before and which medications were used

The major barrier for many people is the cost of hepatitis C treatment with many of the newer direct-acting antivirals. Three months (12 weeks) of treatment can cost as much as $80,000 (USD) and may or may not be covered by your insurance or national health plan. Some people have chosen to get their HCV drugs from a buyers club to circumvent the high costs. 

Interferon and ribavirin

In the past, the standard backbone of treatment was a combination of two medications:

  • Pegylated interferon (Pegasys or Peg-Intron), taken by injection (shot)
  • Ribavirin (Rebetol, Copegus), a pill taken by mouth

The most common side effects of pegylated interferon include:

  • Flu-like symptoms (fever, nausea, muscle aches)
  • Depression
  • Anxiety or irritability
  • Low white blood cell count (neutropenia)

While women tend to do better on HCV therapy than men, studies show that depression is more likely to affect women taking interferon. It is very important to speak to your health care provider about any side effects you are experiencing so he or she can help you manage them properly.

The most serious side effect of ribavirin is anemia, or a reduced number of red blood cells that carry oxygen throughout the body. This side effect can often be managed using a drug called Procrit or Epogen (erythropoietin or EPO).

Ribavirin can also cause serious birth defects. Do not take ribavirin if you are pregnant or planning to become pregnant, and stop taking ribavirin at least six months before becoming pregnant. Women and their male partners must use effective birth control while taking ribavirin. Many providers recommend that women use two forms of birth control to prevent pregnancy while taking ribavirin. Additionally, men taking ribavirin who have female partners are encouraged to use two forms of birth control since sperm exposed to ribavirin can cause birth defects.

Because several of the newer HCV drugs are given in combination with ribavirin to treat people co-infected with HIV and HCV, the recommendations for use of any of these new drugs in pregnant women or women planning to become pregnant are the same as for taking ribavirin: do not take them if you are pregnant or planning to become pregnant, and stop taking them at least six months before becoming pregnant. 

New Drugs in the Pipeline

There are also several HCV drugs and new combinations of recently approved drugs in the development process. The treatments currently being studied are interferon-free, direct-acting antiviral combinations. 

Treatment Guidelines

In April 2014, the World Health Organization (WHO) released guidelines for the screening and treatment of hepatitis C. These guidelines suggest that all people living in areas where hepatitis is common (“high prevalence areas”) be offered an HCV test. 

The 2015 clinical treatment guidelines released by the European Association for the Study of the Liver (EASL) recommend that HCV treatment be prioritized in people living with HIV and HCV. Moreover, the EASL suggests that HCV treatment be prioritized regardless of the degree of liver cirrhosis (scarring). It recommends interferon-free treatment regimens when possible, in part because they are more effective in curing HCV, and in part because they have fewer side effects.  Lastly, the EASL guidelines recommend that those co-infected with HIV and HCV receive the same treatments as those with HCV alone (mono-infected).

The British HIV Association (BHIVA) issued a January 2015 update to its treatment guidelines. This update includes recommendations that (1) all people infected with HCV receive treatment, regardless of the level of liver injury, and (2) DAAs should form the backbone of treatment and interferon should be avoided if possible.

How Effective Is Treatment?

Unlike HIV, successful treatment can cure HCV. Treatment success is measured in different ways. End-of-treatment virological response means HCV is undetectable in the blood at the end of treatment. Sustained virological response, or SVR, means HCV is still undetectable six months after the end of treatment. After this, the virus rarely comes back, and people are considered cured.

It is important that people receiving HCV treatment have their liver enzyme tests and HCV viral load levels monitored regularly, since this can show how well treatment is working. If your HCV level has not started to drop after 12 weeks of treatment, it is unlikely that the treatment is working, and your health care provider will probably advise you to stop taking the drugs. Sometimes a second round of treatment can lead to a cure even if the first attempt was unsuccessful. This is especially true if the first attempt used an older combination of HCV drugs. The newer drugs have increased the effectiveness of HCV treatment significantly.

For people infected with both HIV and HCV, research has also shown that adhering to HCV treatment predicts the best chances of SVR, or curing HCV. Adherence to HIV drugs is very important in keeping viral loads low, avoiding resistance, and maintaining good immune system health. We now know that adherence to HCV drugs is similarly important for the successful treatment and cure of hepatitis C. 

Which to Treat First?

People infected with HIV and HCV face some special treatment issues. Basically, significant liver damage makes it harder to tolerate HIV drugs. At the same time, some HIV drugs can cause liver issues. Therefore, there is some debate about whether to start HIV or HCV treatment first. Generally, the benefits of being on HIV treatment outweigh concerns about liver injury from HIV drugs.

Recent research shows that waiting to treat HCV until a person has serious liver disease decreases the effectiveness of treatment and leads to poor health outcomes and higher likelihood of death. Moreover, we now know that people living with HIV are more likely to develop HCV-related liver damage and develop it faster than HIV-negative people. At CROI 2015, researchers showed that those people living with HIV and HCV who delay HCV treatment remain at risk for scarring of the liver (cirrhosis), liver cancer, and liver-related death, even after being cured of HCV. They also showed that the longer HCV treatment was put off, the worse the outcome.

In the past, when HCV treatment was based on taking interferon, experts often advised waiting, since treatment involved a long course of poorly-tolerated medication that often did not produce a cure. Now, however, there are several interferon-free treatment regimens with much higher success rates for people co-infected with HIV and HCV. 

The current HIV treatment guidelines published by the US Department of Health and Human Services (DHHS) recommend that antiretroviral therapy for HIV be given to all co-infected people, regardless of CD4 count. However, since HCV treatment does not work well for co-infected people with CD4 cell counts below 200, HCV treatment is not recommended until their CD4 counts increase. For co-infected people who have never received HIV treatment and who have CD4 counts above 500, their providers may recommend delaying the start of HIV treatment until they have successfully completed HCV treatment.  

The decision about which to treat first depends on many individual factors, including HIV viral load, CD4 cell count, and amount of existing liver damage. For this reason, it is important to see a health care provider familiar with both diseases whenever possible. As newer, improved HCV drugs are approved, barriers to treating HCV in the presence of HIV will drop as the benefits outweigh the consequences for more and more people.

Taking Care of Yourself

In addition to medical treatment, there are steps you can take to keep your liver healthy, including:

Some herbs may help your liver, but others can cause serious liver damage. Be sure to tell your health care provider about any products you are taking, including over-the-counter or prescription medications, street drugs, herbal remedies, or nutritional supplements.

Additional Resources

Select the links below for additional material related to treatment for Hepatitis C.

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