A Refresher on HIV and HCV Coinfection Management

HIV currently affects 1.2 million Americans and nearly 37 million individuals worldwide.

As our understanding of HIV evolves and new treatments become available, HIV-infected individuals can live longer. This allows us to turn our attention to other infections in these patients. Between 2.5 and 5 million HIV-infected patients worldwide have a coinfection with hepatitis C (HCV).

Clinical Infectious Diseases

published an article in its July 2016 supplement that discussed the management of HIV and HCV coinfections. The authors explained that recent data support HCV treatment as a priority in coinfected patients.

Antiretroviral therapy has drastically improved the lifespan of HIV-infected individuals. Liver disease currently accounts for 14% to 18% of all deaths among HIV-infected patients, making it the most common non-AIDS-related cause of death among these patients.

Even in the absence of HCV, HIV-positive patients are at increased risk of liver disease. Several studies have provided evidence that HIV infection accelerates liver disease. However, the majority of liver disease cases in HIV-positive patients are secondary to HCV coinfection.

HIV and HCV coinfection yields even greater risk for liver disease than either condition separately. One study revealed a 19.5% rate of cirrhosis in coinfected patients, compared with 11% in patients with HCV alone.

Antiretroviral treatment for HIV is effective, but due to the risk of liver disease, clinicians must urge patients to also consider HCV treatment. A meta-analysis of 31 studies found that achieving sustained virologic response (SVR) for HCV yielded a 50% reduction in all-cause mortality.

HCV’s potential for rapid progression with an HIV coinfection increases the importance of prompt treatment. Approximately 33% of patients with HCV develop cirrhosis within 20 years. Coinfection increases this risk 3-fold. Studies testing rapid HCV treatment have yielded excellent results in both clinical trials and real-world applications.

The previous HCV standard of care consisted of interferon alfa-based therapies. Coinfected patients were unlikely to achieve SVR on these regimens alone.

Direct-acting antivirals for HCV have drastically improved SVR rates and management of coinfections. Health care providers should treat HCV in coinfections the same way they treat HCV monoinfections. All treatment courses should be a minimum of 12 weeks.

Antiretroviral therapy should not be stopped during HCV treatment. As these regimens must be given concomitantly, practitioners need to be aware of the potential for drug-drug interactions:

HCV genotype 1a daily regimen

Recommendations due to interaction(s) with HIV antiretrovirals

Elbasvir 50mg/grazoprevir 100 mg

• Only use with the following antiretrovirals: abacavir, emtricitabine, enfuvirtide, lamivudine, raltegravir, dolutegravir, rilpivirine, and tenofovir

Simeprevir 150mg + sofosbuvir 400 mg

• Only use simeprevir with the following antiretrovirals: abacavir, emtricitabine, enfuvirtide, lamivudine, maraviroc, raltegravir, dolutegravir, rilpivirine, and tenofovir

Sofosbuvir 400mg/velpatasvir 100 mg

• Can be used with most antiretrovirals, but not efavirenz or etravirine
• As velpatasvir increases tenofovir levels, recommend baseline and ongoing assessment for tenofovir nephrotoxicity

Ledipasvir 90mg/sofosbuvir 400 mg

• Can be used with most antiretrovirals
• As ledipasvir increases tenofovir levels, recommend baseline and ongoing assessment for tenofovir nephrotoxicity

Paritaprevir 150 mg/ritonavir 100mg/ombitasvir 25mg + dasabuvir 250 mg BID + ribavirin (weight-based dose)

• Only use with the following antiretrovirals: atazanavir, dolutegravir, emtricitabine, enfuvirtide, lamivudine, raltegravir, and tenofovir
• Decrease or hold ritonavir used for HIV protease inhibitor boosting until HCV treatment is complete

Daclatasvir 60 mg + sofosbuvir 400 mg +/- ribavirin (weight-based dose)

• Daclatasvir must be dose reduced to 30 mg with ritonavir-boosted atazanavir
• Daclatasvir must be dose increased to 90 mg with efavirenz or etravirine

Health care providers should counsel HIV- and HCV-infected patients to avoid alcohol consumption to reduce the risk of liver disease. In addition, they should educate their patients on using appropriate precautions to prevent transmission to others and to prevent reinfection once HCV has been cured.