When to initiate treatment of hepatitis C (HCV) in patients with human immunodeficiency virus (HIV) co-infection?

From the Guidelines

Treatment for hepatitis C in HIV-coinfected patients should begin as soon as possible after diagnosis, regardless of liver fibrosis stage, with direct-acting antivirals (DAAs) such as sofosbuvir/velpatasvir, glecaprevir/pibrentasvir, or sofosbuvir/ledipasvir for 8-12 weeks, as recommended by the most recent guidelines 1. The choice of treatment regimen should be based on the patient's HCV genotype, treatment history, and presence of compensated cirrhosis, as well as potential drug interactions with their antiretroviral therapy (ART) 1. Before starting treatment, baseline testing should include HCV genotype, HCV viral load, liver function tests, assessment of liver fibrosis, and renal function 1. Regular monitoring during treatment includes checking HCV viral load at 4 weeks and 12 weeks post-treatment to confirm sustained virologic response (SVR) 1. It is essential to consider the potential for drug-drug interactions between the DAA regimen and the patient's ART, as some combinations may require ART modification 1. Early treatment is recommended because HIV accelerates HCV disease progression, leading to faster development of liver fibrosis, cirrhosis, and hepatocellular carcinoma, and treating HCV improves overall outcomes in HIV patients and reduces the risk of liver-related complications 1.

Some key considerations for treatment of HCV in HIV-coinfected patients include:

• The use of sofosbuvir/velpatasvir for 12 weeks in patients with genotype 3a and compensated cirrhosis, with or without ribavirin, or the use of glecaprevir/pibrentasvir for 12 weeks in patients with compensated cirrhosis 1
• The potential for drug-drug interactions between DAAs and ART, and the need for careful monitoring and potential modification of ART regimens 1
• The importance of baseline testing, including HCV genotype, HCV viral load, liver function tests, assessment of liver fibrosis, and renal function, to guide treatment decisions 1
• The need for regular monitoring during treatment, including checking HCV viral load at 4 weeks and 12 weeks post-treatment, to confirm SVR 1.

Overall, the treatment of HCV in HIV-coinfected patients requires careful consideration of the patient's individual factors, including their HCV genotype, treatment history, and presence of compensated cirrhosis, as well as potential drug interactions with their ART regimen.

From the FDA Drug Label

For patients with HCV/HIV-1 coinfection, follow the dosage recommendations in Table 1 [see Clinical Studies (14)]. HCV/HIV-1 coinfection: For adult and pediatric patients with HCV/HIV-1 coinfection, follow the dosage recommendations in the tables below, respectively. ( 2.2.3)

The treatment of hepatitis C with HIV should be started according to the dosage recommendations for HCV/HIV-1 coinfection, as outlined in the tables provided in the drug labels 2 and 3. Key considerations include:

• Testing all patients for evidence of current or prior HBV infection before initiating treatment
• Monitoring HCV/HBV coinfected patients for HBV reactivation and hepatitis flare during HCV treatment and post-treatment follow-up
• Initiating appropriate patient management for HBV infection as clinically indicated
• Following the recommended treatment regimen and duration based on patient population and HCV genotype.

From the Research

Treatment of Hepatitis C with HIV

• The treatment of hepatitis C in patients with HIV co-infection is crucial to prevent the progression of liver disease.
• Studies have shown that direct-acting antiviral (DAA) regimens, such as ledipasvir/sofosbuvir, are effective in treating hepatitis C in patients with HIV co-infection 4.
• The American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) recommend that patients with hepatitis C and HIV co-infection be treated with DAA regimens, regardless of their CD4 cell count or HIV viral load 4.

Timing of Treatment

• The optimal time to start treatment of hepatitis C in patients with HIV co-infection is not well established.
• However, studies suggest that treatment should be initiated as soon as possible after diagnosis, regardless of the patient's CD4 cell count or HIV viral load 4, 5.
• In patients with advanced liver disease, treatment should be initiated promptly to prevent further progression of liver disease 5.

Treatment Regimens

• Ledipasvir/sofosbuvir is a recommended treatment regimen for patients with hepatitis C genotype 1 or 4 infection, including those with HIV co-infection 4, 5.
• The regimen consists of a fixed-dose combination of ledipasvir and sofosbuvir, with or without ribavirin, and is administered for 12 or 24 weeks 4, 5.
• Studies have shown that ledipasvir/sofosbuvir is highly effective in achieving sustained virologic response (SVR) in patients with hepatitis C and HIV co-infection 4, 5.

Special Considerations

• Patients with decompensated cirrhosis or severe liver disease may require closer monitoring and adjustment of their treatment regimen 5.
• The use of ribavirin in patients with HIV co-infection requires careful consideration, as it may increase the risk of adverse events 5.
• Patients with hepatitis C and HIV co-infection should be managed by a multidisciplinary team, including a hepatologist, an infectious disease specialist, and a primary care physician 4.