Can treatment for Hepatitis C (HCV) and Human Immunodeficiency Virus (HIV) be initiated simultaneously?

From the Guidelines

Yes, it is possible to start treatment for hepatitis C virus (HCV) and HIV simultaneously, though careful medication selection and monitoring are essential. Modern direct-acting antivirals (DAAs) for HCV, such as sofosbuvir/velpatasvir (Epclusa), glecaprevir/pibrentasvir (Mavyret), or sofosbuvir/ledipasvir (Harvoni), can be used alongside HIV antiretroviral therapy (ART) regimens, as indicated by the 2018 recommendations of the international antiviral society-USA panel 1. However, drug-drug interactions must be carefully evaluated. For example, certain HIV integrase inhibitors like dolutegravir or bictegravir combined with nucleoside reverse transcriptase inhibitors often have fewer interactions with HCV medications.

Key Considerations

• Before initiating dual therapy, comprehensive baseline testing should include:
  • Liver function tests
  • HCV viral load
  • HIV viral load
  • CD4 count
  • Assessment of liver fibrosis
• Treatment duration typically ranges from 8-12 weeks for HCV while HIV therapy is lifelong
• The simultaneous treatment approach is beneficial because it addresses both infections promptly, potentially reducing liver disease progression and improving overall outcomes, as suggested by the easl recommendations on treatment of hepatitis c 2014 1

Monitoring and Adherence

Regular monitoring of liver function, viral loads, and potential side effects is crucial throughout the treatment period. Patients should be advised about potential side effects and the importance of strict medication adherence to ensure successful treatment of both infections. It is also important to note that the use of certain medications, such as cobicistat-based regimens, efavirenz, delavirdine, etravirine, nevirapine, ritonavir, and any HIV protease inhibitor, boosted or not by ritonavir, is not recommended in HIV-infected patients receiving simeprevir 1.

Medication Selection

The choice of medication is critical, and clinicians should consult current HCV treatment guidelines, as recommended by the 2018 international antiviral society-USA panel 1. The daily daclatasvir dose should be adjusted to 30 mg daily in HIV-infected patients receiving atazanavir/ritonavir and to 90 mg daily in those receiving efavirenz, as indicated by the easl recommendations on treatment of hepatitis c 2014 1. No drug-drug interaction has been reported between sofosbuvir and antiretroviral drugs, making it a viable option for simultaneous treatment 1.

From the FDA Drug Label

The entrance criteria used for the clinical studies of PEGASYS may be considered as a guideline to acceptable baseline values for initiation of treatment: ... CD4+ cell count greater than or equal to 200 cells/mm 3or CD4+ cell count greater than or equal to 100 cells/mm 3but less than 200 cells/mm 3and HIV-1 RNA less than 5,000 copies/mL in subjects coinfected with HIV

• Key points:
  • The drug label provides guidelines for acceptable baseline values for initiation of treatment in subjects with hepatitis C and HIV.
  • It specifies that subjects with CD4+ cell count greater than or equal to 200 cells/mm^3 or CD4+ cell count greater than or equal to 100 cells/mm^3 but less than 200 cells/mm^3 and HIV-1 RNA less than 5,000 copies/mL can be considered for treatment.
• Answer: The FDA drug label does not directly answer whether treatment of hepatitis C and HIV can be started simultaneously, but it provides guidelines for acceptable baseline values for initiation of treatment in subjects with hepatitis C and HIV 2.

From the Research

Treatment of Hepatitis C and HIV

• The treatment of hepatitis C in patients co-infected with HIV has undergone significant changes with the introduction of direct-acting antivirals (DAAs) 3.
• DAAs have shown excellent efficacy in treating hepatitis C in HIV-co-infected patients, with cure rates similar to those in patients with hepatitis C monoinfection 3.
• The use of DAAs has transformed the treatment of hepatitis C, allowing for the possibility of cure for most patients with much more tolerable regimens 4.

Simultaneous Treatment of Hepatitis C and HIV

• There is evidence to suggest that hepatitis C and HIV can be treated simultaneously, with careful consideration of the patient's HIV disease and the potential for drug interactions 5.
• Optimizing HIV therapy and avoiding specific antiretroviral drugs that may cause hepatotoxicity and myelosuppression is crucial before initiating hepatitis C therapy 5.
• The use of growth factors may be necessary to manage treatment-related neutropenia or anemia during hepatitis C therapy in HIV-co-infected patients 5.

Efficacy of Direct-Acting Antivirals

• Ledipasvir/sofosbuvir has been shown to be effective in treating hepatitis C in patients co-infected with HIV, with high sustained virological response rates 12 weeks post-treatment (SVR12) 6.
• Sofosbuvir/daclatasvir and sofosbuvir/ledipasvir have also been shown to be efficacious and well-tolerated in patients with hepatitis C genotype 4 infection 7.
• The efficacy of DAAs in treating hepatitis C in HIV-co-infected patients has been demonstrated in several studies, with cure rates of over 90% achievable in some cases 3, 4.