Hepatitis C | Nucleus Health
A Dangerous Combination: Hepatitis C and HIV Coinfection
Injection drug use and needle sharing are among the leading causes of the transmission of the hepatitis C virus (HCV) and can significantly increase your risk of contracting the human immunodeficiency virus (HIV) as well. Thus, a person who uses needles to take drugs is susceptible to getting both diseases — a dangerous coinfection.
The Centers for Disease Control and Prevention estimates that 80 percent of people with HIV who inject drugs also have hepatitis C, and that one-third of the total HIV population also has either hepatitis C or hepatitis B. A person with both hepatitis and HIV is at greater risk for several complications, most of them involving the liver, the organ most affected by hepatitis C.
Susanna Naggie, MD, an assistant professor of medicine in the division of infectious diseases at Duke University School of Medicine, and Eugene R. Schiff, MD, a professor of medicine and the director of the Schiff Center for Liver Diseases at the University of Miami Miller School of Medicine, answered questions on HIV/HCV coinfection and discussed how both conditions progress, the potential difficulty with treatment, and the importance of finding a doctor who can manage both viruses.
Q: How common is a diagnosis of HIV/HCV coinfection today?
Dr. Naggie:The prevalence of coinfection of HIV and HCV varies depending on the route of transmission of the HIV infection. Due to the increase in heroin use across many parts of the country, as well as high rates of new HIV infections in men who have sex with men, HIV/HCV coinfection is seen frequently in clinics across the country.
Dr. Schiff:These two viruses are relatively common as a coinfection. Coinfection is usually caused by drug use where there’s blood-to-blood contact. Hepatitis C can also be transmitted through sex, but it’s not as common. However, diagnosis and management of both HIV and HCV have come a long way in the past few decades.
Q: How does hepatitis C affect the progression of HIV, and how does HIV impact HCV?
Naggie:The impact of HIV on HCV infection and HCV-related liver disease is a well-recognized phenomenon. People with HIV infection at the time of their exposure to HCV are less likely to naturally clear the virus, which occurs in 20 to 30 percent of people infected with HCV who don’t have HIV.
The impact of HCV on HIV infection and natural history is less clear, though HIV-infected people with HCV can have poorer CD4 rebound. [CD4 lymphocytes, or T-cells, are white blood cells that help the body fight infections. HIV destroys these cells, and their count is used to evaluate the progression of HIV in a person. The degree to which the CD4 count “rebounds” following initiation of antiretroviral therapy is used to assess whether or not treatment is effective.] Also, HCV as a coinfection appears to increase the risk of other conditions, including malignancy, diabetes, and cardiovascular disease.
Schiff:In the early days of HIV, most people would eventually develop AIDS.People with both HIV/AIDS and hepatitis C had compromised immune systems and often died of opportunistic infections. Liver disease would also progress more quickly in these people, and most people with hepatitis C would end up in the chronic stage of the disease, or cirrhosis. Now, with the antiretrovirals used to treat HIV, the virus is slowed down and rarely develops into AIDS.
Q: Does having HIV cause more long-term liver damage?
Naggie:People with HIV/HCV coinfection have more rapid progression of HCV-related liver disease. Even in the era of combined antiretrovirals, people with HIV/HCV coinfection are more likely to develop cirrhosis, according to research published in the journalAIDSin 2008, and this occurs on an accelerated time line.
Q: Is treatment more complicated when you have both viruses?
Naggie:In prior eras of therapy for both viruses, there were complexities on both sides. Treating a person with HCV infection with antiretrovirals for HIV could result in more hepatotoxicity [damage to the liver] and would require discontinuing treatment. Meanwhile, treating HCV infection resulted in lower viral response rates in HIV-infected persons. Improvements in both HIV antiretrovirals and HCV antivirals have essentially removed these issues from the clinic. Now HIV antiretrovirals have very low rates of hepatotoxicity, and there is rarely a need for discontinuation. With the advent of direct-acting antivirals for HCV infection, the earlier disparity in treatment response for HIV infection has vanished, with HIV/HCV coinfected people achieving the same response rates as someone with just HCV. The primary remaining complexity in treating people with both infections is [potential] drug interactions, not the viruses themselves.
Schiff:It also used to be difficult to keep people on older HCV treatments because they had so many terrible side effects. Cure rates were very low before new treatments for HCV were developed.
Q: What should a person with HIV/HCV coinfection look for in a doctor?
Naggie:Finding a provider who specializes in the care of people with HIV/HCV coinfection would be ideal, but a collaboration between an HIV provider and an HCV treater can also work well. The care of people with HIV/HCV coinfection should certainly be multidisciplinary — to ensure that both viruses and the associated end-organ diseases are being managed appropriately and aggressively.
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