Managing HIV/hepatitis C co-infection in the era of direct acting antivirals

Abstract

Morbidity and mortality from co-morbid hepatitis C (HCV) infection in HIV co-infected patients are increasing; hence, the management of hepatitis co-infection in HIV is now one of the most important clinical challenges. Therefore, the development of direct acting antivirals (DAAs) for treatment of HCV has been eagerly awaited to hopefully improve HCV treatment outcome in co-infected individuals. Indeed, the availability of the first HCV protease inhibitors (PI) boceprevir and telaprevir for HCV genotype 1 patients has changed the gold standard of treating hepatitis C allowing for substantially improved HCV cure rates under triple HCV-PI/pegylated interferon/ribavirin therapy. Moreover, numerous other new DAAs are currently being studied in co-infected patient populations, also exploring shorter treatment durations and interferon-free treatment approaches promising much easier and better tolerated treatment regimens in the near future. Nevertheless, numerous challenges remain, including choice of patients to treat, potential for drug-drug interactions and overlapping toxicities between HIV and HCV therapy. The dramatically improved rates of HCV cure under new triple therapy, however, warrant evaluation of these new treatment options for all co-infected patients.

Figure 1

Optimal duration of dual HCV therapy in HCV/HIV co-infected patients not eligible for triple therapy. (adapted with permission from http://www.europeanaidsclinicalsociety.org/). Legend: i) Where no access to DAA is available or high chances of cure even with dual therapy (favorable IL28B genotype, low HCV viral load and no advanced fibrosis). ii) In patients with baseline low viral load (<600,000 IU/mL) and minimal liver fibrosis. DAA, direct acting antivirals; HCV, hepatitis C virus.

Figure 2

Management of newly diagnosed HIV/HCV co-infected genotype 1 patients (adapted with permission from [25]). Legend: Metavir fibrosis score: F0 = no fibrosis; F1 = portal fibrosis, no septae; F2 = portal fibrosis, few septae; F3 = bridging fibrosis; F4 = cirrhosis; Peg, pegylated interferon; RBV, ribavirin.

Figure 3

Management of HIV-HCV co-infected genotype-1 patients by fibrosis stage/prior treatment (adapted with permission from [25]).