Better Treatment for HCV and HIV Co-infected Patients

Internal Medicine World Report, April 2015,

A pair of studies has demonstrated promising drug regimens for the treatment of HCV/ HIV co infected patients, according to an editorial published in JAMA.

The treatment of hepatitis C virus patients co-infected with human immunodeficiency virus (HIV) has posed a problem for health care providers in the past, but now 2 studies published in JAMA have demonstrated promising results.

In an accompanying editorial, Camilla S. Graham, MD, MPH, who was involved in both studies, commented that HIV patients are 3 times more likely develop cirrhosis or liver decompensation than those affected with HCV alone. She explains that in HIV treatment, the ultimate goal is viral suppression, and treatment can last indefinitely. Similarly, for HCV treatment, sustained virologic response (SVR) is the goal, and it can be attained 12 weeks after completion of treatment. However, HCV treatment in HIV co infected patients is difficult to treat because clinicians — and hepatologists – are hesitate to use interferon alfa, Graham continued.

In the first study, a fixed dose oral combination of ledipasvir and sofosbuvir for 12 weeks was associated with high rates of SVR after treatment completion in a study of 50 HCV patients with an HIV co infection. The patients were treatment naïve, non-cirrhotic patients recruited between June 2013 and September 2014. Adverse events included nasal congestion and myalgia, but there were no serious adverse events that were attributed to the study drugs.

A treatment regimen of all oral interferon free 3 direct acting antiviral (3D) plus ribavirin resulted in high SVR rates among patients with HCV co infected with HIV whether they were treated for 12 or 24 weeks in the second study. The researchers in this study recruited 63 patients between September 2013 and August 2014 who were treatment naïve or had a prior history of treatment failure with peginterferon plus ribavirin therapy. The most common drug related adverse effects were fatigue, insomnia, nausea, and headache, but they were each generally mild.

One key observation Graham noted about these 2 studies is that regimens, which included direct antiviral agents (DAAs) resulted in similar SVR rates for patients co-infected with HIV and HCV compared to patients with only HCV. In the Guidelines for the Use of Antiviral Agents in HIV-1 Infected Adults and Adolescents, Graham continued, redirected healthcare providers to the HCV guidelines for antiviral therapy recommendations, which stated that HIV and HCV co-infected patients should be treated the same as patients with only HIV, after identifying and managing possible antiretroviral medication interactions.

Another point Graham made was that the gap had been narrowed in the treatment of black and white patients with HCV infection (black patients disproportionally suffer more from HCV). Half of the patients across both studies were black, which support the opportunity for higher cure rates in black HCV patients.

“Individuals who are most at risk for re-infection will need to be cured to achieve decreases in the incidence of HCV infection, an idea termed ‘cure as prevention,’” Graham continued, as part of the discussion on the fact that 2 of the 3 patients who did not achieve SVR in the 24 week group of the second study experienced reinfection with a new HCV strain after reporting unprotected intercourse.

“Clinicians who treat patients with HCV must facilitate harm reduction measures as well as provide antiviral treatment to achieve the ultimate goal of eradication of HCV.”

Graham concluded that clinicians caring for HIV patients already possess the skills to carefully and correctly choose drug regimens, but that skill needs to spread to HCV care providers.

“Many clinicians also have experience advocating for their patients, and this skill may be as valuable now as it was in the early days of HIV,” Graham wrote. “With the current concern about the high price of these regimens, it is critical that the patients who are living with HCV and the value of treating this disease remain front and center.”