Andrew Reynolds @projectinform

It wasn’t that long ago when treating hepatitis C in people living with HIV was limited to two drugs: pegylated interferon and ribavirin. These medications were very challenging: People had to take them for a year, inject one of them, suffer severe side effects and worst of all, they were not very effective at curing people. Today, HCV treatment is easier than ever: For most people it can be completed in 8–12 weeks (some people may need 24 weeks), with few pills (and no injections!) and manageable side effects that are usually quite mild. Best of all, they cure people at very high rates, between 90 to 100% of the time. These new treatments also work very well in people living with HIV. HIV infection might complicate treatment, but it’s nothing that can’t be managed and you can still be cured of HCV.

The following are some key points for people living with HIV and HCV. This information comes from the recommendations in The Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents (aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-treatment-guidelines/0) and the “AASLD/IDSA HCV Guidance: Recommendations for Testing, Managing and Treating Hepatitis C” (hcvguidelines.org), the two leading professional guidelines for managing and treating HIV and HCV, respectively. They guide your medical providers in their practice, and offer valuable information to you, too.

Managing HIV in co-infected persons

Managing and treating your HIV maintains your immune system and keeps your HIV viral load undetectable, but it is also good for your HCV. HIV treatment slows down liver damage and reduces the risk of liver-related problems for people who are co-infected.

There can be drug interactions between your HIV and HCV medications. In these cases, it may be necessary to switch your HIV regimen to accommodate the HCV treatment. If you can’t (or don’t want) to change meds, you may be able to try an HCV treatment that doesn’t interact with your HIV medications. Make sure your HIV and your HCV providers know about all the medications you’re taking so they can help you manage any potential interactions.

The most important thing is that you should not stop taking your HIV therapy to take your HCV treatment. You can take treatment for both at the same time.

HCV treatment in co-infected persons

Everyone with HCV should be treated for it regardless of the amount of liver damage one might have, and persons with HIV/HCV co-infection are no exception. In fact, the “AASLD/IDSA Guidance” states that people who are co-infected can be treated and re-treated with the same DAAs as those who are living with HCV alone. There may be some drug interactions between HIV and HCV meds, so make sure your all of your medical providers know what you’re taking.

The cure rates for HIV/HCV co-infected people are extremely good, closely mirroring those of people who do not have HIV. Hepatitis C DAAs are easy to take and the medications have few side effects. There’s never been a better time to treat HCV.

When to begin HCV treatment for people with co-infection

As soon as possible. Co-infected persons who are cured of HCV have lower risk of liver problems down the line. The sooner you get cured, the less likely the liver damage. Even if you find out that your liver has more advanced damage, getting cured reduces the risk of long-term problems. Additionally, depending upon how much damage there is, you might even be able to reverse it.

The only time you might consider holding off on HCV treatment is if your CD4 cells are below 200. If this is the case, it might make sense to wait a bit so the HIV medications can suppress the virus and give your immune system a chance to recover. Talk with your medical provider about the best course of action here.

Maximizing treatment effectiveness

Adherence to your HIV medications is extremely important to keep your viral load suppressed and minimize the risk of developing drug resistance. The same is true of your HCV medications: The better you are at taking your HCV medications, the better your chance of being cured of hep C.

Adherence is more than just taking the pills every day. It includes taking them as prescribed to avoid drug interactions that might weaken the DAA’s effectiveness. Check with your medical provider about everything you’re taking—prescribed and over-the-counter—to make sure you can take them safely and to maximize your chance at a cure.

Preventing re-infection after treatment

You can get hepatitis C more than once. After you’ve been cured, it will still be important to prevent reinfection with HCV. If you inject drugs, use new syringes and injecting equipment and avoid sharing them. People living with HIV are more vulnerable to sexual transmission of HCV, so minimizing your risk of exposure to HCV through safer sex practices (condoms for anal sex, gloves for fisting, and so on) can offer you protection from re-infection.

After you’ve been cured, and if you have ongoing risk that could lead to re-infection, you’ll want to get tested for the virus by doing a viral load test (you’ll always have HCV antibodies) to check for HCV.

Manage other potential liver conditions

People living with HIV are at great risk of having “non-alchoholic fatty liver disease,” or “NAFLD,” even in the absence of HCV or HBV.  NAFLD is related to metabolic disorders that are common in people living with HIV, including diabetes, high cholesterol, and obesity (high body mass index, or BMI, a fancy way of saying “overweight”). These lead to excess fat getting stored in a person’s liver that can lead to problems over time, including cirrhosis and liver cancer. Talk to your medical provider about your risk of NAFLD and monitor liver health after you’ve been cured of HCV. There are no treatments for NAFLD, but many are being studied. Stay tuned to POSITIVELY AWARE for updates on NAFLD and its treatment.

Closing

We can end co-infection. Through improved HCV awareness, routine HCV testing, and expanding HCV treatment, the health and well-being of people living with HIV, will improve. It’s not easy, but we have the tools and the ability.

If you have any questions about HCV treatment, call The Support Partnership’s national hepatitis C helpline: HELP-4-HEP, 1-877-435-7443.