Question:
I am a 48-year-old male with HIV for which I take HAART. I also have HCV genotype 2b for which I want to start treatment in a couple of months with peginterferon and ribavirin. Keeping in mind the adverse reactions I have often had to medication, I would like to know what your opinion is on starting this therapy by gradually increasing the dosage of the ribavirin with a full dosage of interferon or else gradually increasing the dosage of both. I'm hoping a gradual increase might prevent an adverse reaction that would force me to quit the only possibility of treatment, but perhaps it compromises successful treatment by encouraging resistant strains?

 Answer by Mack Mitchell, MD  
Dr. Mitchell is Director of Gastroenterology at the Johns Hopkins Bayview Medical Center,
Baltimore, Maryland and Associate Professor of Medicine, The Johns Hopkins University School of Medicine

I understand your concern about adverse side effects. Although side effects are dose-related, the benefits of treatment are also dose-related. There is evidence that using the maximum tolerated doses of ribavirin and to a lesser extent pegylated interferon, early in the course of therapy, provides the best chances for success. I always begin with the calculated weight-based dose of ribavirin and interferon and then reduce doses if absolutely necessary. Most side effects are manageable.

Question:
I have been HIV/HCV co-infected since 1999, though may have had HCV for much longer than that. My HIV is well controlled with HAART and in 2003 I went through my first try at eradicating HCV. My doctor put me on 42 units of pegIntron and 1000 mg of Rebetol. At week 12 there was a 2+log reduction in HCV VL, and my AST/ALT had normalized at that time. From week 16 to week 48 HCV RNA remained undetectable and LFTs remained normal. Week 49 HCV RNA test (which was performed as end of treatment test for the trial I participated) showed HCV viral load of 439. My doctor repeated this test at week 51 as he thought that a VL of 439 looked more like lab contamination rather than a REAL viral presence. Week 51 tests HCV RNA were undetectable. Week 53 he performed 4 week post treatment follow up at which time HCV VL was 6 million. (Ouch)

Since then my liver enzymes have been hovering around 2-2.5 times baseline values, with exception of (direct) Bilirubin which fluctuated between 0.8 to 2.5. In May of 2005 my HCV viral load was 23 million.

At the beginning of July I have started Interferon (Pegasys) maintenance therapy at 25 units of Pegasys per week. After 6 weeks of taking interferon weekly my AST/ALT have normalized, direct bilirubin is at 0.5, but what really throws me off is that my HCV RNA is once again undetectable. My doctor, who has some 400 HCV and mostly HIV co-infected patients, can't explain why I relapsed in the first place, and more importantly why Pegasys monotherapy is having such a profound virologic effect after such a short period of time.

So I guess my question to you is whether or not my case is as unique as my doctor makes it out to be, and if so, if there might be something to be learned or gained from further examining me, my case, and my circumstances. If you have additional question please feel free to contact me through this email address. Thank you very much for your time and consideration.

Answer by Douglas Dieterich, MD
Dr. Dieterich is Vice Chair and Chief Medical Officer Department of Medicine at The Mount Sinai Medical Center and an attending physician at New York University Tisch Hospital

Question: I recently moved to Washington State and haven't found anyone very knowledgeable about coinfection. I first had hepatitis in 1971 and a relapse in 1973. My question is this: While on peg treatment I lost a lot of my weight, down to 120 lbs and now am 154 and now have just regained it back and although I know I am not well, I still do alright in many ways. The peg treatment was very hard on me and I had trouble with the ribavirin. I have heard they are doing research with anti-fibrotics and feel this would be an excellent option for me, but because of my coinfection with HIV I seem ineligible. I continue to eat well and walk and some exercise and take silimarin, but am worried that someday things will change for the worse.

Can you recommend any knowledgeable people in Washington State that may offer me options, and are there any new therapies on the horizon that might help me? I have learned to practice my own due diligence and if I didn't I would be dead by now, but a person more knowledgeable than myself would be a great asset, but most doctors I have found don't treat coinfection and are not holistic in their approach.

Answer by Marina Núñez, MD, PhD

It looks like you had end-of-treatment response but not sustained response following HCV treatment. If you have F3 in the liver biopsy I think that it is important to treat again, although due to the side effects, the current standard therapy is very hard. Since you [already] received Peg-Intron, now I would try Pegasys, which has been recently approved for the treatment of HCV in HIV/HCV-coinfected patients. I would try the highest doses of RBV possible for your weight.

New therapies are under development, but nothing will be approved really soon. Regarding centers of reference, Johns Hopkins in Baltimore, and several hospitals in California have experience with coinfected patients, and probably there are many others that I am not aware of.

Question:
I have been HIV+ for approximately 4 years with a CD4 count of around 1000 for most of that time. About two years ago I tested positive for hepatitis C following sexual exposure. Unfortunately, due to hospital error, my positive result was mislaid until a few months ago allowing an acute disease to move to the chronic state

For about ten months or so now I have been experiencing what I thought was an allergic reaction similar to hives but could not place any causative agent-- erythema and vasculitis, mainly in my extremities: hands, feet, head, and neck. The main trigger seems to be moving from heat to cold. I have also been generally fatigued. In light of my recent co infection diagnosis however I have began to investigate further. I am in the position of having to wait a further month before my first appointment to see the hepatology/HIV co-infection specialist.

I have seen the condition cryoglobulinemia mentioned in texts in relation to viral infections but cannot seem to find further information on it. Where would be the best source of further information about cryoglobulinemia?

Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

Visit www.google.com and put "cryoglobulinemia" in the SEARCH window. You will find numerous articles in the search results.

Question:
I am requesting detailed information be sent to me on HIV positive people who are chronic hepatitis B carriers. I am concerned that I will get sicker by dealing with someone who has HIV than without it. I am a Hep B carrier and have been since 1987. The problem is I recently met a nice gentleman, whom I would otherwise really consider a potential mate, but he is HIV positive and I just want to make sure I don't get sick. We haven't been intimate yet, but we have kissed. I have children, so I don't want to die before I see them grown with their own children. Please get back to me with some information if you can.

Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

Information on HIV-HCV coinfection is available on this web site in the section HIV-HCV confection.

The major issue is that both HIV and HBV are sexually transmitted diseases, although HIV is less easily transmitted than HBV. HBV can be transmitted by "wet" kissing (saliva from tongue in the partner's mouth), whereas this is not a route for HIV transmission.

The main risk for infection with HIV among heterosexual adults is unprotected (no condom used) anal or vaginal intercourse, or the sharing of contaminated needles (or other injection drug paraphernalia).

Detailed written materials on HIV transmission risk are available free from the Gay Men's Health Crisis (GMHC) in New York City. Call the Hotline there (212-367-1000).

Question:
You used to have an article (I believe under HIV-HCV coinfection) that showed that there was a slower rate of hepatitis C-associated liver disease progression in those people with less than 50 CD4 T cells. I have tried numerous searches in an attempt to relocate this article, but I cannot find it anywhere now. Could you please see if it is still on the site somewhere?

Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

I was unable to locate an article highlighting that issue. In fact, it seems counterintuitive that if CD4 cells decline to fewer than fifty, the risk of liver disease decreases. As the CD4 cell count declines below 50, the immune system weakens further, and the risk of liver disease progression is likely to increase. Below are a few articles that may be relevant to your question:

- HCV Liver Disease Progression Associated with CD4 Counts =400 cells/mm³

- Even with Effective HAART, HIV-HCV Coinfection Has a Negative Effect on CD4 T Cell Recovery, While a Sustained Viral Response (SVR) Is Associated with a Significant Rise in CD4 Count

- As HAART Therapy Prolongs Survival, More HIV-HCV Coinfected Individuals May Experience Morbidity and Death from Progressive Liver Disease

Question:
I am a French gay male HIV + living in London. I have been diagnosed HCV (genotype 4) in June this year after having have stopped HAART (efavirenz/ Combivir). I started interferon beginning of July. On the 5th week (August) I started having very high temperature 24 hrs after the injection, which lasted a few days.

In week 6, the same pattern occurred but this time the temperature did not decrease and i checked into the hospital for blood poisoning and both kidneys infected. As for today, I restarted combination therapy (efavirenz/Combivir) 5 weeks ago and was considering restarting interferon. The nurse which I was seeing since June specialized in HIV/HCV always told me that the hep C was acute for the first 6 months, knowing that I certainly contracted it a few weeks before June, and could restart treatment in this period of time (knowing that all infection has been cleared) because it would be easier to treat. I saw a doctor yesterday who assured me i misunderstood it and an "acute" infection is only 60 days.

I do not know what to think anymore. What shall i do? Restarting in the next few weeks a treatment interferon/ribavirin (as suggested yesterday by this doctor), or wait until a new treatment comes available? I hardly do not see the point of going through what i went through this summer and adding to it this risk of side effects of ribavirin too! Even now would it still better to treat the hep C? Or won't it change anything to "wait and see" a few months or years?

  Answer by Douglas Dieterich, MD
Dr. Dieterich is Vice Chair and Chief Medical Officer Department of Medicine at The Mount Sinai Medical Center and an attending physician at New York University Tisch Hospital.

This is a good question. Just saw some data here at IDSA and it suggests that treatment of the acute infection should begin within about 2-4 months of the diagnosis of the infection. So the cut off is about 90 days. If you wait longer, then you will have to take the meds for about a year instead of 6 months.

The kidney infection was not caused by the interferon. The fevers, however, were probably higher because of it. If you can take it, I would recommend taking it now for at least 6 months.

Question:
Here are the facts:
Confected HIV/HEP C--drug naive on both fronts. HIV seroconversion 6/98;
VL 20-40,000 over last year; T cells 350-450 over last year.
HEPC seroconversion 8/2001 genotype1; slightly elevated enzymes; VL approx 2 mil. Recent biopsy stage 3 fibrosis on 0-6 scale.

Question: Given the above, what are the 3 best HAART combinations to start on prior to commencing HEP C treatment? I am very worried about further liver injury given the accelerated pace of HEP C over the last 2 years. I appreciate your opinion and advice.

  Answer by Chucks Hicks, MD
Charles B. Hicks, M.D. is an Associate Professor of Medicine in the Division of Infectious Diseases and Associate Director of the Duke University AIDS Research and Treatment Center, Durham, NC.

You have clearly looked in to this situation and are appropriately "pro-active" in wanting to get treatment started. Your HIV viral load is relatively low and as such there are quite a number of different treatment options that will likely work well. The final choice is something that you should decide upon with you health care provider and should take into account your own thoughts about timing, frequency of dosing, potential side effect profiles, and so on. The key to success is to find a combination that you can take consistently. If you can incorporate it in to your life schedule such that you never miss a dose, you will likely do very well with any number of different combinations.

As far as the impact of being HCV co-infected is concerned, there are only a few ramifications from my perspective. The main one probably is that you might want to avoid nevirapine since in some studies, nevirapine has demonstrated increased liver toxicity in hepatitis co-infected patients. My suggestion would

probably be to start with a two nucleoside plus efavirenz combination. If you want a true once a day treatment you could use enteric-coated didanosine, lamivudine, and efavirenz, all taken at bedtime on an empty stomach.

An alternative might be to use tenofovir, lamivudine, and efavirenz, but that would optimally involve taking tenofovir with food and efavirenz on an empty stomach. If once daily is not crucial, Combivir and efavirenz is a popular choice and protease inhibitor combinations are also potentially attractive. The good news in 2003 is that antiretroviral-naïve patients have many options available to them and the likelihood of success is extremely high if you start therapy and are highly adherent. Good luck.

Question:
I need to make a choice about treatment for HCV and a few things came
to mind that I hope to know before making a final decision. First, a bit of background, HIV T cells and viral load are 285 and 880 respectively.

I am currently taking Viread, 3TC, and Ziagen. Because of serious cholesterol and lipodystrophy problems, this is the present combo of the drugs that I am on. My doctor is concerned that if I add Sustiva I will get resistance to that class of drugs. (I am not resistant to any PI's, was on Viracept, 3TC, and D4T for 3 years and have a history of kidney stones). We are hoping for approval of atazanavir soon. I am having a problem with resistance to D4T and AZT, which brings me to my questions. I did Rebetron treatment for 8 months and my HCV VL dropped some initially but then returned to high levels and I was stopped.

Isn't ribavirin in the same class of drugs as D4T and AZT? Is it possible that my resistance to them is caused by the use of ribavirin? Is it possible to become resistant to ribavirin and is there a resistance test for it? I want to go ahead with a peg/ribavirin treatment. My numbers aren't great and an ultrasound showed progression to mild cirrhosis. My liver enzymes are, AST 71, Alt normal, ALK Phos 170, Gamma Gt 220, my HCV VL is 2 mil and my Alpha Feto Protein is 29.8.

Any insight into the resistance questions and another opinion would be so greatly appreciated. I do realize you can't tell me what to do, but the more informed I am, the more confidence I have in my treatment decision. Thanks so much in advance!

  Answer by Douglas Dieterich, MD
Dr. Dieterich is Vice Chair and Chief Medical Officer Department of Medicine at The Mount Sinai Medical Center and an attending physician at New York University Tisch Hospital.

Ribavirin is not really an antiviral against HCV and therefore there can't be a resistance problem. You should go for treatment and not worry about the RBV other than the fact that it can cause anemia.

Question:
I am infected with both HIV and HCV genotype 1b. Last year I did 6 months treatment with PEG-Intron & Ribavirin and was not able to respond. My doctor now wants me to try Pegasys & Ribavirin, and I am more than eager to start but at the same time would like to stop my HIV regimen while on Hep C treatment or at least the first 3 months because I feel it could have a better outcome.

My doctor does not seem to agree with me and would rather keep me on my HIV regimen that consists of Viramune/Viread/Epivir. He says I have an easy combo but I am concerned about lactic acidosis and failing the Pegasys combo.

  Answer by Douglas Dieterich, MD
Dr. Dieterich is Vice Chair and Chief Medical Officer Department of Medicine at The Mount Sinai Medical Center and an attending physician at New York University Tisch Hospital.

You are much more likely to fail HCV treatment if you are off HIV meds. Your MD is correct and I would continue with his advice. It is very reasonable.

Question:
How can I get on your e-mail list? I am an HIV+, 56-year-old male with Type II Diabetes. I am currently being evaluated for an insulin pump. With all of my previous focus on maintaining my drug regimen, now I must think about performing blood glucose tests and injecting insulin. I am afraid that I may forget one or the other and do not want to. I have been faithful in my medication adherence. My viral load is undetectable and my T-Cell count was 488 in November of 2002. I am anxiously awaiting the results of my labs from a January 16, which I expect to be just as positive. The only way I am surviving is by looking positively at life and what it has to offer.

My expected outcome is to be approved for an insulin pump and the focus on living and taking about 4 glucose tests per day. I can remember to push the button to get my daily doses of insulin. This seems to be a good routine for me. I had dementia as a part of AIDS and have a shaky short-term memory and some long-term memory loss.

I do not believe that I am either unique or special. I am looking for someone that I can chat with (electronically) and share my ideas, feelings and fears, and more importantly, learn from someone in a similar situation. I am not asking you to be a matchmaker but any assistance you could provide will be greatly appreciated.

Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

We will add you to our email subscriber email list. Regarding a chat room or a support group: I suggest browsing through our list of links of HIV and hepatitis organizations. Some of these organizations offer chat rooms and group support via the Internet. Go to HIV and AIDS Web Sites (24 sites)

Question:  
I am a person co-infected with HIV/HCV. I have been on testosterone (Androgel) therapy for a few years in order to help me keep some muscle mass. Recently, I read an article that mentioned about possibly acquiring avascular necrosis on the hips from using testosterone or exercise. I have also read that testosterone makes lipoatrophy (sunken cheeks) worse. What is your opinion on this? Can all this explain the reason why I'm having pain on my right buttock and right lower back?

  Answer by Chucks Hicks, MD
Charles B. Hicks, M.D. is an Associate Professor of Medicine in the Division of Infectious Diseases and Associate Director of the Duke University AIDS Research and Treatment Center, Durham, NC.

Testosterone is an anabolic steroid that is used therapeutically to treat male patients whose levels of testosterone are low. This condition is known by the medical term hypogonadism, and is thought to be more common among HIV-infected males. All anabolic steroids have the effect of increasing muscle mass and are thus sometimes also used for this purpose medically as well as illicitly by body builders and others. Since HIV-infected persons may also experience loss of muscle mass, testosterone is sometimes prescribed to HIV-infected men to preserve or build muscle mass.

There are potential long-term complications to the use of testosterone in men who do not have hypogonadism, which may include avascular necrosis of the hip (although the relationship between testosterone use and avascular necrosis is not completely characterized). Since testosterone also reduces fat to muscle ratios, it probably enhances any tendencies for fat loss including fat loss in the cheeks.

The balance between the possible benefits of testosterone and its potential adverse events can be difficult to weigh for any one individual. The pain you are describe seems unlikely to be related to your testosterone usage, and I would urge you to see your doctor to get it checked out. That would also be a good time for you to discuss your testosterone use and make the decision as to whether you want to continue.

Question:  
I am a person co-infected with HIV/HCV. I had a liver biopsy on April 2001 and it showed 2nd grade fibrosis and 2nd grade inflammation. Early this year (March), I was put on PEG-Intron/ribavirin treatment but after almost 6 months my viral load was still high, and my doctor decided it was best to stop. It's been close to four months since I stopped treatment, and my viral load is up to 16,000 from little over 1,000, but liver enzymes are at normal range. I'm in the process of getting back to work now and would like to wait at least another 6 months before I go into treatment again.

Can you please advise me if this is a good move? I don't feel so bad at all in terms of physical health with the exception of a bit of pain on my upper right quadrant once in a while and pain on the back side of my feet. I will truly appreciate your opinion and would like to thank you for such a great web site.

  Answer by Douglas Dieterich, MD
Dr. Dieterich is Vice Chair and Chief Medical Officer Department of Medicine at The Mount Sinai Medical Center and an attending physician at New York University Tisch Hospital.

It would be OK to stop for a while and then restart with the other brand if you like. If you took the Peg for 6 months, your biopsy probably got better anyway at least half a stage. I always like to give people a little holiday between treatments. The likelihood of a response the second time around is higher.

Question:
I am looking around to see if there is an important conference event in the months/year to come about HIV/HCV co-infection? Could you please help with information? I am a member of the Community in the UK, a volunteer on the Terrence Higgins Trust "Living well with HIV" help line and an EATG member.

Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

Below are listed several upcoming viral hepatitis-related professional meetings:

EASL International Consensus Conference on Hepatitis B
September 12 - 14, 2002, Geneva, SW

42nd Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC)
September 27-30, 2002, San Diego, CA

Therapies for Viral Hepatitis

October 29-31, 2002, Cambridge, MA

Infectious Diseases Society of America (IDSA)
October 24-27, 2002, Chicago, IL

53rd American Association for the Study of Liver Diseases (AASLD) annual Meeting and Postgraduate Course
November 1-5, 2002, Boston, MA

Question:
I have a son who is HIV positive. Yesterday he told me he also has hepatitis C. He is also incarcerated at the Holliday unit of Huntsville, Texas TDC. They have not been giving him the same medication for HIV that he was taking at home: Sustiva, Zerit and Ziagen. They told me they switched [his medications] because the County neglected to give him ANY medication for a period of three weeks and that set him back to point -0-. I am not well educated on what goes on with the viral load or the T-Cell count. I have been told the viral load is supposed to be low and the T-Cell count high. What happens now that they have discovered he has hepatitis C? I understand that there is no cure for either one. Why did they just find out this after seven years or more that he has had the HIV? What can I do to see that he gets the best care? The words to him were, "If you get any worse, we will ship you to Galveston." This is where the hospital is in Texas that treats HIV and these diseases. Please tell me something so I can get some help. His crime was that of self-defense and he pleaded guilty because a lawyer told him he would get less time. I am very concerned.

  Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

It's difficult to comment on your son's prognosis, and to offer advice about his situation. You do not mention what HIV therapy he is taking now, after they stopped giving him Sustiva, Zerit and Ziagen. Your son ought to be taking an HIV drug regimen that is at least equivalent in potency to the one he had before.

It would be best for your son to have a hepatitis C specialist evaluate him for his HCV infection. If he became infected with HCV many years ago, then he is at higher risk for hepatitis C disease progression. However, if he was not infected with HCV until more recently, he probably is not at such a high risk for immediate disease progression. Still, HIV accelerates HCV disease progression (makes it worse), and your son would benefit from seeing physician(s) who are knowledgeable about both infections. He should undergo blood tests to determine evaluate the condition of his liver and probably he should have a liver biopsy.

Getting attention and help for your son may require the intervention of enlightened and caring health care providers at his detention center. Alternatively, you may want to contact a lawyer and ask how the detention authorities can be forced to give him access to a hepatologist (HCV specialist) so that it can be determined if he urgently needs drug therapy for his HCV infection. You may also want to contact an AIDS service organization in your or his geographic area and inquire if they can help him to gain access to the proper medical evaluation and care that he needs as someone who is co-infected with HIV and HCV.

Question:
I am wondering if you can point me in the right direction. I need to obtain statistics (incidence) for HIV/HCV co-infection rates in Florida (particularly Ft. Lauderdale area), California (particularly San Diego area), and Washington, DC. Do you have this-information readily available?

  Answer by Ronald Baker, PhD
Ronald Baker is publisher and editor in chief of HIV and Hepatitis.com

Reliable (or even unreliable) statistics on the incidence of HIV/HCV coinfection are hard to come by. We don't have the information you are seeking.

I suggest that you contact the US Centers for Disease Control and Prevention in Atlanta. They should have at least some of this information. I suggest that you also contact the local Health Departments in Ft Lauderdale, San Diego and Washington, DC, who might also be able to provide you with this information.

Good luck!

Question:
A good friend of mine has HCV, HIV, diabetes, and heart disease. I am concerned about the level of care he is getting from his HMO.

Out of respect for his privacy I haven't gotten all the details about the treatment he is receiving, but I'd like to know what the most current research indicates is generally the best path. I know every case requires individual review, but maybe you can key me into what I should be hearing about his treatment to be sure he is in good hands.

His liver disease is rather advanced and he is beginning to get a big abdomen. He has had problems with serious stomach bleeding (varices) and has needed at least two blood transfusions in the last 3 months. The heart disease in a healthy person would be treated with surgery, but they say his liver couldn't handle the surgery. Meanwhile, I'm not aware of any opportunistic infections from the HIV. But they say that if he needed HIV drugs, they would destroy his liver.

Basically his doctors have told him they can't do much but give him nitroglycerin for the heart disease, insulin for his diabetes, and palliative care as his liver disease progresses. They've said that interferon is contraindicated because his liver disease is so advanced and because of his HIV. They've also said that the HIV combined with the heart disease disqualifies him for transplantation.

Does this information sound accurate?

He lives in San Diego, and perhaps there is someone in Southern California working on the cutting edge of HIV/HCV coinfection you could tell me about so I could see about getting him a second opinion.

  Answer by Douglas Dieterich, MD
Dr. Dieterich is Vice Chair and Chief Medical Officer Department of Medicine at The Mount Sinai Medical Center and an attending physician at New York University Tisch Hospital.

This sounds very complicated. The best person to see in San Diego is Tarek Hassneinin at UCSD. He is familiar with both HIV and HCV. Other than that it is difficult for me to comment on such a difficult situation. Medicine and Surgery can only do so much. This is a great argument for early treatment for both HIV and HCV so that the situation does not get this severe.