Coinfection

ICAAC 2009: HIV Positive People May Respond Poorly to Pegylated Interferon without Ribavirin for Acute Hepatitis C

Pegylated interferon alone may not be adequate for treatment of acute hepatitis C virus (HCV) infection in HIV positive individuals, and addition of ribavirin "seems necessary" for coinfected patients, according to a small study reported at the 49th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC 2009) this week in San Francisco.

In the face of a rising incidence of acute hepatitis C among HIV positive people -- including an ongoing outbreak of apparently sexually transmitted HCV among gay and bisexual men in several cities in Europe, Australia, and the U.S. -- the optimal therapy for acute HCV in coinfected patients is unclear.

Standard treatment for chronic hepatitis C for both HIV positive and HIV negative people is pegylated interferon administered with ribavirin, which reduces the risk of post-treatment relapse. Numerous studies of HIV negative patients have demonstrated that pegylated interferon alone produces a high rate of sustained virological response (SVR; undetectable HCV RNA 6 months after completion of therapy). 

Based on a previous study showing good outcomes, the investigators advocated pegylated interferon monotherapy for acute hepatitis C in HIV-HCV coinfected patients. "[W]e believe that, at present, there is not enough evidence to firmly support combination therapy with peginterferon and ribavirin for the treatment of acute HCV infection in HIV positive patients," they wrote at the time.

In the study presented at ICAAC, the researchers conducted further analysis of pegylated interferon monotherapy in 12 coinfected patients. Acute HCV infection was diagnosed on the basis of HCV antibodies and HCV RNA (viral load), along with clinical signs or elevated alanine aminotransferase (ALT). Infection was considered acute if patients had a negative serology test within 1 year prior to the positive test.

All but 1 of the patients were men, the median age was 45 years, 8 had hard-to-treat HCV genotype 1, and 4 had genotype 4. Overall, the group had well-controlled HIV disease; half had undetectable HIV viral load on antiretroviral therapy (ART) and the median CD4 count was 517 cells/mm3.

The patients were observed for 12 weeks to see if spontaneous viral clearance occurred. If not, they were treated with 180 mcg/week pegylated interferon alfa-2a (Pegasys). Those who experienced rapid virological response (RVR; HCV RNA < 50 IU/mL) at week 4 continued on monotherapy. Those who did not achieve RVR could add weight-adjusted ribavirin at their physician's discretion. Week 12 early virological response (EVR; at least a 2 log10 drop in HCV RNA) results were presented.

Results

"Peginterferon alfa-2a monotherapy resulted in a high percentage of non-response in HIV-infected patients with acute HCV infection," the investigators concluded. "Unlike the situation in acute HCV monoinfected patients, combination or add-on therapy with ribavirin seems necessary in HIV-infected patients with acute HCV infection."

University Med. Ctr. Utrecht, Utrecht, Netherlands.

9/15/09

Reference

JE Arends, T Mudrikova, AMJ Wensing, and others. High Percentage of Non-Response with Peginterferon-alfa-2a Monotherapy for the Treatment of Acute Hepatitis C in HIV Infected Patients. 49th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC 2009). San Francisco. September 12-15, 2009. Abstract H-222.