By Ronald Baker, PhD

The revised European AIDS Clinical Society (EACS) HIV treatment recommendations, presented October 26, 2007 at the 11th annual EACS conference in Madrid, Spain include for the first time guidelines for the management of HIV coinfection with hepatitis C or hepatitis B.

These guidelines have been formulated from the text of the "short statement" of the First European Consensus Conference on the Treatment of Chronic Hepatitis C and B in HIV-coinfected Patients (2005) [1] and from the Updated Recommendations from the HCV-HIV International Panel: Care of Patients Coinfected with HIV and Hepatitis C [2].

Highlights of the EACS recommendations for the treatment and management of HIV-HCV and HIV-HBV patients include, but are not limited to, the following:

Assessment of HIV Positive Patients at Initial and Subsequent Visits

In addition to many other laboratory parameters, HIV positive patients should be offered the following hepatitis-related tests on their initial physician visit and then annually thereafter:

Prevention and Support

1. Management and therapeutic options for compensated HIV-HBV coinfected patients with no immediate indication for anti-HIV therapy (CD4 count > 350 cells/mm3)

2. Management and treatment options for compensated or cirrhotic HIV-HBV coinfected patient with an indication for HIV treatment (CD4 count >/= 350 cells/mm3 or already on HAART)

* If feasible and appropriate from the perspective of maintaining HIV suppression. In some cases of intolerance to tenofovir, entecavir (Baraclude) may be advisable.

** Some experts strongly recommend that any HBV-infected patient requiring HAART should receive tenofovir + lamivudine unless there is evidence of tenofovir intolerance.

Treatment of Hepatitis C in HIV Coinfected Patients

1. Treatment of hepatitis C offers the possibility of eradicating HCV within a defined time period. This is advantageous for the subsequent management of HCV patients. As a result, every patient should be considered for treatment when the possible benefits of treatment outweigh the risks. Anti-HCV treatment should also be considered in the context of faster liver fibrosis progression in HIV-HCV coinfection and with better hepatitis C treatment outcomes with improved management of these patients.

2. Information on liver fibrosis staging is important for making treatment decisions in HIV-HCV coinfected patients. However, a liver biopsy is NOT mandatory for considering treatment of chronic hepatitis C. Anti-HCV therapy is particularly recommended in patients with a high likelihood of achieving a sustained virological response (SVR): patients with HCV genotype 2 or 3, and patients with genotype 1 if HCV viral load is low (< 400,000 to 500,000 IU/mL).

3. In case of a liver biopsy or FibroScan (transient elastometry) showing lower grades of fibrosis (F0-F1), regardless of HCV genotype, treatment can be deferred. A liver disease stage assessment is especially important for patients with a low chance of SVR.

4. The combination of pegylated interferon alpha and ribavirin is the treatment of choice for HCV infection. The standard dose for pegylated interferon alpha-2a (Pegasys) is 180 microgram once weekly and for pegylated interferon alpha-2b (PegIntron) is 1.5 microgram/kg body weight once weekly. An initial weight-adapted dose of ribavirin of 1000 (weight < 75 kg) to 1200 (weight > 75 kg) mg once daily is recommended for patients with all genotypes.

5. The primary aim of anti-HCV treatment is sustained virological response defined as undetectable serum HCV RNA 24 weeks after the end of therapy, evaluated using sensitive tests.

6. If chronic hepatitis C is detected early in the course of HIV infection (before the initiation of HAART is necessary), hepatitis C treatment is advised. However, if a coinfected patient has severe immunodeficiency (CD4 count < 200 cells/mm3), the CD4 count should be improved using HAART prior to commencing anti-HCV treatment.

7. If an early virological response of at least 2 log10 reduction in HCV RNA from baseline is not achieved at week 12, treatment should be stopped.

8. During treatment with pegylated interferon plus ribavirin, ddI (didanosine; Videx) is contraindicated in patients with cirrhosis and should be avoided in patients with less severe liver disease. D4T (stavudine; Zerit) and AZT (zidovudine; Retrovir) should also be avoided if possible. The role of abacavir (Ziagen) is uncertain, but cohort data at least suggests lower SVR results in patients receiving abacavir-containing HAART.

9. In patients with acute HCV infection, HCV therapy is recommended if the HCV RNA is confirmed positive (1 week apart) by week 12 post-HCV transmission, as SVR rates following treatment of acute HCV infection are higher than for treatment of chronic hepatitis C.

The guidelines outline and briefly define the diagnostic procedures for hepatitis C in HIV coinfection and how often they should be performed. These include the following:

* Low viral load defined as less than 400,000 IU/L when using pegylated interferon + ribavirin. There is no standard conversion formula for converting the amount of HCV RNA reported in copies/mL to the amount reported in IU. The conversion factor ranges from about 1 to 5 HCV RNA copies per IU.

Proposed Optimal Duration of Pegylated Interferon + Ribavirin in HIV-HCV Coinfected Patients

Classifications and Interventions for HIV-HCV coinfected Non-responders or Relapsers to Prior Interferon-based Therapy

10/30/07

Source

European AIDS Clinical Society. Guidelines for the Clinical Management and Treatment of Chronic Hepatitis B and C co-infection in HIV-infected Adults. Presented at the 11th European AIDS Conference. Madrid, Spain. October 26, 2007.

References

1. Short Statement of the first European Consensus Conference on the treatment of chronic hepatitis B and C in HIV coinfected patients. Journal of Hepatology 42: 615-624. 2005.

2. V Soriano, M Puoti, MS Sulkowski, Y Benhamou, and others. Updated Recommendations from the HCV-HIV International Panel: Care of Patients Coinfected with HIV and Hepatitis C. AIDS 21: 1073-1089. 2007.