New paradigms in the management of HIV and hepatitis C virus coinfection

Purpose of review: Chronic hepatitis C virus infection is currently one of the leading causes of morbidity and mortality in HIV-infected individuals, mainly in hemophiliacs and intravenous drug users. The bidirectional interferences between hepatitis C virus and HIV have clinical consequences and complicate the management of coinfected individuals. Recent findings: There is an increased rate of liver complications among coinfected patients due to the decrease in opportunistic infections resulting from the use of potent antiretroviral therapy and accelerated progression to liver cirrhosis in the HIV setting. Conversely, the risk of hepatotoxicity of antiretrovirals is higher in the presence of chronic hepatitis C. While the standard therapy for hepatitis C in HIV is the combination of pegylated interferon plus ribavirin, overall treatment responses are lower in HIV-coinfected than in hepatitis C virus-monoinfected patients. Moreover, interactions between ribavirin and HIV drugs (i.e. didanosine, zidovudine) are associated with higher risks of side effects. Summary: Given the accelerated progression to end-stage liver disease in coinfected patients, treatment of hepatitis C should be a priority. While hepatitis C therapy should not be denied in the absence of contraindication, it should be reassessed at week 12 and therapy continued only in patients showing more than 2 log drops in viremia, to avoid side effects. Most recent data suggest that adequate selection of candidates, expert management of side effects, and prescription of appropriate ribavirin doses (in genotypes 1 -4) and extending treatment (in genotypes 2-3) all might allow response rates in coinfected patients to approach those seen in hepatitis C virus-monoinfected individuals.