Impact of HIV Coinfection in Persons with Chronic Hepatitis C Infection: In the United States, approximately 5 to 10 percent of patients with chronic hepatitis C (HCV) infection are coinfected with HIV. Coinfection with HIV accelerates the progression of hepatic fibrosis and results in a more aggressive course of liver disease (Figure 1). Cirrhosis has been observed to occur 12 to 16 years earlier in those coinfected with HCV and HIV compared with those who have HCV monoinfection. For HIV-infected patients with HCV coinfection, liver-related morbidity and mortality is a prominent non-AIDS-defining complication—up to 90% of liver-related deaths in HIV-infected patients are attributable to HCV. Unfortunately, patients coinfected with HCV and HIV have decreased access to liver transplantation compared with HCV monoinfected patients. For all of these reasons, treatment of HCV in this patient population should have a high priority. Historically, treatment of HCV in patients coinfected with HIV had limited uptake, largely due to a low response rate with interferon-based therapy, a high rate of adverse effects, concerns for interactions with antiretroviral medications, and high prevalence of comorbidities, such as psychiatric conditions and chemical dependency. The recent availability of highly effective all-oral HCV regimens has generated major enthusiasm and interest for the treatment of HCV in persons coinfected with HIV.
Historic Approach to Treatment: For patients coinfected with HCV and HIV, initial trials with interferon monotherapy or dual therapy with standard interferon plus ribavirin were associated with very low SVR rates and significant toxicity. Response rates were higher with peginterferon and ribavirin in coinfected patients, but still suboptimal, as summarized in a table format (Figure 2) and a graph illustration (Figure 3). The peginterferon and ribavirin combination regimen had particularly low SVR rates among those with genotype 1 HCV (typically less than 30%). Further, the SVR rates with peginterferon and ribavirin was 15 to 25% lower in coinfected patients than in HCV monoinfected patients. In 2011, the addition of a first-generation HCV protease inhibitor (telaprevir or boceprevir) to peginterferon and ribavirin improved SVR rates with GT1 to approximately 60% and narrowed the gap in treatment response between coinfected and monoinfected patients to approximately 15%. This triple therapy regimen, however, proved to be quite complex and challenging due to interactions with antiretroviral medications, greater pill burden, food requirements, and additional adverse effects. With the advent of all-oral regimens that include new direct acting antiviral agents (DAAs) that are safe, highly effective, and have fewer drug interactions, the older regimens of peginterferon and ribavirin or peginterferon and ribavirin plus a first-generation protease inhibitor are no longer recommended for treatment of HCV in coinfected patients.