Hepatitis C in human immunodeficiency virus co-infected individuals: Is this still a “special population”?

Abstract

A substantial proportion of individuals with chronic hepatitis C virus (HCV) are co-infected with human immunodeficiency virus (HIV). Co-infected individuals are traditionally considered as one of the “special populations” amongst those with chronic HCV, mainly because of faster progression to end-stage liver disease and suboptimal responses to treatment with pegylated interferon alpha and ribavirin, the benefits of which are often outweighed by toxicity. The advent of the newer direct acting antivirals (DAAs) has given hope that the majority of co-infected individuals can clear HCV. However the “special population” designation may prove an obstacle for those with co-infection to gain access to the new agents, in terms of requirement for separate pre-licensing clinical trials and extensive drug-drug interaction studies. We review the global epidemiology, natural history and pathogenesis of chronic hepatitis C in HIV co-infection. The accelerated course of chronic hepatitis C in HIV co-infection is not adequately offset by successful combination antiretroviral therapy. We also review the treatment trials of chronic hepatitis C in HIV co-infected individuals with DAAs and compare them to trials in the HCV mono-infected. There is convincing evidence that HIV co-infection no longer diminishes the response to treatment against HCV in the new era of DAA-based therapy. The management of HCV co-infection should therefore become a priority in the care of HIV infected individuals, along with public health efforts to prevent new HCV infections, focusing particularly on specific patient groups at risk, such as men who have sex with men and injecting drug users.

Keywords: Human immunodeficiency virus, Hepatitis C, Coinfection, Antiviral agents, Anti-retroviral agents, Natural history, Epidemiology, Pathogenesis, Therapy

Core tip: This manuscript focuses on hepatitis C virus/human immunodeficiency virus (HIV) co-infection, two intersecting epidemics with great global health interest. It reviews the epidemiology, pathogenesis and natural history of chronic hepatitis C in HIV infected individuals. It also reviews the impact of antiretroviral therapy on the natural history of chronic hepatitis C and the liver. Moreover, it shows that the outcomes of treatment with the newer direct acting antivirals against hepatitis C are similar in the mono-infected and co-infected patients, providing informative data extracted from relevant clinical trials. It argues that HIV infected individuals should no longer be designated as a “special population” among those with chronic hepatitis C, as this could delay their access to the new treatments.