February 5, 2001
The packed room overflowing into the hall reflected the interest in and the importance of Hepatitis C in HIV-infected persons. Kenneth Sherman gave a State-of-the-Art presentation on HIV Hepatitis C co-infection that highlighted the important areas where our knowledge is lacking.
Co-infection is important worldwide, but accurate figures are limited to subpopulations in different geographic areas. The true picture of the epidemiology of co-infection is only slowly emerging. Thus, estimates of the number of co-infected persons worldwide are highly speculative. As a hepatologist, Dr. Sherman said his focus is on the liver, not on the virus, and specifically on fibrosis of the liver. Persons with Hepatitis C who do not experience fibrosis do not go on to develop cirrhosis, liver failure, or hepatocellular carcinoma. Roughly 20% of non-co-infected persons will develop fibrosis. Risk factors include the genotype of virus, age, and alcohol use. There is a wealth of data that HIV infection increases the risk of fibrosis and death due to liver disease. Dr. Sherman reviewed data suggesting that lower CD4 cell counts may influence the risk as well. He reviewed studies that look at the effect of Hepatitis C on the course of HIV infection. Several show increased progression to AIDS but it is not consistent from study to study.
Dr. Sherman highlighted the fragmentary nature of studies on the treatment of Hepatitis C in HIV. Many studies are small, and European studies may not be as useful for North American physicians since the genotype distribution, which effects the response to interferon, is very different. Some studies suggested poorer responses among co-infected persons treated with interferon, but there is a suggestion that when the CD4 count is above 350, the response is the same as in HIV-negative people.
The use of Ribavirin is now the standard of care. Based on results presented in the last few months at the liver meetings, Dr. Sherman predicted that pegylated interferon plus Ribavirin will be the standard of care. Studies of peg interferon and Ribavirin in HIV infected persons are ongoing and should be available next year.
For the patient and the physician with HIV/Hepatitis C co-infection, a great deal of uncertainty remains about when to biopsy and when to treat. Perhaps we may move toward early Hepatitis C treatment if the CD4 count is very high, and focus on immune reconstitution first using HAART if the CD4 count is lower. Better predictors and better treatments are urgently needed.
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