Hepatitis C is a serious global health problem. Worldwide, an estimated 170 million people have been infected with the hepatitis C virus (HCV). In the United States, an estimated 4 million people have been infected with HCV; 2.7 million of them have developed chronic hepatitis C. The U.S. estimate may be low, as many high-prevalence populations were excluded from HCV surveillance. Up to one quarter of HIV-positive individuals in the U.S. are coinfected with HCV.
Since viral inactivation procedures and effective donor screening have almost completely eliminated the risk of hepatitis C infection from blood transfusions and blood products, the majority of new HCV infections occur via injection drug use with shared, unsterilized equipment. HCV is prevalent among current and former injection drug users; up to 90% have been infected.
Many questions about HCV transmission remain unanswered. HCV can be transmitted through sex, from mother to infant, and via dialysis at centers with inadequate infection control procedures. Men who have sex with men, sex workers, people with multiple sex partners, and partners of HIV/HCV-coinfected persons have higher-than-average HCV prevalence rates, yet the routes and risks of sexual transmission are unclear. The risk of HCV transmission from mother to infant is about 5%; the risk increases if the mother is HIV/HCV coinfected. Interventions to reduce the risk of mother-to-infant transmission have yet to be identified. While it has been speculated that HCV may be transmitted from shared tubes used for intranasal drug use and from crack pipes, the risk of HCV transmission from non-injection drug use has not been quantified. Current HCV prevention strategies for injection drug users are inadequate, and education about HCV transmission and prevention is lacking.
Hepatitis C is not invariably chronic; 15% to 45% of those infected achieve spontaneous viral clearance. Chronic HCV infection can result in fibrosis (mild liver scarring) and cirrhosis (serious liver scarring). Symptoms may include fatigue, depression, and confusion ("brain fog").
The course of chronic HCV varies widely and depends on a number of factors, including age, race, sex, and alcohol consumption. People living with HCV and their health care providers need better information about prognostic factors and risk of disease progression to make informed decisions about care and treatment. The most serious clinical consequences of HCV infection are cirrhosis, hepatocellular carcinoma, and hepatic decompensation (liver failure). HCV-related end-stage liver disease is the leading indication for liver transplants in the United States, where there is a critical shortage of donor livers. Potentially life-saving vaccinations for hepatitis A and B are recommended by CDC, but have not yet been universally incorporated into HCV care.
Acute HCV is usually asymptomatic and often goes undiagnosed. A series of blood tests is available to diagnose chronic HCV infection, predict and monitor the effects of treatment, and measure other complications of HCV infection. Liver biopsy is still considered the "gold standard" for assessment of liver damage and determining the need for treatment, although it is expensive, invasive, unpopular with patients, and subject to substantial interpretive variation. Hepatocellular carcinoma (HCC) occurs in 1-4% of cirrhotics annually. Current surveillance techniques are suboptimal for early diagnosis of hepatocellular carcinoma.
Provider education on HCV is limited. Many high-risk and high-prevalence populations lack access to regular medical care. Outreach strategies for diagnosis of HCV and linkage of newly diagnosed HCV-infected persons to care programs are needed.
Treatment for HCV -- a 6-to-12 month course of pegylated interferon and ribavirin -- has many drawbacks, including potentially severe side effects. On average, treatment eradicates HCV in about half of patients, but various factors can dramatically increase or decrease the likelihood of a sustained virological response. Initial reports suggest that HCV treatment may be particularly effective during acute infection. Treatment may also improve the condition of the liver, even in people who do not have a sustained virological response.
Primary care providers often do not receive adequate information about efficacy and side effects of HCV treatment. Moreover, even for expert clinicians, numerous questions about treatment remain: Can treatment success rates be improved by optimizing dosing regimens? Is treatment safe and effective across all populations with high HCV rates-especially drug and alcohol users and people with psychiatric co-morbidities, who have often been excluded from clinical trials? Is there a role for treatment even in people who don't clear the virus? Can improvements in the management of side effects make treatment more tolerable? When and how should people acutely infected be treated? How effective are herbs such as milk thistle as complementary and alternative therapies for HCV? These questions are relevant not only for HCV monoinfection but also for HCV/HIV coinfection.
In 1999, CDC added hepatitis C infection to the list of opportunistic infections (OIs) associated with HIV. HIV accelerates HCV disease progression, and HCV-related end-stage liver disease has become a leading cause of death among HIV-positive people. Although potent antiretroviral therapy has significantly increased survival, some studies have reported a blunted immune response to antiretroviral therapy among HCV-coinfected individuals. HCV coinfection increases the risk of hepatotoxicity from antiretroviral therapy. Vaccination for HAV and HBV may be less immunogenic in individuals with advanced HIV disease.
HCV treatment is less effective for HIV/HCV-coinfected people, and they tend to experience more severe side effects. Although promising data have emerged on the survival of coinfected liver recipients, restrictive policies at transplant centers and refusal to reimburse for transplantation have limited access to transplantation for HIV-positive candidates. For these reasons, people coinfected with HIV and HCV and their health care providers face complicated decisions about care and treatment for both infections.
HCV is prevalent among African Americans, the incarcerated, the poor, current and former injection drug users, people with psychiatric disorders, and HIV-positive persons. These groups face significant barriers to care and treatment. Incarcerated individuals have had to resort to legal action to obtain HCV treatment, and most still do not receive it. Inadequate, decreasing funding of AIDS Drug Assistance Programs (ADAPs) has limited access to HIV and HCV treatment for HIV-positive individuals. Expected cuts in Medicaid threaten access to HCV treatment for many more.
It is in this environment that TAG is releasing Hepatitis C and HIV/HCV Coinfection: A Critical Review of Research and Treatment. This report is meant to serve as a blueprint for activism as well as a source of information.
TAG's Coinfection Project closely monitors new data on the epidemiology and natural history of HIV/HCV coinfection, as well as the development of new diagnostics, prophylaxes, and treatments for hepatitis C in both the pre- and postmarketing stages. We advocate for the expeditious development, proper clinical research and regulation, ease of access, and optimal use of these drugs. We work with the pharmaceutical companies, NIH, FDA, researchers, and other treatment activists to achieve these objectives. TAG also educates members of the HIV community about coinfection with hepatitis C.
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