The New York-based HIV advocacy organisation Treatment Action Group has released extensive recommendations for research and service development for the estimated 4 million individuals infected with hepatitis C in the United States and the global population of people with hepatitis C, estimated at 170 million.

Hepatitis C Virus (HCV) and HIV/HCV Coinfection: A Critical Review of Research and Treatment, was written by Tracy Swan and Daniel Raymond and edited by Kenneth E. Sherman, MD, PhD.

Volume I (Clinical Science) is a critical review of research on epidemiology, transmission, natural history, diagnosis, and treatment of hepatitis C monoinfection and treatment of HIV and HCV for HIV/HCV coinfected people. Volume II is a critical review of research on molecular virology, immune response and pathogenesis of hepatitis C, and details of HCV drug development.

Key recommendations include:

Prevention and surveillance

• Implement national surveillance for chronic HCV infection.

• Provide HCV testing and education for high-risk and high-prevalence populations.

• Increase access to sterile injection equipment.

• Increase access to drug treatment and methadone maintenance programs.

• Institute CDC's recommendations for prevention of HCV transmission in hemodialysis facilities. Clarify routes and risks of HCV sexual transmission.

• Clarify the risk of non-injection drug use behaviors associated with HCV transmission, such as smoking or sniffing.

• Research mechanisms and interventions to decrease mother-to-infant transmission.

• Develop protocols for HCV counseling and testing for pregnant women, and offer voluntary HCV counseling and testing to pregnant women.

• Develop and implement HCV prevention strategies for the developing world.

• Promote screening and vaccination for hepatitis A and hepatitis B among individuals infected with HCV or coinfected with HIV/HCV.

• Create an "opt-out" system for organ donation in the United States and include discussion of organ donation as part of school health education programs and regular medical care.

Diagnosis

• Educate primary care providers about diagnosis of acute and chronic HCV infection.

• Develop and market oral fluid test kits for HCV-antibody testing.

• Promote use of a standardized system for evaluation of liver biopsy.

• Continue research on non-invasive testing methods to replace or reduce the need for liver biopsy.

• Identify and validate prognostic markers and more effective screening methods for early diagnosis of hepatocellular carcinoma.

Treatment of HCV infection

• Increase knowledge of treatment and care for hepatitis C patients among primary care providers.

• Identify optimal dosing strategies.

• Increase research on treatment safety and efficacy in understudied populations.

• Increase research on strategies to manage side effects of HCV treatment.

• Identify when and in whom treatment for acute HCV should be initiated; optimal regimen; and duration of treatment.

• Establish prospective, long-term follow-up studies to assess the durability and clinical benefit of histological responses in virological responders, relapsers, and non-responders.

• Investigate safety and efficacy of alternative therapies for HCV infection.

• Establish prospective, longitudinal cohort studies of the natural history of HIV/HCV coinfection in the era of HCV treatment and HAART.

• Develop guidelines for the care and treatment of coinfected individuals.

• Establish a universal definition of hepatotoxicity and characterize its severity.

• Explore pharmacokinetics and drug levels of antiretroviral agents and other drugs commonly used by coinfected individuals.

• Include HIV/HCV-coinfected individuals in early-phase HCV treatment trials.

• Explore strategies to optimize HCV treatment for HIV/HCV-coinfected persons.

• Support access to and research on liver transplantation for HIV-positive and HCV/HIV-coinfected individuals.

Care and support

• Provide full access to hepatitis C care and treatment for all of those in need.

• Do not withhold treatment from active drug users; decisions should be made on an individualized basis.

• Strengthen linkages among substance abuse treatment programs, methadone maintenance programs, medical and mental health providers, and HIV/HCV prevention programs.

• Increase capacity to provide individualized medical care and treatment to coinfected active drug users.

• Develop integrated, multidisciplinary systems of care for individuals with multiple co-morbidities (HIV, HCV, psychiatric disorders, addiction).

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