Evaluation of the HIV-infected patient with chronic hepatitis C virus infection
- Arthur Y Kim, MD, FIDSA
Arthur Y Kim, MD, FIDSA
- Assistant Professor of Medicine
- Harvard Medical School
As death rates from opportunistic infections in HIV-infected patients have declined with the introduction of potent antiretroviral therapy (ART), morbidity and mortality from end-stage liver disease has increased. These clinical observations provide strong rationale for the evaluation and treatment of the HIV-infected patient with chronic hepatitis C virus (HCV) infection.
The HIV/HCV-coinfected patient benefits from a multi-disciplinary team approach and intensive support throughout treatment. The complexities of hepatitis C management in this patient population will be reviewed here. The epidemiology, natural history, diagnosis, and treatment of HCV in the HIV-infected patient are discussed elsewhere. (See "Epidemiology, natural history, and diagnosis of hepatitis C in the HIV-infected patient" and "Treatment of hepatitis C virus infection in the HIV-infected patient".)
History — HIV-infected patients who are being seen for evaluation and possible treatment of hepatitis C should undergo a complete history and physical examination.
Substance abuse — Patients with a history of substance abuse who are currently abstinent should be interviewed about the stability of their recovery since the use of interferon has been associated with relapse of drug use . Active injection drug use does not rule out the possibility of treatment; rather decisions about offering therapy should be based on the patient's ability to adhere to medications, return for follow-up, and avoid reinfection (eg, avoidance of sharing needles) [2,3]. Treatment of addiction with drugs such as methadone or buprenorphine can effectively facilitate HCV treatment in drug users. (See "Treatment of hepatitis C virus infection in the HIV-infected patient".)
Alcohol use should also be detailed; coinfected patients should be counseled against the use of alcohol, which has been associated with acceleration of disease progression in patients with HCV infection . Furthermore, CD4 counts may improve after patients stop drinking alcohol . (See "Epidemiology, natural history, and diagnosis of hepatitis C in the HIV-infected patient".)
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- INITIAL EVALUATION
- - Substance abuse
- - Psychiatry history
- - Other past medical history
- - Medication history
- - Social history
- - Pregnancy
- - Family history
- - Sexual history
- Physical examination
- Laboratory screening
- Screening for tuberculosis
- Interpretation of aminotransferases
- Patients with suspected cirrhosis
- STAGING OF LIVER DISEASE
- Role of the liver biopsy
- - Advantages
- - Limitations
- - When should a liver biopsy be obtained
- - When should a biopsy be repeated
- Noninvasive serum fibrosis markers
- Transient elastography
- IMAGING STUDIES
- - Screening for hepatocellular carcinoma
- CT scanning
- SUMMARY AND RECOMMENDATIONS