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 chronic 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 chronic 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".)
- Zdilar D, Franco-Bronson K, Buchler N, et al. Hepatitis C, interferon alfa, and depression. Hepatology 2000; 31:1207.
- Sylvestre D. Hepatitis C treatment in drug users: perception versus evidence. Eur J Gastroenterol Hepatol 2006; 18:129.
- Taylor LE, Gholam PM, Schwartzapfel B, Rich JD. Hepatitis C treatment in an HIV-HCV-coinfected patient with drug addiction and psychiatric illness: a case report. AIDS Read 2005; 15:629.
- Poynard T, Bedossa P, Opolon P. Natural history of liver fibrosis progression in patients with chronic hepatitis C. The OBSVIRC, METAVIR, CLINIVIR, and DOSVIRC groups. Lancet 1997; 349:825.
- Pol S, Artru P, Thépot V, et al. Improvement of the CD4 cell count after alcohol withdrawal in HIV-positive alcoholic patients. AIDS 1996; 10:1293.
- Schaefer M, Heinz A, Backmund M. Treatment of chronic hepatitis C in patients with drug dependence: time to change the rules? Addiction 2004; 99:1167.
- Farel C, Suzman DL, McLaughlin M, et al. Serious ophthalmic pathology compromising vision in HCV/HIV co-infected patients treated with peginterferon alpha-2b and ribavirin. AIDS 2004; 18:1805.
- Wong SF, Jakowatz JG, Taheri R. Management of hypertriglyceridemia in patients receiving interferon for malignant melanoma. Ann Pharmacother 2004; 38:1655.
- Rallón NI, Naggie S, Benito JM, et al. Association of a single nucleotide polymorphism near the interleukin-28B gene with response to hepatitis C therapy in HIV/hepatitis C virus-coinfected patients. AIDS 2010; 24:F23.
- Pineda JA, Caruz A, Rivero A, et al. Prediction of response to pegylated interferon plus ribavirin by IL28B gene variation in patients coinfected with HIV and hepatitis C virus. Clin Infect Dis 2010; 51:788.
- Pérez-Elías MJ, García-San Miguel L, González García J, et al. Tuberculosis complicating hepatitis C treatment in HIV-infected patients. Clin Infect Dis 2009; 48:e82.
- Uberti-Foppa C, De Bona A, Galli L, et al. Liver fibrosis in HIV-positive patients with hepatitis C virus: role of persistently normal alanine aminotransferase levels. J Acquir Immune Defic Syndr 2006; 41:63.
- Saadeh S, Cammell G, Carey WD, et al. The role of liver biopsy in chronic hepatitis C. Hepatology 2001; 33:196.
- Yano M, Kumada H, Kage M, et al. The long-term pathological evolution of chronic hepatitis C. Hepatology 1996; 23:1334.
- McGovern B, Fiore J, Wurcel A, et al. Delivering therapy for hepatitis C virus infection to incarcerated HIV-seropositive patients. Clin Infect Dis 2005; 41 Suppl 1:S56.
- McGovern BH. Hepatitis C in the HIV-infected patient. J Acquir Immune Defic Syndr 2007; 45 Suppl 2:S47.
- Veronese L, Rautaureau J, Sadler BM, et al. Single-dose pharmacokinetics of amprenavir, a human immunodeficiency virus type 1 protease inhibitor, in subjects with normal or impaired hepatic function. Antimicrob Agents Chemother 2000; 44:821.
- Brinkman K, Smeitink JA, Romijn JA, Reiss P. Mitochondrial toxicity induced by nucleoside-analogue reverse-transcriptase inhibitors is a key factor in the pathogenesis of antiretroviral-therapy-related lipodystrophy. Lancet 1999; 354:1112.
- Duong Van Huyen JP, Landau A, Piketty C, et al. Toxic effects of nucleoside reverse transcriptase inhibitors on the liver. Value of electron microscopy analysis for the diagnosis of mitochondrial cytopathy. Am J Clin Pathol 2003; 119:546.
- McGovern BH, Ditelberg JS, Taylor LE, et al. Hepatic steatosis is associated with fibrosis, nucleoside analogue use, and hepatitis C virus genotype 3 infection in HIV-seropositive patients. Clin Infect Dis 2006; 43:365.
- Soriano V, Miró JM, García-Samaniego J, et al. Consensus conference on chronic viral hepatitis and HIV infection: updated Spanish recommendations. J Viral Hepat 2004; 11:2.
- Nunes D, Fleming C, Offner G, et al. HIV infection does not affect the performance of noninvasive markers of fibrosis for the diagnosis of hepatitis C virus-related liver disease. J Acquir Immune Defic Syndr 2005; 40:538.
- Shire NJ, Rao MB, Succop P, et al. Improving noninvasive methods of assessing liver fibrosis in patients with hepatitis C virus/human immunodeficiency virus co-infection. Clin Gastroenterol Hepatol 2009; 7:471.
- Sandrin L, Fourquet B, Hasquenoph JM, et al. Transient elastography: a new noninvasive method for assessment of hepatic fibrosis. Ultrasound Med Biol 2003; 29:1705.
- de Lédinghen V, Douvin C, Kettaneh A, et al. Diagnosis of hepatic fibrosis and cirrhosis by transient elastography in HIV/hepatitis C virus-coinfected patients. J Acquir Immune Defic Syndr 2006; 41:175.
- Vergara S, Macías J, Rivero A, et al. The use of transient elastometry for assessing liver fibrosis in patients with HIV and hepatitis C virus coinfection. Clin Infect Dis 2007; 45:969.
- Kirk GD, Astemborski J, Mehta SH, et al. Assessment of liver fibrosis by transient elastography in persons with hepatitis C virus infection or HIV-hepatitis C virus coinfection. Clin Infect Dis 2009; 48:963.
- Puoti M, Bruno R, Soriano V, et al. Hepatocellular carcinoma in HIV-infected patients: epidemiological features, clinical presentation and outcome. AIDS 2004; 18:2285.
- Bräu N, Fox RK, Xiao P, et al. Presentation and outcome of hepatocellular carcinoma in HIV-infected patients: a U.S.-Canadian multicenter study. J Hepatol 2007; 47:527.
- Salmon-Ceron, D. J Hepatology 2009; 50:739.
- 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
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS