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Back To Vidyya HIV/Hepatitis C Co-infection To Be Discussed At Infectious Disease Society Of America Meeting (IDSA)

New Research Leads To First Guidelines On How To Treat Patients With Two Deadly Diseases

The more than 300,000 Americans infected with the potentially deadly combination of HIV and hepatitis C are a focus at this year's Infectious Diseases Society of America meeting. The hepatitis C virus (HCV) has become a leading cause of death in HIV patients, but researchers are expected to unveil new solutions during IDSA presentations.

The Hepatitis Resource Network (HRN), a non-profit alliance for research, treatment and prevention of viral hepatitis with more than 84 member institutions, is holding a pre-IDSA symposium today titled "Issues and Controversies in Hepatitis C and HIV/HCV Co-infection." During a presentation at IDSA tomorrow, HRN President Douglas Dieterich, MD, Chief of Gastroenterology and Hepatology at Cabrini Medical Center, will present the results of a new clinical study that found hepatitis C treatment to be just as effective in patients with HIV as in those without it. Symposium presenters will also address the treatment guidelines for co-infection, recently formulated by a panel of experts to meet what physicians have described as "an overwhelming need."

"Now that HIV patients are living longer thanks to better treatments, slower-developing hepatitis C is an emerging threat," said Dr. Dieterich. "The good news is that we can effectively manage hepatitis C in many co-infected patients, and that new treatment guidelines offer a common-sense approach."

Study Brings Hope

Dr. Dieterich's retrospective study evaluated the effect of standard combination therapy for HCV, interferon alfa-2b (an immune booster) with ribavirin (an antiviral drug), in patients with HIV and hepatitis C. Patients received a standard dosage (3 million units of interferon injected twice per week with 800-1200 milligrams of oral ribavirin daily) for six to 14 months. Most patients (85%) also received highly active anti-retroviral therapy (HAART), a mixture of HIV therapies.

In co-infected patients receiving the combination therapy for hepatitis C, 40 percent had a sustained virologic response, defined as HCV viral levels too low to be detected at 3 and 6 months after the end of treatment. Median HIV RNA levels remained at less than detectable levels (less than 400 copies/ml) as well.

Study results also show that ribavirin, part of the combination therapy for hepatitis C, does not interfere with the action of some HIV medications, such as AZT (zidovudine or Retrovir(R)) or D4T (stavudine or Zerit(R)). HIV viral loads remained under control with ribavirin present in the body. The most common side effect seen with ribavirin was anemia, which was effectively treated with epoetin alfa or EPO therapy in most cases.

"Our study found that combination therapy for hepatitis C may be just as effective in co-infected patients as it is in patients with hepatitis alone," Dr. Dieterich said. "By lowering liver toxicity, hepatitis C treatment also allows physicians to treat HIV more aggressively. Some of the most effective and widely used HIV treatments may cause liver toxicity, which can halt treatment in co-infected patients unless we stop hepatitis C from attacking the liver at the same time."

A Nationwide Effort

Dr. Dieterich's study is just one early example of several studies that are currently exploring treatment for HIV and hepatitis C. The Hepatitis Resource Network is sponsoring two large-scale clinical trials using the standard of care -- interferon alfa-2b and ribavirin in combination -- to treat hepatitis C and co-infection. Additional trials will soon begin that will explore the efficacy of a new monotherapy, pegylated interferon (PEG) -- a modified version of interferon. Researchers anticipate that PEG will be twice as effective as standard interferon monotherapy with fewer side effects and require fewer injections per week. Clinical trials are also underway to determine the efficacy of PEG in combination with ribavirin.

Guidelines for Treatment

Dr. Dieterich and HRN Vice President Mark S. Sulkowski, MD, assistant professor of Medicine at Johns Hopkins, recently co-chaired a meeting where 16 researchers and leading experts in HIV and hepatitis convened to develop guidelines for management of HIV and HCV co-infected patients. The guidelines, titled Expert Perspectives: Strategies for the Management of HIV/HCV Co-infection, focus on how to identify candidates for treatment, manage the unique challenges faced by co-infected patients, and on how to best use HAART while using interferon alfa and ribavirin to treat hepatitis C infection. They are available online in a CME monograph at

While many physicians still hesitate to treat HCV in HIV patients, the guidelines stress that combination therapies for HIV and HCV may be used simultaneously. They recommend that physicians treat both viruses as if the patient had one or the other by staggering the initiation of treatments and carefully monitoring liver function.

"The management of chronic hepatitis C infection in persons infected with HIV, who are often taking multiple anti-HIV medications, can be quite complicated and, to date, there has been little information to guide physicians," Dr. Sulkowski said. "Nonetheless, it is clear that hepatitis C is a major problem, leading to liver failure and death in some HIV-infected persons. More importantly, effective HCV treatments are available, and it's essential that persons co-infected with HIV and HCV be considered for treatment with combination interferon and ribavirin.

A Deadly Combination

The U.S. Public Health Service recently identified hepatitis C as an opportunistic infection of HIV -- meaning HCV infection acts more aggressively in HIV-infected persons, with a 7-fold increase of death due to HCV-related liver disease when compared to the persons infected with HCV alone. HCV infection and HCV-related liver disease also significantly increases the risk of severe liver toxicity due to antiretroviral drugs and may interrupt or even prevent the aggressive treatment of the HIV disease.

Hepatitis C infects an estimated 4 million Americans, four times as many as have HIV. When left untreated, HCV can progress for decades with no symptoms, leading eventually to cirrhosis (scarring of the liver), liver failure and death. Chronic hepatitis C results in an estimated 8,000 to 10,000 deaths per year, with the death toll expected to triple within the next 10 to 20 years.

In a recent "Dear Citizen" letter to the American public, U.S. Surgeon General David Satcher, MD, described hepatitis C as a "silent epidemic" because so few of those infected are aware of it. This letter marks only the second time in history that a health crisis has warranted this type of national warning. The first time was for AIDS.

The Hepatitis Resource Network, founded in 1997, is a joint initiative with the goal of enlisting more specialists, from the fields of infectious disease and gastroenterology, in the battle against viral hepatitis. Gastroenterologists traditionally treat diseases of the liver, but, like HIV, hepatitis C is also a chronic viral infection and the combined expertise of infectious disease specialists and gastroenterologists is needed to address this emerging epidemic in the United States. HRN is a non-profit organization supported by grants from five pharmaceutical companies and a drug wholesale firm.

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Editor: Susan K. Boyer, RN
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