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
"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
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)
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