HCV & HIV

hiv ribbon(BlackDoctor.org) — Following up from our last article on hepatitis B infection in HIV disease, we will now discuss another one of HIV’s party companions, Hepatitis C.  In the last article, I introduced HIV as a “party virus” to convey the point that other infections commonly occur along with HIV infection.

Many of these other infections, such as the hepatitis viruses, herpes, and human papilloma virus, are also sexually transmitted or transmitted by sharing needles for intravenous drug use.  Recall that there are several different hepatitis viruses, but they are not related at all.

The only thing they have in common is that they attack the liver, but they are structurally different, infect liver cells and reproduce differently and even damage the liver by different methods.  Hepatitis C (HCV) is mainly transmitted by intravenous drug use, when infected needles are shared, while about 10% of individuals are infected through sexual intercourse with an infected person.

However, among gay men, there is a growing epidemic of HCV infection among individuals who do not use intravenous drugs. It appears that anal intercourse without the protection of a condom can increase the risk of sexual transmission of HCV.  It can be transmitted from a pregnant mother to her infant. Overall, in the US, about 30% of HIV patients also have HCV infection (perhaps 300,000 people).  However, in clinics where I have worked in Washington DC and Baltimore, as many as 50% of patients have both HCV and HIV infection. A small percentage have HIV and both HBV and HCV.  Much of this disease stems from heroin use.

About 15% of people infected with HCV can eliminate the infection by their own immune system. The other 85% or so develop a chronic infection that is around for life.  Chronic HCV infection may not present with symptoms, however, soon after infection, some people will experience certain symptoms and signs such as nausea, vomiting, diarrhea, loss of appetite, fatigue, dark-colored urine, grayish-colored stools.  The skin and the whites of the eyes (the sclera) may appear yellowish.  These symptoms do not linger and may soon go away.  The patient may have increased levels of liver enzymes in the blood, which indicate that liver damage is occurring, but these levels can fluctuate.  The best test to diagnose this infection is the test for the presence of HCV antibodies in the blood.

In a previous article, I described the dangers of HBV infection and HCV infection causes the same risks.  Our biggest concerns are that HCV can cause cirrhosis of the liver, which is a serious, life-threatening condition by itself.  It may take 20 years or more for HCV infection to progress to cirrhosis but having HIV infection can accelerate this process. Even worse, liver cirrhosis often can progress to liver cancer, which has no effective treatments.  African-Americans have 5 year survival rates for liver cancer almost half those of whites, which are only about 5%, but this varies from study to study.

Just as with HBV, HIV infection increases the progression of liver disease for a patient who is also infected with HCV.  So, for patients with both HIV and HCV, the first step in managing these conditions should always be to control the HIV disease first.  This is usually the easiest step.  Also, for both HBV and HCV infection, it is imperative that the patient stop drinking because alcohol can also increase the damage to the liver.  Unlike HBV, there is no vaccine effective yet for HCV, however, there are some effective treatments discussed below.  There are 6 strains of HCV called genotypes.  These different strains of the virus do not respond the same to HCV treatment.  For example genotype 2 has a high cure rate from treatments where as genotype 1 has the lowest rate of cure.

Good news and bad news.

Unlike the situation for HIV disease, treatment for HCV can often lead to a cure.  If the treatment successfully reduces HCV virus to an undetectable level, and remains so after several months of treatment, the virus may continue to be undetectable after the treatment is stopped.  HIV is different because the virus comes back as soon as the medicines are stopped.nThis “cure” is referred to as a sustained virologic response (SVR).  This is very good news! But….(seems like there’s always a “but”), HCV treatment is no picnic.  Unlike HIV treatment which can be as simple as one pill once a day, with few side-effects, such is not the case for HCV treatment.  HCV therapy can be a challenging course with the patient at risk for many side-effects, and no definite promise of a cure.  We’ll talk about the treatment regimen later.  African-Americans have two more pieces of bad news.  I mentioned above that different strains of HCV respond differently to the currently recommended best treatments.  It turns out that most African-Americans (virtually all of the cases I’ve personally seen) are infected with genotype 1a or 1b, the strains that respond least well to therapy!  As if that weren’t enough, African-Americans have been recognized for some time to have lower responses rates to HCV treatment, even after accounting for the effects of HCV strain.  We now think that African-Americans have genetic variation in the way the body processes a key component of the HCV treatment, the drug interferon.  This can result in a diminished response to interferon in some individuals, while others have a perfectly good response. So the combination effects of HCV strain and genetics resulted in lower expectations for good treatment outcomes in African-Americans treated for HCV.

HCV Treatment

By far the best currently available regimen for HCV is a combination of two drugs, interferon and ribavirin.  Again and again, clinical studies have shown these two components are needed to work together and produce the best cure rates (SVR).  Interferons are naturally produced by the body.  They are part of our God-given defense against infection by viruses.  When viruses attack the body, many types of cells produce interferons in response.  This chemical can spread to un-infected cells and prepare them to fight the virus. Under the control of interferon, cells began to produce proteins that will prevent a virus from replicating if it infects the cells.  The virus’s genetic material is broken down, and the cell is blocked from making the viruses proteins.  These powerful actions of interferon can be launched against many different types of viruses.  Both HCV and HBV respond well to interferon treatment.  Even HIV infection may show some modest response to interferon.  The interferon we use is modified to a form that allows it to circulate for a longer time in the patient’s bloodstream (pegylated interferon), which allows the drug to be taken just once a week!  Because interferon is a protein, it must be administered by injection under the skin, like insulin in diabetes.

Unfortunately, interferon treatment has lots of side-effects. Administration of interferon produces symptoms that are similar to having the flu, fevers, muscle aches, weakness.  These symptoms are very uncomfortable but can be managed with typical flu medicines.  This side-effect also becomes easier to tolerate over time.  Other side-effects can include insomnia (difficulty sleeping), hair loss (alopecia), depression (which can be severe and requires treatment), and even a reduction in the infection-fighting white blood cells.  While most of these side-effects can be managed, interferon treatment is clearly not a walk in the park.

Ribavirin is believed to wor
k by altering HCV genetic material, making it unstable and unable to replicate and assemble new copies of HCV.  This drug can have side-effects as well, including anemia, or low red blood cell counts.

New Treatments

We have learned a lot form HIV infection on how to treat other viral infections. Similar to HIV, HCV also has a protease enzyme which is involved in processing proteins that form the structural backbone of the virus. Telapravir and Bocepravir   are experimental HCV protease inhibitors.  These drugs are so potent, they can reduce the HCV viral load over 1000-fold to undetectable in just a few days. They are very effective against HCV viruses of all genotypes. However, this rapid reduction in the virus in the blood quickly leads to drug resistance if these drugs are use alone.  Therefore, in many current studies, these drugs are combined with interferon and ribavirin initially, to protect against resistance.  Hopefully they will be approved soon.  There are other promising candidates as well.

Summary

1) HCV can be transmitted in the same ways HIV can
2)  It is a dangerous virus that can lead to cirrhosis and liver failure, or liver cancer, but this usually takes a couple decades to develop
3) HCV may not produce any symptoms so ask your medical provider to be tested
4) HIV makes HCV progress more quickly, so control HIV first
5) Some treatments may cure HCV but that depends on a number of factors
6) Protect yourself!

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