'Hepatitis C (HCV) is a leading cause of death for those with HIV,' said Tracy Swann, 'It is one of the most important advocacy issues' because coinfection hastens disease progression and complicates treatment of both viruses. She spoke at a forum organized by the Treatment Action Group (TAG) at the 10th Conference on Retroviruses and Opportunistic Infections in Boston.
'The U.S. has no clinical guidelines for treating coinfected people,' she said, furthermore, they are almost always excluded from clinical trials of new drugs to treat either disease.
TAG released an updated series of research and policy recommendations for HIV/HCV coinfection at the forum. (available at: www.aidsinfonyc.org/tag/comp/hcvhivresearch.html)
The stigma of drug use, which is how many people became coinfected, shapes how many healthcare providers interact with these patients, said Donald Grove, director of operations with the Harm Reduction Coalition. Under-dosing of methadone is just one of the tactics used to force patients to 'get with the program' and get clean.
He urged increased use of needle-exchange programs to reach out with medical service to one segment of the coinfected population, because that 'is the only place that accepts these patients where they are.'
Jules Levin lamented the fact that few people are involved with advocacy surrounding HCV infection, despite the fact that at least 4 million Americans are believed to be infected with the virus. That is reflected in the fact that 'there is very little commitment from the upper echelons of the Bush administration' or congressional leaders, he said, 'this is not a priority for them.'
The executive director of the National AIDS Treatment Advocacy Project (NATAP) (www.natap.org) is taking the lead in organizing a national coalition to work on issues of HIV/HCV coinfection. It organized a congressional briefing on February 25.
MEDICAL PROGRESS
'We have made tremendous progress [in treating hepatitis C] in a very short time,' said Kenneth E. Sherman, MD, PhD, Director of Hepatology at the University of Cincinnati College of Medicine. 'It is the only chronic virus infection that we can cure,' though only about half the time. However, too often those advances are not carried forward into everyday practice.
One unanswered question is 'who needs to be treated right now,' rather than wait for better therapies likely to be available in 5-10 years. It has become clear that coinfection accelerates the progression of HCV, though the reverse does not appear to be the case.
Sherman said that HCV patients with a CD4 count below 500 'are more difficult to treat.' It suggests to him that HIV treatment guidelines should be modified for the coinfected patient, to initiate therapy earlier and 'not let them drift down to 350 or below.'
He advises selecting an anti-HIV regimen that will put less stress on the liver of those who are coinfected. That is particularly true if both infections are treated simultaneously.
The standard anti-HCV therapy of interferon and ribavirin puts its own burdens on the liver. It multiplies the potential for drug interactions and toxicities with HIV drugs and antidepressants that may be prescribed for either condition. Many of those combinations have not been systematically examined for possible drug interactions.
In research presented at the retroviral conference, Sherman and others showed that using ribavirin and anti-HIV cocktail that contained didanosine (ddI) at the same time, resulted in 'a 5-fold increased likelihood of events suggestive of mitochondrial toxicity,' a severe and often deadly liver disorder, compared with other regimens.
Ribavirin and ddI 'should be co-administered with caution and ddI should be suspended if signs or symptoms suggestive of mitochondrial toxicity develop,' he said.
Lisa Hirschhorn, MD, director of HIV medical care and research at the Dimock Community Health Center in Boston, compared the state of knowledge of HCV treatment with that of HIV a decade ago. She hoped that lessons from that earlier era can be applied to coinfection.
One of them is understanding that interferon can dramatically worsen depression. There is need for mental health support, including possible administration of antidepressants prior to starting that drug.
Those interested in coinfection advocacy can contact Michaela Leslie-Rule (212) 219-0106 ext 20, or michaela@natap.org
