Hepatitis C and HIV coinfection

If you are living with HIV and have been diagnosed with hepatitis C, there is good news: hepatitis C today is cured just as well as in anyone else. With direct-acting antivirals, more than 95% of coinfected patients clear the virus for good, the same rates achieved in people who only have hepatitis C. Treatment lasts 8 to 12 weeks, is taken as pills and is very well tolerated.

This is a profound change. Until recently, hepatitis C and HIV coinfection was considered “difficult to treat,” because the only available regimen, interferon with ribavirin, cured fewer than half of these people and caused significant side effects. That paradigm is over. Current guidelines recommend treating hepatitis C in every person with HIV, without exception, and no longer describe them as a “special population.”

Why do hepatitis C and HIV occur together?

Hepatitis C and HIV share routes of transmission, which is why they are often found in the same person. The main ones are:

• Blood, above all through sharing injection-drug equipment. This is the most important route for hepatitis C.
• Sexual contact, especially in practices that involve contact with blood. HIV makes sexual transmission of hepatitis C easier.
• Mother-to-child transmission, during pregnancy or delivery, more likely when HIV is not controlled.

A meaningful share of people with HIV has or has had hepatitis C, with figures that vary widely by country and group. For this reason, everyone with HIV should be tested for hepatitis C at least once, and tested again if the risk of exposure continues.

Why does treating it matter?

Because HIV changes the natural course of hepatitis C, and almost always for the worse. In a coinfected person, the infection is more likely to become chronic, and liver damage advances faster: fibrosis progresses sooner and the risk of cirrhosis and liver cancer is higher. This accelerated course is more pronounced when HIV is poorly controlled, with low CD4 counts, and is made worse by alcohol use and older age.

Today liver disease is one of the leading causes of illness and death in people with HIV whose infection is already under control. Curing hepatitis C halts that progression. Once the virus is cleared, the risk of liver complications falls clearly, and recent studies show that, after cure, people with well-treated HIV have an outlook comparable to those without it.

How is it diagnosed?

The workup starts with a blood test that looks for antibodies against hepatitis C. If they are positive, active infection is confirmed by measuring the virus’s genetic material (HCV RNA) with a PCR test. This second step is key, because it distinguishes a current infection from one that has already resolved.

In people with HIV it is worth keeping in mind that, when immunity is severely compromised, antibodies can in rare cases be negative despite infection. That is why, when suspicion is strong, it is justified to measure HCV RNA directly even if antibodies do not appear.

Assessment before treatment

Before starting treatment, your medical team needs a clear picture of both infections. The assessment includes:

• The HIV status: CD4 count, viral load and which antiretroviral therapy you are receiving.
• The hepatitis C status: viral load and, when relevant, the virus genotype.
• The liver status: liver enzymes, a blood count and an estimate of fibrosis.

To measure fibrosis, liver biopsy is now rarely used. Non-invasive methods are preferred, such as elastography (for example FibroScan) and blood indices, which estimate liver damage without needing to sample the liver. Knowing whether cirrhosis is present is important, because it can change the length of treatment and calls for long-term monitoring of the liver.

Treatment

Treatment consists of direct-acting antivirals (DAAs), oral medications that act on the hepatitis C virus and eliminate it. Pan-genotypic regimens, which work for all genotypes, are the most widely used:

• Sofosbuvir with velpatasvir, for 12 weeks.
• Glecaprevir with pibrentasvir, usually for 8 weeks in people without cirrhosis.

Studies in people with HIV confirmed what was expected: with these regimens hepatitis C is cured in more than 95% of cases, with or without cirrhosis, and with very few side effects. Cure is called sustained virologic response, meaning the virus remains undetectable in the blood three months after finishing treatment. It is a definitive cure.

The key point: interactions with HIV therapy

The most important point in a coinfected person is that HIV therapy is not stopped. It must be continued throughout hepatitis C treatment, because well-controlled HIV is part of a good outcome.

The aspect that demands attention is interactions between the hepatitis C antivirals and some HIV antiretrovirals. Certain combinations can raise or lower drug levels in the blood and, with that, affect their safety or effectiveness. So, before starting, the medical team reviews the antiretroviral therapy and, if needed, adjusts it or switches a drug for a while. This is one more reason for treatment to be coordinated jointly by the HIV specialist and the hepatologist, and for you not to self-medicate or stop medications on your own.

With this precaution, treating hepatitis C in people with HIV is as simple and effective as in everyone else.

What about liver transplant?

Liver transplant, which years ago was considered off-limits in people with HIV, is today a real option for those who develop decompensated cirrhosis, as long as HIV is well controlled. Being able to cure hepatitis C before or after transplant has greatly improved these results.

The essentials

Hepatitis C and HIV coinfection speeds up liver damage, but it is curable. If you have HIV, ask to be tested for hepatitis C. And if you have both infections, know that hepatitis C can be eliminated with a short, well-tolerated and highly effective treatment, always keeping your HIV therapy going and under the care of your medical team.

See also

• Hepatitis C
• Hepatitis B and HIV coinfection
• Cirrhosis
• Liver transplant