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HIV and Hep C co-infection question.

Dr. Chung,

I am the assistant editor of AIDS Treatment News. We often receive correspondence from incarcerated individuals, sometimes with treatment questions. Since medical and AIDS care in prisons is sometimes sub-standard, we try to provide any assistance we can. We have a question from a prisoner in New Jersey who has been HIV positive for six years and Hep C, and is on AZT, viramun and videx. His t-cell count is stable at 789. He has high sugar at 147 mgldl. He wants know if he should start hep C treatment and if he should discontinue HIV medications while treating hep C. Any information would be helpful. Many thanks, --A.

from Jules Levin--

This patient should consider a biopsy, as that is the best way to assess liver disease stage and to decide when HCV treatment needs to be started. The decision on when to begin therapy is a new question in HCV/HIV coinfection and is somewhat controversial. Opinions vary. There are a number of reasons to begin therapy if the biopsy is stage 2 and 3. Some docs would start therapy at stage 2 (don'y forget that, in general, HCV progression is accelerated by HIV) and some would wait. I think therapy would generally be recommended if at stage 3. Of course, the decision to start therapy also depends on other considerations.

For example, clinically depressed patients may not qualify for therapy, and a patient needs to have adequate blood test results (platelets, etc). Patients with diabetes need to watch sugar after starting HCV therapy. Viramune may not be the best HIV drug for a person with HCV. AZT and ddI may have interactions with ribavirin. In the test tube this has been seen but clinically AZT does not appear to be a problem in preliminary research. DDI levels may increase with RBV which in theory could increase ddI side effects/tox but this has not been studied clinically. With cd4 so high at 789 this is a good time to consider therapy as having high cd4s may help response to HCV therapy. The patient should not stop their HIV therapy unless there is severe hepatoxtocity. JL

Dr.Chung writes--

I think the decision to treat HCV is predicated on the stage of HCV disease. this is best addressed with a liver biopsy. If there is more advanced disease, I think that anti-HCV treatment may be warranted if no contraindications. The antiretroviral therapy need not be discontinued, although I think that ddI toxicity may be something to watch for. RC Ask our Experts All Questions