Treatment and Monitoring of Persons with HCV/HIV Co-infection

Treatment indication

  1. Every person with HCV/HIV co-infection must be considered for DAA based anti-HCV treatment regardless of liver fibrosis stage
  2. Due to similar HCV cure rates and tolerability in HCV/HIV co-infected persons as in HCV mono-infected persons under DAA therapy, treatment indication and regimens are to be the same as in HCV monoinfection

Treatment selection

  1. DAA combinations are now standard of care for chronic HCV infection, see Tables HCV Treatment Options in HCV/ HIV Co-infected Persons. IFN-based therapies and first generation PIs (boceprevir and telaprevir) are not recommended because of insufficient efficacy and increased toxicities.
  2. Selection of DAA combinations is based upon stage of liver fibrosis, HCV GT(i), pre-treatment history and resistance-associated substitutions (RAS) if tested
  3. Due to drug-drug interactions in particular with HIV and HCV PIs, careful checking for interactions is urgently recommended prior to starting HCV therapy, see Drug-drug Interactions between Viral Hepatitis Drugs and ARVs or http://www.hep-druginteractions.org
  4. Resistance testing, if available, should be considered before re-treatment of persons who failed after a PI-and/or NS5A inhibitor-containing agent. The triple combination of SOF/VEL/VOX for 12 weeks is the treatment of choice for re-treatment, especially if resistance testing is not available. In persons with complex mutations patterns SOF+GLE/PIB + RBV for 12-16 weeks can also be considered. In case of unavailability of SOF/VEL/VOX or SOF + GLE/PIB other regimens with at least two active DAAs could be combined with the preferential use of one drug with high genetic barrier to resistance and with extended treatment durations and potentially addition of RBV. In patients with decompensated cirrhosis SOF/VEL + RBV for 24 weeks is the only available option for re-treatment in case of contraindication to liver transplantation

i. If pangenotypic regimens are foreseen, HCV GT determination is not mandatory before starting treatment. HCV GT determination should be considered in persons at risk of reinfection in order to differentiate between relapse and re-infection in case of reemergence of HCV RNA after therapy

Treatment goal

  1. The primary aim of HCV treatment is SVR12 defined as undetectable HCV-RNA 12 weeks after the end of therapy (evaluated using sensitive molecular tests) or HCV core antigen levels where HCV- RNA assays are not available or not affordable. SVR12 corresponds to a definitive cure of HCV infection in the vast majority of cases

Treatment monitoring

  1. In PLW with advanced fibrosis (≥ F3) differential blood count, creatinine, liver enzymes, bilirubin, albumin and INR measurement after 2-4 weeks of therapy is recommended. In HBsAg negative PLWH with positive anti-HBc, monitoring of ALT and HBV-DNA in case of ALT elevation is recommended
  2. In PLWH with impaired renal function undergoing SOF based treatment creatinine should also be monitored
  3. HCV-RNA measurement during therapy should only be performed in order to assess compliance and/or break-through in PLWH experienced to oral DAAs; HCV-RNA should be measured at end-of-treatment and at week 12 or 24 after treatment cessation (to assess SVR). In PLWH receiving all oral DAA therapy, no association between viral load at any given time-point during therapy and SVR has yet been found. If HCV RNA determination is not available SVR can be identified by a negative
    HCV core antigen 24 weeks after treatment end
  4. HIV-VL every 12 weeks

Post-Treatment monitoring

  1. Surveillance for HCC and for oesophageal varices should be continued if the respective indications were present pre-treatment, despite achieving SVR, see Assessment of PLWH at Initial & Subsequent Visits, Cancer: Screening Methods, Liver Cirrhosis: Classification and Surveillance, Liver Cirrhosis: Management
  2. All PLWH with concurrent causes of liver disease should undergo periodical clinical assessments
  3. Increase in body weight and changes in lipid and glucose metabolism have been described after SVR. Thus, surveillance, counseling and treatment for obesity and metabolic alterations should be enforced after SVR, see Lipodystrophy and Obesity: Prevention and Management

Treatment of recently acquired HCV infection

  1. IFN-containing HCV regimens are no longer recommended
  2. HCV treatment immediately after diagnosis is recommended in PLWH with ongoing risk behavior to reduce onward transmission. IFN-free treatment with DAAs is recommended as in treatment naïve persons without cirrhosis (except for those with pre-existing cirrhosis), see HCV Treatment Options in HCV/HIV Co-infected Persons
  3. If treatment is not indicated immediately, HCV-RNA should be re-measured 4 weeks later. Treatment is recommended in PLWH without a decrease of 2*log10 of HCV-RNA at 4 weeks compared with initial HCVRNA, due to the very low probability of spontaneous clearance, and in persons with persistent serum HCV-RNA 12 weeks after diagnosis of recently acquired HCV, see Management of Recently acquired HCV in Persons with HIV Co-infection
  4. For more detailed information on the management of recently acquired HCV infection we refer to the Recommendations on Recently acquired and early chronic hepatitis C in MSM from the European treatment network for HIV, hepatitis and global infectious diseases consensus panel

See online video lectures HCV/HIV Co-infection-Part 1 from the EACS online course Management of HIV and Co-infections