Optimal Management of HIV-HCV Coinfection

Abstract

Around 25 % of HIV-positive individuals are HCV coinfected. HIV infection clearly worsened the natural history of chronic HCV infection, and despite the improved cares of comorbidities (chronic alcohol intake, metabolic syndrome, poor immune status by an earlier and better immune restoration with antiretrovirals (ARV), and finally by a decreasing hepatotoxicity of ARV), liver-related mortality remains one of the main causes of mortality in HIV/HCV-coinfected patients as compared to HIV monoinfected patients. Treatment options in HIV-HCV-coinfected patients have been greatly improved in the last few years. The treatment of acute HCV infection in HIV-positive individuals using the association of pegylated interferon/ribavirin (PEG-IFN/RBV) (with a first-generation protease inhibitor in genotype 1-infected patient) will allow a HCV virologic cure in around 80 %. In chronically infected patients, the PEG-IFN/RBV association has demonstrated an efficacy of 20–40 % in genotype 1 and higher in other genotypes, and increasing with optimization of dosing and duration, stopping rules and ART adjustment; the adjunction of telaprevir or boceprevir for genotype 1 increased the chance of HCV cure to around drug-70 % with drug interaction concerns. Physicians are today, in 2014, in a period of transition between the standard treatment combining PEG-IFN and RBV with or without first-generation HCV protease inhibitors according to HCV genotype and oral combinations of different classes of direct-acting antivirals (DAAs) with a pan-genotypic antiviral potency and a fair safety which will clearly change the prognosis of HIV/HCV-infected patients. The DAA combination removes HIV-infected patients (like cirrhotics or liver transplant recipients) as difficult-to-treat patients.