The treatment of HIV/HCV co-infection presents many questions that have not yet been answered or on which there is no consensus. Since it is a recently introduced issue, the guidelines in the literature are divergent on some points. The still fragmented knowledge and lack of long-term worldwide experience in the treatment of such co-infections has forced referral facilities to constantly update their approaches. Some guidelines for the management of the HIV/HCV coinfected patient have been proposed, and new recommendations are particularly necessary: • Management of patients with persistently normal aminotransferase levels. • Definition and quantification of liver fibrosis: when and how? • Predictors of the response to anti-HCV therapy in coinfected patients. • Therapeutic doses of pegylated interferon and ribavirin. • Treatment duration. • Treatment of nonresponsive and recidivist patients. • Treatment of acute infection in HIV-positive patients. • HIV/HCV/HBV co-infected patients. • Interaction between antiretroviral drugs and anti-HCV therapeutics. • Antiretroviral hepatotoxicity in co-infected patients. • Antiretroviral drugs and recommended doses in hepatic insufficiency. Management of Patients with Persistently Normal Aminotransferase Establishing the persistence of normal aminotransferase levels in HCV-infected patients is difficult, especially in coinfected patients. Fluctuations in the levels of aspartate aminotransferase and alanine aminotransferase are common in this group of patients due to several factors, among which are the use of drugs of hepatotoxic potential, alcohol abuse, and infection with other opportunistic agents. In contrast to mono-infected patients, who present persistently normal alanine aminotransferase levels (~25%), co-infected patients present levels of 7-9%. However, of such patients, 25-40% present advanced liver fibrosis, which leads to liver cirrhosis. The rapid evolution of fibrosis in co-infected patients, even in those with normal transaminase levels, indicates treatment, based on patient motivation, duration of the disease, fibrosis stage, and viral load of HCV. Definition and Quantification of Liver Fibrosis: When and How? Various studies have demonstrated the rapidity of liver fibrosis progression in HIV/HCV co-infected patients. Such patients, even those presenting little or no fibrosis, should undergo histological evaluation at least every two years. Unfortunately, since it is an invasive procedure, liver biopsy might present complications resulting from technical performance. Pathologist reports are often made difficult by the small size of the liver fragments obtained in the biopsy, which has repercussions for the indication of anti-HCV therapy. Despite the disadvantages of liver biopsy, it remains the principal technique for determining the severity of hepatic injury.
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Oct 29, 2010
Seiji Ishiguro + 5
Open Access