Hepatitis C is a disease of the liver caused by the hepatitis C virus (HCV). Because HCV and HIV are both spread through infected blood (for example, by sharing needles), many people are co-infected with both viruses. Over time, HCV can cause serious liver damage including cirrhosis (scarring), liver cancer, and life-threatening liver failure.

Not everyone who has HCV needs treatment. About 10-25% of people infected with HCV will clear the virus naturally without treatment. The rest will develop chronic, or long-lasting, infection. Even among people with chronic HCV, most will not develop serious liver damage. If such damage does occur, it usually takes 10 years or longer. But research shows that HIV+ people may develop HCV-related liver damage faster than HIV-negative people.

Doctors use a test called a liver biopsy to help decide who needs HCV treatment. In this procedure, a small sample of liver tissue is removed using a hollow needle and examined under a microscope. Though it may cause some temporary discomfort, complications of liver biopsy are rare.

Treatment is usually not recommended for people with little or no liver damage. But doctors may still decide to treat co-infected patients because liver damage can progress more quickly in HIV+ people. Due to the risk of severe side effects, people with very advanced liver disease (decompensated cirrhosis) should only be treated by an experienced liver specialist or in a clinical trial.

Unlike HIV, decisions about HCV treatment are not based on specific viral load levels (amount of HCV in the blood); however, people with undetectable HCV viral load do not need treatment. Treatment decisions are also not based on symptoms alone, since the early stages of liver damage do not always cause symptoms or abnormal lab test results.

Treatment for HCV has improved dramatically in recent years. Today, the standard treatment is a combination of two medications:

• Pegylated interferon (Pegasys or Peg-Intron)
• Ribavirin

Pegylated interferon is a manufactured version of a natural immune system chemical that helps your body fight HCV. It is injected under the skin once weekly. Ribavirin is an antiviral medication that is taken as a pill twice daily.

The length of HCV treatment depends on the type of HCV a person has and whether they are co-infected with HIV. There are several different types of HCV, called genotypes. Genotypes 2 and 3 are easier to treat and treatment usually lasts six months for HIV-negative people. Genotype 1 - the most common in the U.S.- is harder to treat, so treatment usually lasts 12 months for HIV-negative people. Some researchers think longer treatment (an extra six months) may work better for co-infected people.

Genotype 1

• 12 months for HIV-negative people
• 12-18 month for co-infected people

Genotypes 2 and 3

• 6 months for HIV-negative people
• 6-12 months for co-infected people

Unlike HIV, successful treatment can cure HCV. Treatment success is measured in different ways. End-of-treatment virological response means HCV is undetectable in the blood at the end of treatment. Sustained virological response, or SVR, means HCV is still undetectable six months after the end of treatment. After this, the virus rarely comes back, and people are considered cured.

For HIV-negative people, combination treatment with pegylated interferon plus ribavirin cures HCV in about 80% of those with genotype 2 or 3, and about 45% of those with genotype 1. This combination works better than an older form of interferon (known as standard or conventional interferon), or interferon used without ribavirin (monotherapy). Ribavirin seems to help prevent relapse after treatment is completed, but it is not effective without interferon.

The same combination of drugs is used to treat people co-infected with HIV and HCV. However, treatment does not work as well for co-infected people. In one large study, sustained virological response rates were about 60% for genotype 2 or 3 and about 30% for genotype 1.

People receiving HCV treatment should have their liver function tests and HCV viral load levels monitored regularly, since this can show how well treatment is working. If your HCV level has not started to drop by 12 weeks, it is unlikely that the treatment will work, and your doctor will probably advise you to stop taking the drugs.

Certain groups of people tend to respond better to HCV treatment, including:

• Women
• Younger people (under age 40-50)
• Whites (African Americans respond less well)
• People with lower HCV viral load
• People with less advanced liver damage

In addition to getting rid of HCV, successful treatment can also bring lab tests back to normal (called a biochemical response) and improve the health of your liver (called a histological response). Research shows that this can happen even if HCV is not completely cleared from the body. In such cases, doctors sometimes recommend continuing “maintenance therapy” with lower doses of pegylated interferon in the hopes of reducing liver damage.

Sometimes a second round of treatment can lead to a cure even if the first attempt was unsuccessful. This is especially true if the first attempt used the older form of interferon or interferon without ribavirin. Different types of interferon and new drugs that directly attack HCV are currently in clinical trials.

There is some uncertainty about whether to start HIV or HCV treatment first. Effective HIV treatment may reduce the risk of liver damage, so you may be less likely to need HCV treatment. On the other hand, treating HCV first seems to make it easier to tolerate medications for HIV. HCV treatment does not work well and is not recommended for co-infected people with CD4 cell counts below 200.

The decision about which to treat first depends on many individual factors, including HIV viral load, CD4 cell count, and amount of existing liver damage. For this reason, it is important to see a doctor familiar with both diseases whenever possible.

Like most medications, the drugs used to treat HCV can cause side effects. The most common side effects of pegylated interferon include:

• Flu-like symptoms (fever, nausea, muscle aches)
• Depression
• Anxiety or irritability
• Low white blood cell count (neutropenia)

Some doctors think people with pre-existing depression, other mental health conditions, or active substance use should not be treated with interferon because the risk of mental health side effects is higher. But studies show that anti-depressants can help manage or even prevent depression during treatment.

The most serious side effect of ribavirin is anemia, or a reduced number of red blood cells that carry oxygen throughout the body. This side effect can often be managed using a drug called Procrit (erythropoietin or EPO).

Ribavirin can also cause birth defects. Do not take ribavirin if you are pregnant or planning to become pregnant. Women and their male partners must use effective birth control while taking ribavirin. It is important to stop ribavirin at least six months before trying to get pregnant.

Sometimes reducing the doses of pegylated interferon or ribavirin can reduce side effects, but this also makes it less likely that treatment will be successful.

HCV medications can interact with some of the drugs used to treat HIV. Ribavirin should not be used with Videx EC (didanosine or ddI), because the combination can increase the risk of lactic acidosis, a rare but potentially fatal side effect.

While treatment for HCV can be challenging, it may help to know in advance what side effects to expect. Various medications can help manage these side effects. Peer support groups can also help you get through treatment. And remember, unlike HIV therapy, HCV treatment usually lasts no more than 6 to 18 months.

Besides medical treatment, there are steps you can take to keep your liver healthy, including:

• Eating a healthy diet
• Avoiding alcohol and street drugs
• Getting regular moderate exercise
• Getting vaccinated against hepatitis A and B

Some herbs may help your liver, but others can cause serious liver damage. Be sure to tell your doctor about any products you are taking, including over-the-counter or prescription medications, street drugs, herbal remedies, or nutritional supplements.

1		Highleyman, L. (2003). HIV and hepatitis co-infection. San FranciscoAIDS Foundation BETA: Retrieved May 2006 from http://www.sfaf.org/treatment/beta/b52/b52_hiv_hepatitis.html.
2		National Institutes of Health. (2002). NIH Consensus Development Conference Statement: Management of Hepatitis C: Retrieved May 2006 from http://consensus.nih.gov/2002/2002HepatitisC2002116html.htm.
3		Soriano, V., et al. (2004). Care of patients with hepatitis C and HIV co-infection. AIDS, 18(1). 1-12.
4		Torriani F.J., et al. (2004). Peginterferon alfa-2a plus ribavirin for chronic hepatitis C virus infection in HIV-infected patients. New EnglandJournal of Medicine, 351. 438-450.