Treatment of Hepatitis C in People Living with HIV

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What Is Hepatitis C?

Hepatitis C is a disease of the liver caused by the hepatitis C virus (HCV). Over time, HCV can cause serious liver damage including fibrosis (scarring), liver cancer, and life-threatening liver failure (cirrhosis). For more information on HCV, including how it is spread, tests for HCV, and co-infection with HIV and HCV, see our fact sheet on Hepatitis C.

Treatment of HCV/HIV Co-Infection

Treatment options for those living with both HIV and HCV have improved a great deal in recent years, and there are several promising new drugs. These new drugs are often referred to as direct-acting antivirals, or DAAs.

In the past, the standard treatment was a combination of pegylated interferon plus ribavirin. Both interferon and ribavirin can cause serious side effects, and together have not always been very successful in getting rid of HCV in the body. As a result, many people have not used this form of treatment, or stopped taking it due to side effects.

For a list of medications used to treat hepatitis C, please look here.

Direct-acting antivirals

Many new direct-acting antivirals, or DAAs, are now available to treat HCV. DAAs work in much the same way as HIV drugs – they disrupt the ability of the hepatitis C virus to multiply in the body. There are several classes of DAAs defined by where and how they act to stop HCV from multiplying.  

Each DAA works differently against each of the six different genetic types (called genotypes) of HCV that exist worldwide. Because different genotypes respond differently to different treatments, it is important to have a genotype test before you begin treatment.

The good news is that DAAs tend to have fewer and less serious side effects are generally more effective than the older interferon-based treatment. DAA success rates in real-world settings are often over 90 percent (depending on genotype, existing liver damage, etc.). The course of treatment with the newer drugs is also shorter, often only 12 weeks. It is important to note that some people may need to take HCV treatment, including DAAs, for longer than 12 weeks to be successfully cured of hepatitis C.

Which HCV treatment is right for you will be based on several factors, including: 

  • Your HCV genotype
  • The health of your liver, including how much scarring (fibrosis) it has
  • Your overall health, including any other medical conditions you may have
  • Which HIV drugs you are taking (as some HCV drugs interact with HIV drugs)
  • Which side effects you may experience from the HCV drugs and how your body is likely to handle them
  • If you have taken HCV treatment before and which medications were used
  • Which medicines are covered through your insurance

The major barrier for many people is the cost of hepatitis C treatment with many of the newer DAAs. Prices are falling, but these drugs are still expensive. Treatment may or may not be covered by your insurance or national health plan. Some people have chosen to get their HCV drugs from a buyers club to avoid the high costs. 

Interferon and ribavirin

In the past, the standard basis of treatment was a combination of two medications:

  • Pegylated interferon (Pegasys or Peg-Intron), taken by injection (shot)
  • Ribavirin (Rebetol, Copegus), a pill taken by mouth

This combination is no longer used regularly due to the availability of newer DAAs, which are generally safer, more effective, and easier to take.

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 with a drug called Procrit or Epogen (erythropoietin or EPO). It is very important to speak to your health care provider about any side effects you are experiencing so they can help you manage them properly.

Ribavirin can also cause serious birth defects. Do not take ribavirin if you are pregnant or planning to become pregnant, and stop taking ribavirin at least six months before becoming pregnant. Women and their male partners must use effective birth control while taking ribavirin. Many providers recommend that women use two forms of birth control to prevent pregnancy while taking ribavirin. Additionally, men taking ribavirin who have female partners are encouraged to use two forms of birth control since sperm exposed to ribavirin can cause birth defects.

Because several of the newer HCV drugs are given in combination with ribavirin to treat people living with HIV and HCV, the recommendations for use of any of these new drugs in pregnant women or women planning to become pregnant are the same as for taking ribavirin: do not take them if you are pregnant or planning to become pregnant, and stop taking them at least six months before becoming pregnant. 

Treatment guidelines

Various guidelines around the world now recommend that people who are vulnerable to getting HCV (such as people who inject drugs) be offered an HCV test; that everyone living with HCV be treated – preferably with DAAs – regardless of the liver damage they have suffered; and that people living with both HIV and HCV be treated for their HCV with the same drugs taken by people who are only living with HCV.

How Effective Is Treatment?

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 three months after the end of treatment. After this, the virus rarely comes back, and people are considered cured.

It is important that people receiving HCV treatment have their liver enzymes tested 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 after 12 weeks of treatment, it is unlikely that the treatment is working, and your health care provider will probably advise you to stop taking the drugs. 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 an older combination of HCV drugs. The newer drugs are significantly more effective.

For people living with both HIV and HCV, research has also shown that adhering to HCV treatment predicts the best chance of SVR, or curing HCV. Adherence to HIV drugs is very important in keeping viral loads low, avoiding resistance, and maintaining good immune system health. We now know that adherence to HCV drugs is similarly important for the successful treatment and cure of hepatitis C. 

Which to Treat First?

People living with both HIV and HCV face some special treatment issues. Basically, significant liver damage makes it harder to tolerate HIV drugs. At the same time, some HIV drugs can cause liver issues. Therefore, there is some debate about whether to start HIV or HCV treatment first. Generally, the benefits of being on HIV treatment outweigh concerns about liver injury from HIV drugs.

Recent research shows that waiting to treat HCV until a person has serious liver disease decreases the effectiveness of treatment, and leads to poor health outcomes and higher likelihood of death. Moreover, we now know that people living with HIV are more likely to develop HCV-related liver damage and develop it faster than people not living with HIV. Waiting to start HCV treatment has been shown to risk liver damage, including death, even after HCV is cured. The longer you wait, the worse the outcome.

The current HIV treatment guidelines published by the US Department of Health and Human Services (DHHS) recommend that antiretroviral therapy for HIV be given to all co-infected people, regardless of CD4 count. However, since HCV treatment does not work well for co-infected people with CD4 cell counts below 200, HCV treatment is not recommended until their CD4 counts increase. For co-infected people who have never received HIV treatment and who have CD4 counts above 500, their health care providers may recommend delaying the start of HIV treatment until they have successfully completed HCV treatment.  

The decision about which to treat first depends on many individual factors, including HIV viral load, CD4 cell count, and degree of existing liver damage. For this reason, it is important to see a health care provider familiar with both diseases whenever possible. As newer, improved HCV drugs are approved, barriers to treating HCV in the presence of HIV will drop as the benefits outweigh the risks for more and more people.

Taking Care of Yourself

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

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

Additional Resources

Select the links below for additional material related to treatment for Hepatitis C.
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