Lecture: viral coinfection (HIV + HCV/HBV)

Today’s lecture focused on the nuances of treating patients with coinfection, that is, HIV with either HCV or HBV.  First, we discussed HBV.  One treatment tenet is straightforward: no matter the variables involved (ie. viral load) antiviral treatment is indicated.  Tenofovir is a good choice because of its low viral-resistance profile; tenofovir-emtricitabine is another good option. 

While HIV-HBV treatment paradigms are relatively simple and without side effect, HIV-HCV coinfection is more tricky.  One important take home message is that the HCV should be treated aggressively!  This is true even in the cirrhotic patient.  A major rationale is that post-transplant outcomes for HIV-HCV coinfection are poorer than HCV monoinfection.  If renal failure or high MELD score are involved is such cases, transplant should not be pursued.  We learned that at least half of the UNOS regions in the US are not actively transplanting these patients.

If you plan to start a patient on HCV triple therapy, that patient should be maintained on either raltegravir or truvada for the HIV (and recall, interferon has 1-log efficacy against HIV as well).  If you encounter anemia (which is particularly common in the triple therapy setting) dose-reducing ribavirin to 600 mg qd is appropriate, and SVR rates generally do not suffer.  We learned that overall, SVR rates are still very high (>60%) when HIV-HCV coinfection is present.  There is emerging evidence that SVR at 12 weeks is possible in some cases, but this information has not been widely publicized yet.

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