During the 17th International Symposium on Viral Hepatitis and Liver Diseases 2021-Global Hepatitis Summit (ISVHLD & GHS 2021), Professor Jurgen Rockstroh of the University of Bonn, Germany, shared the report on "Overview of Treatment of HCV Infection Among HIV-Positive Patients". Based on the content of this topic, Professor Jurgen Rockstroh was interviewed in Hepatology Digest, specifically as follows.
What are the clinical characteristics of HIV and HCV co-infection? What is the pathogenesis?
Prof. Jurgen Rockstroh: In the setting of having HIV and hepatitis C co-infection, the liver disease takes an unfavorable course. That is strongly associated with the immune deficiency, which is HIV associated. The more the CD4 count drops, the higher becomes the risk of developing relevant liver disease. Fibrosis progression is accelerated particularly with low CD4 counts. That is the reason why in the old days, it was recommended that early treatment for HIV in patients with HIV/HCV co-infection before other patients groups. Nowadays, when everyone should receive HIV treatment anyway, there is no need for prioritization, but the hallmark of co-infection is that there is faster fibrosis progression and such a high risk for liver disease related events and eventually death through liver disease. In the European cohort, that is ten-fold higher than in patients who don’t have HIV. So it is really an unfavorable course of liver disease in the setting of HIV associated immune deficiency.
In the treatment of HIV and HCV infection, how to choose the order of treatment? What is the corresponding treatment strategy?
Prof. Jurgen Rockstroh: Usually when we see a patient who is newly diagnosed with HIV and hepatitis C co-infection, we would first try to stabilize the HIV infection. So we first treat HIV, and then because nowadays we mostly use regimens that are integrase inhibitor based, and complete control of virus replication occurs usually within four weeks or at the latest after three months, we then start with the hepatitis C treatment. You could also argue that you could treat hepatitis C first and then treat HIV, but in general, it seems better to stabilize the HIV infection then commence hepatitis C therapy. Modern hepatitis C therapy is only 8-12 weeks of therapy, so it finishes pretty fast and works very well with >95% cure rate. But in general, that is our procedure.
Please talk about how to treat HIV combined with HCV infection based on recent or latest clinical research? What are the past and existing treatment methods? What are the differences?
Prof. Jurgen Rockstroh: In the setting of HIV and hepatitis C, when you choose your HIV regimen and your HCV regimen, you have to be aware of drug-drug interactions. In particular, hepatitis C protease inhibitors interact with NNRTIs and PIs, which we use for treatment of HIV. Probably the best choice is to start with an integrase inhibitor based regimen for treating HIV, as all non-boosted integrase inhibitors (dolutegravir, bictegravir or raltegravir) do not interfere with hepatitis C drugs. Then, after achieving undetectability, we would then start with hepatitis C therapy, and there you can choose between preferably two different pangenotypic regimens (sofosbuvir/velpatasvir) which can easily be co-administered with the integrase inhibitor based therapy, or GP (glecaprevir-pibrentasvir), which can also be administered depending on baseline cirrhosis or nodes for 8-12 weeks. With that, we have excellent DAA combinations, which are easily combinable. If you have a patient who comes with resistance to certain HCV drugs and you are in a very complex regimen for HIV, then treatment for hepatitis C can become very challenging because of drug-drug interactions. Always make sure you use the Liverpool website for checking drug-drug interactions between hepatitis C and HIV drugs before you start therapy.
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