Efficacy of treatment of acute hepatiitis C in patients with HIV infection

In a paper in the 13 May edition of AIDS, Stephanie Dominguez and colleagues reported impressive responses to treatment of hepatitis C in a prospective pilot study of 25 consecutive HIV-positive men from two clinic in Paris, with acute HCV infection (documented seroconversion to HCV antibody or positive HCV RNA with negative PCR in previous 6 months). [1]

HCV was diagnosed due to clinical symptoms in 7 patients and following a rise in liver enzyme activity during routine HIV monitoring in 18 men.

At baseline, 23/25 patients were on HAART, with viral load <200 copies/mL: median CD4 count was 345 cells/mm3. Only one patient, with HCV genotype 3, spontaneously cleared HCV by week 12, with all other patients maintaining HCV RNA >50 copies/mL. Median time between acute HCV diagnosis and start of study was 14 weeks.

As four patients declined treatment and one patient was contraindicated for ribavirin therapy, 19/25 were treated with PEN interferon alpha-2a (180ug/week plus 800mg RBV/day) for 6 months, followed by 6 month follow-up.

The study reported sustained virological response (SVR) rates in 10/14 (71%) patients with evaluable data at 24 weeks after the end of HCV treatment. The authors reported that study treatment was well tolerated, with no change in CD4 cell count and concluded early treatment of acute HCV infection with PegIFN alpha-2a and ribavirin for 24 weeks yields a high sustained virological response rate in HIV-infected patients.

Comment

In general, the cohort data for treatment of acute HCV infection in coinfected patients, are still evolving. Data from London (SVR) and Germany (EOT) indicate lower response rates 50-60% SVR, but these are still better than in chronic infection. As in HCV-monoinfection the optimal treatment strategy of PegIFN-monotherapy or PegIFN + RBV (800 mg or 1000-1200 mg) remains an open question.

Given the lower response rate in coinfected patients the role of RBV 1000 1200 mg/d should be assessed. Given the general low number of patients a cooperation of the cohorts for analysing and collecting the data would be a major advantage.

This paper was submitted for publication in November and accepted in January 2006, therefore the results from the full cohort should already be available and will hopefully be presented in Toronto. Nevertheless, these data support the recommendation for early treatment of acute HCV infection from the European Consensus Conference for coinfection last year. [2]

This highlights the clinical importance of diagnosing acute HCV – particularly in the UK where approximately 200 cases of sexual HCV infection has been reported in HIV-positive gay men in London and Brighton over the last few years. Routine HCV testing of gay men associated with higher risk for HCV infection (group sex, shared toys, recreational drug use, fisting, UAI, recent STI) is clearly important.