First European recommendations for the treatment of patients co-infected with HIV and HBV/HCV
The following is an edited version of a press release from the European Consensus Conference
The First European Consensus Conference on the Treatment of Chronic Hepatitis B and C in HIV Co-infected Patients, which was held in Paris in March, ended with the adoption of recommendations on treating patients using the best therapeutic protocols available.
The two day conference attracted more than 950 participants and brought together leading European and North American specialists on AIDS and liver disease. On the basis of the presentations, discussion and debate, a jury of ten physicians from eight European countries, presided by Professor Alfredo Alberti from Italy and Professor Nathan Clumeck of Belgium, drew up the recommendations. “Our goal is to ensure that a consistent therapeutic approach is adopted at the European level, and to increase the number of patients who are diagnosed and treated,” said Professor Clumeck. “Today there is too much variation from one country to another. Our recommendations are adapted to the European context, both in terms of the patients and the health care systems.”
Co-infection with HIV and the HCV or HBV is common: more than one quarter of HIV-positive individuals are infected with HCV and nearly 10% with HBV. The increased life expectancy of HIV-positive patients has brought to the fore the problem of hepatitis, a disease that progresses relatively slowly. Cirrhoses and liver cancer due to hepatitis C have become the number one cause of mortality among AIDS patients. For these patients, hepatitis C develops into cirrhosis in five to ten years on average, compared to 30 or so years for the general population.
Such co-infections are especially common in certain high-risk groups, especially IV drug users (in this group, 90% of HIV-positive patients might be infected with HCV or HBV), and among immigrants. Treatment of co-infections is therefore doubly complex: first, because treating two viruses simultaneously requires choosing the right combination of medicines, and second, because patients in the most widely affected groups need particular psychological and social support to help them adhere to the treatment regimen despite the side effects and the constraints of taking pills regularly.
The recommendations concern two main areas:
1. Overall patient care
Routine treatment of the hepatitis C virus should be adopted since today there are drugs that can eliminate the virus in 15 to 60% of patients depending, in particular, on the viral genotype. Treatment for HBV does not eradicate the virus, but can prevent progression toward liver disease. At the European level, only a small minority of patients are treated for hepatitis viruses. Multidisciplinary teams composed of doctors, psychologists, social workers and patients’ organisations must provide support for patients to ensure treatment adherence and observance.
A multidisciplinary approach is also necessary for alcoholic patients, since alcoholism aggravates hepatitis B and C.
Patients infected with HIV but not HCV or HBV should be vaccinated against these viruses. If their immune status is too weakened for vaccination to be effective, the vaccine should be given following the implementation of anti-retroviral treatment for HIV and once the immune defenses have been built up.
Prevention campaigns must be organised to stop the transmission of HCV and HBV, especially through vaccination and with programmes specially targeting IV drug users (to avoid needle sharing, for example), since the prevalence of these viruses is on the rise.
2. Therapeutic protocols
Protocols differ for HCV, which can be eliminated, and for HBV, for which drugs can only slow or stop progression of the disease.
HIV/HCV: Treatment consists of a combination of pegylated interferon and ribavirin. The consensus meeting recommends increasing the dose of ribavirin among patients infected with genotype 1 HCV, which is more resistant to treatment than the other genotypes. After the first three months of treatment, efficacy can be assessed to determine whether or not to continue to the end of the treatment period (48 weeks).
HIV/HBV: Antiviral compounds are effective against both HIV and HBV, but they are complex to administer because both viruses may develop resistance to the drugs. The choice of which combinations to use must be made according to identifiable resistance and the specific biological parameters of each patient.
For patients whose immune system has been significantly depressed (low CD4 counts), antiretroviral treatment for HIV must first enable the CD4 count to rise, before treatment for HCV can begin.
There is a need for further studies to better understand the natural progression of co-infections and to determine exact treatment dosages and durations. Data about infection with HBV and HIV/HBV co-infection is especially lacking. One of the pressing questions that must be addressed is whether or not to continue HBV treatment, perhaps with reduced doses, when the viral response is not very satisfactory, in order to slow progression toward liver disease or the worsening of hepatitis B disease. The members of the jury also recommended that studies to evaluate new drugs currently under development be conducted at an earlier stage among patients co-infected with HIV and hepatitis B and C viruses.
These recommendations are now published in the May 2005 issue of Journal of Hepatology.