Hepatitis C in patients with human immunodeficiency virus infection - Diagnosis, natural history, meta-analysis of sexual and vertical transmission, and therapeutic issues

Hepatitis C (HCV) infection occurs in as many as 33% of the patients with h uman immunodeficiency virus (HIV) infection. In view of their improved surv ival, liver disease will become more clinically significant in patients coi nfected with HIV/HCV. Several studies in patients with hemophilia have show n that coinfected patients develop earlier and more severe liver disease, i ncluding hepatocellular carcinoma. In nonhemophilic cohorts, lower CD4 coun ts are associated with an increased prevalence of cirrhosis. However, HCV i nfection does not seem to alter the natural history of HIV infection in mos t cases. Human immunodeficiency virus coinfection in pregnant women increas es the risk of perinatal HCV transmission 2-fold, with more than 25% of occ urrences involving transmission of both viruses: cesarean delivery signific antly decreases this risk. The expanded use of highly active antiretroviral therapy may lead to further improvement in morbidity and mortality from HI V infection. Thus, the management of coexistent HCV liver disease will need to be formulated. We suggest that alcohol be disallowed. Interferon and ri bavirin in combination are likely to become the therapy of choice, particul arly in coinfected patients with higher CD4 counts, lower HCV viremia, and non-1 genotype. During treatment, complete blood cell counts need to be clo sely monitored. Future controlled trials will determine the efficacy and sa fety of long-acting interferon preparations. Administration of highly activ e antiretroviral therapy, with the intent to prevent decreases in CD4 count s, seems crucial in stemming liver disease progression. However, some drugs have clear-cut hepatotoxic potential and patients with known liver disease should be closely monitored.