Special considerations in the initiation and management of antiretroviral therapy in individuals coinfected with HIV and hepatitis C.
BACKGROUND
Although hepatitis C (HCV) treatment efficacy has improved in recent years, the majority of HIV/HCV-coinfected individuals may not enjoy the full benefits of these treatments and appropriate HIV management is crucial. Evidence is accumulating regarding the impact of HIV/HCV coinfection on the response to, and safety and tolerability of, antiretroviral therapy (ART) in this population.


METHODS
Computerized, English-language literature searches of MEDLINE and PubMed databases (January 1985 to May 2004) for studies of HIV and HCV infection in humans to examine critically (a) the impact of HCV on the HIV virologic and immunologic response to ART; (b) the safety and tolerability of ART in coinfected individuals; and (c) the relationship between immune suppression and immune restoration on hepatic injury.


RESULTS
Three key messages emerged regarding the use of ART in HIV/HCV-coinfected individuals: (a) although HCV appeared to have no impact on HIV virologic response, the data are equivocal regarding immunologic response; (b) morbidities associated with HCV infection, such as insulin resistance, diabetes, mitochondrial dysfunction, and liver inflammation, are also associated toxicities of ART, and (c) both immune suppression and restoration can contribute to the onset and acceleration of HCV-related liver disease.


CONCLUSIONS
The CD4 cell count threshold for initiating ART in HIV/HCV-coinfected patients may be higher because of the impact of immune suppression and restoration on the onset of HCV-associated liver disease and the possibility of a blunted immune response to ART at lower CD4 cell counts. Further, overlapping morbidity between HCV-related mitochondrial and metabolic disease manifestations and ART toxicities warrant careful attention by clinicians.
Braitstein
Paula
P
British Columbia Center for Excellence in HIV/AIDS, University of British Columbia, Vancouver, Canada. paulab@interchange.ubc.ca
Palepu
Anita
A
Dieterich
Douglas
D
Benhamou
Yves
Y
Montaner
Julio S G
JS
D017088:AIDS-Related Opportunistic Infections / Q000188:drug therapy*; D044966:Anti-Retroviral Agents / Q000009:adverse effects / Q000276:immunology / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods; D018791:CD4 Lymphocyte Count; D002908:Chronic Disease; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology / Q000821:virology; D006526:Hepatitis C / Q000276:immunology*; D006801:Humans; D007108:Immune Tolerance / Q000276:immunology; D008099:Liver / Q000201:enzymology / Q000276:immunology
D044966:Anti-Retroviral Agents