HCV and HIV Coinfection: Decreasing Barriers to an HCV Cure With Use of a Simplified Treatment Algorithm
Hepatitis C virus (HCV) is one of the leading causes of liver-related morbidity and mortality globally, while also being the most reported bloodborne infection in the United States. With the acquisition of HIV and HCV infections sharing common risks for transmission, the incidence of coinfection is not an uncommon finding. Approximately 6.2% of people living with HIV are coinfected with HCV, with the highest rate being observed among people who inject drugs (82.4%), followed by men who have sex with men (MSM) (6.4%) and heterosexually exposed or pregnant individuals (2.4%). When looking at the United States specifically, the CDC estimates approximately 21% of people with HIV are coinfected with HCV, with the highest incidence seen in those who inject drugs, similar to the global data.
Approximately one-third of patients with HCV will have liver disease progress to cirrhosis, with a median time to progression of 20 years. Several risk factors can accelerate the rate of disease progression: older age, male sex assigned at birth, alcohol use, and coinfection with HIV, particularly those with lower CD4 cell counts. In those who develop cirrhosis and are coinfected with HIV, end-stage liver disease and hepatocellular carcinoma occurs at a faster rate compared with those individuals who do not have HIV, regardless of viral suppression status. With the advent of direct-acting antivirals (DAAs), the morbidity and mortality rate of patients coinfected with HCV and HIV has declined.
Current guidelines, including those of the American Association for the Study of Liver Diseases (AASLD)/Infectious Diseases Society of America (IDSA) and Department of Health and Human Services (HHS), recommend all people with HIV be screened initially for HCV. Those at high risk, including people who inject drugs or MSM, should be screened annually due to a higher incidence of coinfection.
People who are HCV- or HIV-positive should be screened for hepatitis B virus (HBV) before initiating HCV treatment, as those who are coinfected with HBV are at risk for HBV reactivation. Those who are not immune to HBV should be vaccinated as soon as possible. For those who are coinfected with HBV, antiretroviral therapy (ART) should include at least 2 agents that are active against HBV.
Over the last 10 to 15 years, treatment for HCV has changed significantly from the use of combination regimens requiring subcutaneous injections of interferon and oral ribavirin to all oral regimens with a sustained virologic response (SVR) of 95%. With the currently available DAAs, people with HCV/HIV coinfection have similar SVRs to those who are HIV-negative. Coinfected individuals should be initiated on ART, with the HHS guidelines recommending any changes to ART be made at least 2 weeks before starting DAAs for HCV.
In 2023, the AASLD/IDSA treatment guidelines were updated to include the addition of the simplified algorithm in treatment-naive individuals with HIV/HCV coinfection.