HIV AND HCV Co-infection:
Prof. Dr. Med. J. Reichen: Natural history progression
to cirrhosis is more rapid in HCV positive patients co-infected with HIV (6.9)
vs 23.2 years;
(1). Overall survival of HIV positive patients not affected by the
presence of HCV (2,3). However, HCV predisposes to death from liver failure
(3,4). In a more recent study in hemophiliacs co-infection was associated with
a worse outcome (32). HCV infection induces a more rapid progression to AIDS
(5,6, 32). The course of HCV is more aggressive (RR 3) in the presence of
AIDS-defining symptoms (32). Epidemiology Horizontal transmission: HIV much
more likely to be transmitted than HCV (18/164 vs. 2/164) (7,8).
However, sexual transmission more likely in co-infected than in only
HCV-infected (9). Homosexual contacts not a risk factor for HCV transmission
(10). Vertical transmission is more likely by HIV co-infected mothers (11-13);
the converse is also true, i.e. HIV transmission to the fetus is more likely
in doubly infected mothers (14). Only 9 % co-transmission of both viruses to
the child; co-infected children have abnormal transaminases and
thrombocytopenia but progression to AIDS appears to be delayed by the presence
of HCV virus (15).
Breast-feeding is safe even in co-infected mothers (16). Serology Viral
load higher in HIV positive patients (1,17,18,33). Antibody response
diminished in patients with CD4 < 500 (19). Virus variability higher in co-infected
patients (20), but once AIDS develops quasi-species diminish (21). Biopsy
Fibrosis more severe (21; 33); relative risk to have cirrhosis is increased
2.2 fold in co-infected patients (22). Inflammation diminishes when the CD4
count falls below 400 (23). More often cholestatic features with a peculiar
granulocytic cholangitis in co-infected patients (24). Biochemical cholestasis
is a poor prognostic sign (4). Treatment Uncontrolled studies suggest that the
response rate to interferon is similar in HIV positive as in negative patients
(25-27; 33). Viral load < 107 and CD4 count > 500 predictors of
sustained response (26). Some patients exhibit a dramatic fall of CD4 count
during interferon treatment (28).
Treatment of HIV infection with protease inhibitors increases viremia
and cytolysis (29). Tri-therapy not associated with change in HCV virus load
(30). Because of the worse outcome in co-infected patients, HCV has recently
been proposed to be treated as an opportunistic infection (32). Response rates
to interferon in three controlled trials Ref.
HCV + HIV + HCV + HIV
(31) SR 1/12 6/12
(26) CR
SR 26/80
18/26 10/27 9/10 (33) CR SR 17.5 % 11.1 % 26.6 % 12.5 %
Mortality in co-infected patients (32).
