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Hepatitis C in the HIV-Infected Person

Mark S. Sulkowski, MD; and David L. Thomas, MD
[+] Article and Author Information

From Johns Hopkins University School of Medicine, Baltimore, Maryland.


Grant Support: In part by the National Institute on Injection Drug Abuse (DA-011602, DA-16078, and DA-13806).

Requests for Single Reprints: David L. Thomas, MD, MPH, Division of Infectious Diseases, Johns Hopkins University School of Medicine, 424 Bond Street, Baltimore, MD 21231; e-mail, dthomas@jhmi.edu.

Current Author Addresses: Dr. Sulkowski: Division of Infections Diseases, Johns Hopkins University School of Medicine, 1830 East Monument Street, Room 448, Baltimore, MD 21287-0003.

Dr. Thomas: Division of Infectious Diseases, Johns Hopkins University School of Medicine, 424 Bond Street, Baltimore, MD 21231.


Ann Intern Med. 2003;138(3):197-207. doi:10.7326/0003-4819-138-3-200302040-00012
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Because of shared routes of transmission, hepatitis C virus (HCV) infection is common in HIV-infected persons, who have been experiencing increasing HCV-related morbidity and mortality since the advent of effective antiretroviral therapy. Infection with HIV appears to adversely affect the outcome of hepatitis C, leading to increased viral persistence after acute infection, higher levels of viremia, and accelerated progression of HCV-related liver disease. In addition, hepatitis C may affect the course and management of HIV infection. The medical management of hepatitis C in HIV-infected persons is complicated by immune suppression, potential drug interactions and toxicities, and other forms of liver disease. In addition, there is little published experience with the safety and efficacy of the best available anti-HCV medications in HIV-infected persons. Thus, current efforts must be directed at preventing HCV and HIV infections and applying the principles learned in treating persons with either infection to manage those with both. Future efforts should include studies of the pathogenesis of HCV infection in HIV-infected persons and large, prospective studies that demonstrate the optimal management of persons co-infected with HIV and HCV. Such efforts will help to eliminate HCV-related liver disease as an emerging threat to HIV-infected persons.

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Figure 1.
Prevalence of anti–hepatitis C virus (HCV) in HIV-infected persons receiving medical care in the Johns Hopkins HIV clinic (n= 1955) according to self-reported HIV exposure risk category.
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Figure 2.
Clinical management of antiretroviral-associated hepatotoxicity in the person co-infected with hepatitis C virus (HCV) and HIV.Mycobacterium avium

Clinical management of antiretroviral-associated hepatotoxicity must be individualized. In addition, serious hepatotoxicity has been associated with the use of all available antiretroviral medications; the optimal use of these medications in persons with underlying liver disease has not been established. The long-term impact of mild to moderate elevations in liver enzyme levels on progression of HCV-related fibrosis is unknown, and the effectiveness of anti-HCV therapy for the suppression of drug-related liver toxicity has not been evaluated. *Based on reference 61. †Consider acute hepatitis A and hepatitis B virus infection, other infectious causes of hepatitis (for example, cytomegalovirus, Epstein–Barr virus, complex), acute cholecystitis, ethanol and other illicit drugs, other hepatotoxic medications (for example, fluconazole and trimethoprim–sulfamethoxazole), and nucleoside analogue reverse transcriptase inhibitor–related lactic acidosis syndrome due to mitochondrial toxicity. ‡ Patients with grade 3 or 4 hepatotoxicity and no symptoms of acute hepatitis who do not discontinue antiretroviral therapy should be monitored closely. ALT = alanine aminotransferase; AST = aspartate aminotransferase.

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