Management Guidelines for the HCV/HIV Co- Infected Adult
Recommendations of a Multidisciplinary Expert Panel

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Comprehensive Management of the Coinfected Patient

I.a Address substance use issues

In order to ensure optimal management of the viral infections, substance use issues must be addressed preferably first or at least concurrently [66]. This is crucial:

• to maximize the potential for adherence to antiviral treatment and follow-up
• to minimize progression of disease ( e.g. alcohol has been shown to accelerate HCV progression)
• to prevent Hepatitis C reinfection in HCV treatment responders who clear the virus, as previous infection does not confer immunity
• to enable the patient to appreciate the complexity and the commitment to complicated anti-viral treatment regimens and follow-up
• to better prepare the individual to cope with side effects of treatment (e.g. the flu-like symptoms associated with interferon treatment could simulate opiod withdrawal states)
• to minimize the risk of HCV/HIV treatments worsening or destabilizing a concurrent addiction (e.g. the trigger effect of interferon injections or the unmasking or worsening of coexisting depression
• the incidence of which is higher in those with substance dependence)

Recommendations:

Comprehensive addictions assessment for anyone with a history of IDU (IIIA)

Screening for the presence of alcohol disorders (e.g. the C.A.G.E. questions) (IIIA)

Screening of all patients for the presence of mood disorders (IIIA)

Referral to a specialist in addictions where appropriate (IIIA)

Ongoing participation in an addiction treatment program where indicated. The intensity of treatment to be determined by the level of recovery achieved by the individual (IIIA)

I.b Address Alcohol Use

Alcohol use (>50 gm/day) has been demonstrated to accelerate the course of liver disease in patients with HCV infection [33,34].

Recommendations:

Patients with coinfection should abstain from alcohol intake or minimize to <50 gm/day. Abstinence is preferable. Abstinence is essential for those with a history of prior alcohol abuse. One standard drink contains 13.6 grams of alcohol and is equivalent to one bottle (355 ml) beer (5% alcohol), 150 ml (5 ounces) wine (10-12% alcohol) or 90 ml (3 ounces) fortified wine (16-18% alcohol) or 45 ml (1.5 ounces) liquor (40% alcohol). Fifty grams of alcohol is contained in 3.6 standard drinks).(II-3 A)

II.a Assess patient for other hepatic viral infections

Recommendations:

All co-infected patients should be evaluated for infection and immunity to Hepatitis A (Hepatitis A IgG) and Hepatitis B (HBsAg and HBcAb if the HBsAg is negative). Immunize as appropriate with post vaccination monitoring of antibody response (HBsAb), not required for anti-HAV. (IIB)

Discuss risk of transmission of one or both infections. All co-infected patients should be made aware that transmission of hepatitis C from person to person is enhanced by co-infection with HIV. (IIIC)

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