HCV/HIV Co infection [79

• Approximately 25 percent of HIV-infected persons in the Western world have chronic hepatitis C. In the United States, up to 10 percent of those with chronic hepatitis C may be HIV-co infected, an estimate based on the assumptions that there are 2.7 million persons infected with HCV and that approximately 250,000 of those with HIV infection are also infected with HCV
• All HIV-infected persons should be tested for HCV, and all HCV-infected persons with HIV risk factors should be tested for HIV.
• HCV RNA testing should be performed to confirm HCV infection in HIV-infected persons who are positive for anti-HCV, as well as in those who are negative and have evidence of unexplained liver disease.
• Hepatitis C should be treated in the HIV/HCV-coinfected person in whom the likelihood of serious liver disease and a treatment response are judged to outweigh the risk of morbidity from the adverse effects of therapy
• Initial treatment of hepatitis C in most HIV-infected persons is peginterferon alfa plus ribavirin for 48 weeks
• Given the high likelihood of adverse events, HIV/HCV-coinfected patients on HCV treatment should be monitored closely.
• Ribavirin should be used with caution in persons with limited myeloid reserves and in those taking zidovudine and stavudine. When possible, patients receiving ddI should be switched to an equivalent antiretroviral before beginning therapy with ribavirin
• HIV-infected patients with decompensated liver disease may be candidates for orthotopic liver transplantation

OTHER MEDICAL THERAPIES
• Amantadine, which has been studied as monotherapy and in combination with IFN and with IFN and ribavirin. Although amantadine appeared to provide benefit in a few trials in naïve [102] and nonresponder [103] patient cohorts, most RCTs showed no benefit associated with amantadine therapy [104-108]. Therefore, amantadine cannot be recommended as a component of antiviral therapy for chronic hepatitis C.
• IFN beta has properties similar to IFN and therefore has been studied as therapy for HCV infection. Studies of treatment with IFN beta, however, show no advantage over treatment with IFN alfa [109-112]; IFN beta has not been approved for treatment of hepatitis C and cannot be recommended.
• IFN gamma, which has potential antifibrotic effects resulting from inhibition of stellate cell activation and proliferation, has also been evaluated in patients with chronic hepatitis C. Preliminary, promising data notwithstanding [113,114], a recent multicenter RCT failed to confirm an antifibrotic effect of IFN gamma in patients with chronic hepatitis C.
• Similarly, interleukin-10, evaluated in a preliminary, three-month trial, was found to have no antiviral effect [115,116] but possibly an antifibrotic effect [116].
Pregnancy and Hepatitis C
• Women chronically infected with hepatitis C may have an uneventful pregnancy without worsening of liver disease or increased risk of fetal malformations
• Elevated serum alanine aminotransferase level decreased from 56 percent at the beginning of pregnancy to 7 percent by the third trimester, returning to 55 percent six months after delivery
• Vertical transmission of the virus occurs, but appears to be much less efficient than for hepatitis B, occurring in about 5 to 10 percent of infants born to anti-HCV positive women [117].
• The risk of infection is approximately threefold higher in infants born to women co-infected with HCV and HIV [118,119].
• Transmission only occurs from mothers who are HCV-RNA positive (as opposed to those who are anti-HCV positive but HCV-RNA negative); the risk of transmission may, like HIV, be in part related to the level of viremia at the time of birth.
• There is no evidence that breastfeeding is a risk for infection among infants born to HCV-infected women [119]





FOLLOW UP
Follow up for acute Hepatitis C
• See at 1 or 2 weekly intervals until aminotransferase levels are normal (usually 4-12 weeks)
• Follow up after six months for development of chronic hepatitis C
Follow up during treatment
• If patient is on interferon, it is advised that complete blood counts (CBC) be obtained pretreatment and monitored routinely during therapy. Alpha interferon therapy should be discontinued in patients who develop severe decreases in neutrophil (<0.5 × 10 9 /L) or platelet counts (<25 × 10 9 /L).Routine monitoring for adverse effects includes a CBC weekly for the first month then CBC monthly
• Recommend HCV RNA at 12 weeks of therapy.Patients who do not achieve virologic suppression or a 2- log decrease in HCV RNA at 12 weeks may have therapy discontinued, although factors such as degree of fibrosis and tolerability of therapy should be considered.
• Patients should have blood chemistry evaluations 2 weeks after initiation of treatment to assess for potential toxicities.
• Chemistry evaluations and pregnancy tests in women should be done routinely at each follow-up visit and not less often then every 4-6 weeks during treatment.
•
Follow up after treatment
• If persons whose treatment continues through 48 weeks, and whose qualitative measurement of HCV RNA at that time is negative, should be retested for HCV RNA 24 weeks later to document an SVR
• If patient has Hepatitis C genotype 2 or 3, the virologic response should be assessed at 24 weeks (end of treatment) and at 48 weeks to determine whether patients have achieved a sustained virologic response.
Patients not receiving treatment
• Serial HCV viral loads should not be routinely performed for patients who are not receiving antiviral treatment.
• Liver biopsies every 4-5 years may be considered for those patients in whom treatment is deferred because of mild fibrosis (Metavir score <2 or Ishak score <3) if progression of disease affects the decision to treat
Peri natal period

• Infants born to infected mothers should be screened for HCV. Because of the presence of maternal antibodies, children younger than twelve (12) months should only be tested by HCV RNA methods, but children over twelve months can be tested using the anti-HCV EIA test.
• Children positive for either anti-HCV or HCV RNA should be evaluated for the presence or development of liver disease, and children with persistently abnormal ALT’s should be referred to a specialist for medical management.