In the U.S., approximately 1.1 million people are living
with human immunodeficiency virus (HIV) infection.
An estimated 25% of those infected with HIV are coinfected with hepatitis C virus (HCV).1 In 2008, there were
147,352 veterans with chronic HCV enrolled in Veterans
Health Administration (VHA) care. More than 5800 were
also identified as being HIV positive.2
HCV is one of the most important causes of chronic
liver disease in the U.S. HCV progresses more rapidly to
liver damage in HIV-infected persons.3 HIV/HCV coinfection more than triples the risk for liver disease, liver failure, and liver-related death compared to HCV infection
alone.4 Several national guidelines, including the VHA’s,
recommend that all HCV-infected patients be tested for
HIV.5 Current national guidelines also recommend that
all HIV-infected persons be screened for HCV infection.6
Those who test positive for HCV should receive further
medical evaluation to determine if they have chronic infection and liver disease; if so, they should be offered
education, risk reduction strategy counseling, and consideration for anti-HCV therapy.
The treatment of HIV/HCV coinfection presents complex and evolving challenges. Many coinfected patients
use illicit drugs and alcohol. They may have complicated
medical, social, and psychiatric issues. This article will review the distinctive challenges that face federal health
care workers who attend to patients who are HIV/HCV
coinfected, including current recommendations for care
and new approaches in medical management.
HEPATITIS C VIRUS
Hepatitis C virus is a single-stranded RNA virus that
is transmitted by percutaneous exposure to blood or
blood products (usually via injection drug use), through
sexual intercourse, and from mother to infants. At least
6 distinct HCV genotypes (genotypes 1-6) and more than
50 subtypes have been described. Genotype 1 is the most
common HCV genotype in the U.S. and is the most diffi-
cult to treat.
Approximately 75% to 85% of acute HCV infections result in chronic persistence. In HCV-infected individuals,
60% to 70% will develop chronic liver disease, 5% to 20%
eventually develop cirrhosis, and 1% to 5% die from either
cirrhosis or hepatocellular carcinoma (HCC). The timeline
for developing chronic complications of HCV infection is
accelerated when the individual is coinfected with HIV.
EPIDEMIOLOGY IN THE VHA AND MILITARY
The Centers for Disease Control and Prevention (CDC)
estimate that approximately 3.2 million individuals in
the U.S. are currently infected with HCV. The VHA is the
single largest HCV care provider in the U.S., with a sero-prevalence rate of 5.4%—3 times the national average—
and over 170,000 veterans with confirmed chronic HCV.2
Chronic viral hepatitis is a major public health problem
in the VHA because of the number of chronically infected
individuals and the potential for progression to cirrhosis,
HCC, and other life-threatening conditions.
HCV infection among active military forces is lower
than in the VHA and the general civilian population, with
a reported overall prevalence of 0.48% in 1997.7 From
2000 to 2011, there were 808 incident cases of acute and
2738 incident cases of chronic HCV infection among active component members of the U.S. Armed Forces. The
crude overall incidence rate for chronic HCV infection
was 17.48 per 100,000 person-years, with the highest
rates in the over-40 years age group.8
Current data indicate that over 1000 active duty and
reserve military members are infected with HIV.9 Some
HIV and Hepatitis C Coinfection
COL Susan L. Fraser MD, USA; and Urvi H. Patel, PharmD
Chronic HCV infection is a major cause of morbidity and mortality in HIV-infected
patients. This article reviews the therapeutic challenges facing VA health care
providers who attend to patients with HIV/HCV coinfection and discusses current
recommendations for care and new approaches to medical management.
COL Fraser is the chief of Infectious Diseases and Dr. Patel is Infectious Diseases and
Critical Care pharmacist, both at Fort Belvoir Community Hospital, Fort Belvoir, Virginia.