Considerations for Antiretroviral Use in Patients with Coinfections
Hepatitis C Virus/HIV Coinfection
Last Updated: October 25, 2018; Last Reviewed: October 25, 2018
Panel's Recommendations Regarding Hepatitis C Virus/HIV Coinfection
Panel's Recommendations |
- All people with HIV should be screened for hepatitis C virus (HCV) infection (AIII). Patients at high risk of HCV infection should be screened annually and whenever incident HCV infection is suspected (AIII).
- Antiretroviral therapy (ART) may slow the progression of liver disease by preserving or restoring immune function and reducing HIV-related immune activation and inflammation. For most persons with HCV/HIV coinfection, including those with cirrhosis, the benefits of ART outweigh concerns regarding drug-induced liver injury. Therefore, ART should be initiated in all patients with HCV/HIV coinfection, regardless of CD4 T lymphocyte cell count (AI).
- Initial ART regimens that are recommended for most patients with HCV/HIV coinfection are the same as those recommended for individuals without HCV infection. However, when treatment for both HIV and HCV is indicated, the ART and HCV treatment regimens should be selected with special consideration for potential drug-drug interactions and overlapping toxicities (AIII) (see discussion in the text below and in Table 15).
- All patients with HCV/HIV coinfection should be evaluated for HCV therapy, which includes having their liver fibrosis stage assessed to inform the length of their therapy and subsequent risk of hepatocellular carcinoma and liver disease complications (AIII).
- Persons with chronic HCV/HIV coinfection should be screened for active and prior hepatitis B virus (HBV) infection by testing for the presence of hepatitis B surface antigen (HBsAg) and antibodies to hepatitis B surface (HBsAb) and core (HBcAb; total or IgG). Persons who are not immune to HBV infection (HBsAb negative) should receive anti-HBV vaccination (AIII).
- HBV reactivation has been observed in persons with HBV infection during HCV treatment with direct-acting antivirals (DAAs). Accordingly, persons with HCV/HIV coinfection and active HBV infection (HBsAg positive) should receive ART that includes two agents with anti-HBV activity prior to initiating HCV therapy (AIII).
|
|
Table 15. Concomitant Use of Selected Antiretroviral Drugs and Hepatitis C Virus Direct-Acting Antiviral Drugs for Treatment of Hepatitis C Virus in Adults with HIV
The recommendations in this table for concomitant use of selected HIV drugs with FDA-approved HCV DAA drugs are based on available PK interaction data or are predictions based on the known metabolic pathway of the agents. In some cases, there are not enough data to make any recommendations, and these instances are indicated in the table. In all cases where HIV and HCV drugs are used concomitantly, patients should be closely monitored for HIV and HCV virologic efficacy and potential toxicities. As the field of HCV therapy is rapidly evolving, readers should also refer to the latest drug product labels and the HCV Guidance for updated information.
Note: Interactions with FPV, IDV, NFV, and SQV are not included in this table. Please refer to the FDA product labels for information regarding drug interactions with these HIV PIs.
Table 15. Concomitant Use of Selected Antiretroviral Drugs and Hepatitis C Virus Direct-Acting Antiviral Drugs for Treatment of Hepatitis C Virus in Adults with HIV
Selected HIV Drugs |
HCV Direct-Acting Antiviral Agents |
NS5A Inhibitor |
NS5B Inhibitor |
Coformulated |
|
|
SHOULD NOT BE USED IN THOSE WITH MODERATE TO SEVERE HEPATIC IMPAIRMENT
(Cirrhosis classified as Child Pugh class B or C)
|
NS5A/NS5B Inhibitor |
NS5A/NS5B Inhibitor |
NS5A/NS5B Inhibitor/NS3/4A Protease Inhibitor |
NS5A Inhibitor/NS3/4A Protease Inhibitor |
NS5A Inhibitor/NS3A/4A Protease Inhibitor
|
NS5A Inhibitor/NS3A/4A Protease Inhibitor plus NS5B Inhibitor
|
NS3A/4A Protease Inhibitora |
Daclatasvir |
Sofosbuvir |
Ledipasvir/ Sofosbuvir
|
Sofosbuvir/ Velpatasvir
|
Sofosbuvir/ Velpatasvir/ Voxilaprevir
|
Glecaprevir/ Pibrentasvir
|
Elbasvir/ Grazoprevir
|
Ombitasvir/ Paritaprevir/ Ritonavir plus Dasabuvira
|
Simeprevir |
NRTIs |
3TC |
√ |
√ |
√ |
√ |
√ |
√ |
√ |
√ |
√ |
ABC |
√ |
√ |
√ |
√ |
√ |
√ |
√ |
√ |
√ |
FTC |
√ |
√ |
√ |
√ |
√ |
√ |
√ |
√ |
√ |
TDF |
√ |
√ |
√
Monitor for TDF toxicity. |
√
Monitor for TDF toxicity. |
√
Monitor for TDF toxicity. |
√ |
√ |
√ |
√ |
TAF |
√ |
√ |
√ |
√ |
√ |
√ |
√ |
√ |
√ |
PIs |
Unboosted ATV |
√ |
√ |
√ |
√ |
X |
X |
X |
√b |
X |
ATV/r or ATV/c |
√
↓ DCV dose to 30 mg/day |
√ |
√
If a PI/r or PI/c is used with TDF, ↑ TDF concentrations are expected. If coadministration is necessary, monitor for TDF-associated toxicities.d
|
√
If a PI/r or PI/c is used with TDF, ↑ TDF concentrations are expected. If coadministration is necessary, monitor for TDF-associated toxicities.d
|
X |
X |
X |
√c |
X |
DRV/r or DRV/c |
√ |
√ |
√
If a PI/r is used with TDF, ↑ TDF concentrations. Monitor for TDF-associated toxicities.d Consider monitoring for hepatotoxicity.e
|
X |
X |
X |
X |
LPV/r |
√ |
√ |
X |
X |
X |
X |
X |
TPV/r |
? |
X |
X |
X |
X |
X |
X |
X |
X |
NNRTIs |
DOR |
√ |
√ |
√
If used with TDF, monitor for TDF toxicity.
|
√ |
√ |
√ |
√ |
√ |
√ |
EFV |
√
↑ DCV dose to 90 mg/day
|
√ |
X |
X |
X |
X |
X |
X |
ETR |
√
↑ DCV dose to 90 mg/day
|
√ |
X |
X |
X |
X |
X |
X |
NVP |
√
↑ DCV dose to 90 mg/day
|
√ |
X |
X |
X |
X |
X |
X |
RPV |
√ |
√ |
√ |
√ |
√ |
√ |
X |
√ |
INSTIs |
BIC/TAF/FTC |
√ |
√ |
√ |
√ |
√ |
√ |
√ |
√ |
√ |
DTG |
√ |
√ |
√
If used with TDF, monitor for TDF toxicity.
|
√ |
√ |
√ |
√ |
√ |
√ |
EVG/ c/ TDF/ FTC |
√
↓ DCV dose to 30 mg/day
|
√ |
X |
√
If used with TDF, monitor for TDF toxicity
|
√
If used with TDF, monitor for TDF toxicity. Consider monitoring for hepatotoxicity.e
|
√
If used with TDF, monitor for TDF toxicity. Consider monitoring for hepatotoxicity.f
|
X |
X |
X |
EVG/ c/ TAF/ FTC |
√
↓ DCV dose to 30 mg/day
|
√ |
√ |
√ |
√
Consider monitoring for hepatotoxicity.e |
√
Consider monitoring for hepatotoxicity.f
|
X |
X |
X |
RAL |
√ |
√ |
√ |
√ |
√ |
√ |
√ |
√ |
√ |
CCR5 Antagonist |
MVC |
√ |
√ |
√ |
√ |
√ |
√ |
√ |
X |
√ |
|