Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Exposed and HIV-Infected Children

The information in the brief version is excerpted directly from the full-text guidelines. The brief version is a compilation of the tables and boxed recommendations.

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Hepatitis C Virus

Last Updated: November 6, 2013; Last Reviewed: November 6, 2013

Panel's Recommendations for Hepatitis C Virus
Panel's Recommendations
  • Testing for hepatitis C virus (HCV) infection should be performed on any child whose mother is known to have the infection (AIII). All HIV-infected adults and adolescents should be tested for HCV infection (AIII).
  • Recommendations for route of delivery and infant feeding for HIV/HCV-coinfected women and their infants are the same as those for HIV-monoinfected women and their infants (AII). 
  • Diagnostic evaluation for HCV infection in the first 18 months of life after HCV exposure: 2 negative HCV RNA tests at or after age 2 months, including one at or after age 12 months, definitively excludes HCV infection (BIII). Two positive HCV RNA results before age 18 months are required for definitive diagnosis of HCV infection (BIII).
  • Diagnosis of HCV infection in the child older than age 18 months: Screen with anti-HCV antibody test and confirm active viral infection with HCV RNA polymerase chain reaction testing (AIII).
  • Adolescents should be counseled to avoid injection drug use; if using drugs, they need HCV (and HIV and HBV testing), and appropriate referral and therapy, including drug treatment. Other exposures, such as through unprotected sex, (commercial) tattooing and body-piercing, represent a much lower risk of transmission but should also be avoided (BIII).
  • All children (regardless of HIV and HCV infection status) should receive standard vaccination with hepatitis A and B vaccines (AIII).
  • Treatment of children aged <3 years who have HCV infection usually is not recommended (BIII).
  • Treatment should be considered for all HIV/HCV-coinfected children aged ≥3 years who have no contraindications to treatment (BIII).
  • A liver biopsy to stage disease is recommended before deciding whether to initiate therapy for chronic HCV genotype 1 infection (BIII). However, some specialists would treat children infected with HCV genotypes 2 or 3 without first obtaining a liver biopsy (BIII).
  • Treatment of HCV-infected children, regardless of HIV status, should include interferon alfa (IFN-α) plus ribavirin combination therapy (AI). Duration of treatment for HIV/HCV-coinfected children should be 48 weeks, regardless of HCV genotype (BIII).
  • Ribavirin and didanosine should not be used together (AIII). 
  • When possible, ribavirin and zidovudine should not be administered simultaneously because both are associated with anemia (BII*).
  • IFN-α therapy is contraindicated for children with decompensated liver disease, substantial cytopenias, renal failure, severe cardiac or neuropsychiatric disorders, and non-HCV-related autoimmune disease (AII*).
  • Use of erythropoietin can be used to manage clinically significant anemia during HCV treatment (AIII).
Rating of Recommendations: A = Strong; B = Moderate; C = Optional
Rating of Evidence: I = One or more randomized trials in children† with clinical outcomes and/or validated endpoints; I* = One or more randomized trials in adults with clinical outcomes and/or validated laboratory endpoints with accompanying data in children† from one or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes; II = One or more well-designed, nonrandomized trials or observational cohort studies in children† with long-term outcomes; II* = One or more well-designed, nonrandomized trials or observational studies in adults with long-term clinical outcomes with accompanying data in children† from one or more similar nonrandomized trials or cohort studies with clinical outcome data; III = Expert opinion

†Studies that include children or children/adolescents, but not studies limited to post-pubertal adolescents

Dosing Recommendations for Prevention and Treatment of Hepatitis C Virus (HCV)
Indication First Choice Alternative Comments/Special Issues
Primary Prophylaxis
 None
 N/A
 N/A
Secondary Prophylaxis
 None N/A N/A
Treatment IFN-α Plus Ribavirin Combination Therapy:
  • Pegylated IFN-α: Peg-IFN 2a 180 µg/1.73 m2 body surface area subcutaneously once per week (maximum dose 180 µg) OR Peg-IFN 2b 60 µg/m2 body surface area once per week 
PLUS
  • Ribavirin (oral) 7.5 mg/kg body weight twice daily (fixed dose by weight recommended):
    •   
    • 25–36 kg: 200 mg a.m. and p.m.
    • >36 to 49 kg: 200 mg a.m. and 400 mg p.m.
    • >49 to 61 kg: 400 mg a.m. and p.m.
    • >61 to 75 kg: 400 mg a.m. and 600 mg p.m. 
    • >75 kg: 600 mg a.m. and p.m.
Treatment Duration: 
  • 48 weeks, regardless of HCV genotype 
 None Optimal duration of treatment for HIV/HCV-coinfected children is unknown and based on recommendations for HIV/HCV-coinfected adults 

Treatment of HCV in children <3 years generally is not recommended. 

Indications for treatment are based on recommendations in HIV/HCV-coinfected adults; because HCV therapy is more likely to be effective in younger patients and in those without advanced disease or immunodeficiency, treatment should be considered for all HIV/HCV-coinfected children aged >3 years in whom there are no contraindications to treatment

For recommendations related to use of telaprevir or boceprevir in adults, including warnings about drug interactions between HCV protease inhibitors and HIV protease inhibitors and other antiretroviral drugs, see Adult OI guidelines.

IRIS may be manifested by dramatic increase in transaminases as CD4 cell counts rise within the first 6–12 weeks of cART. It may be difficult to distinguish between IRIS and drug-induced hepatotoxicity or other causes of hepatitis.

IFN-α is contraindicated in children with decompensated liver disease, significant cytopenias, renal failure, severe cardiac disorders and non-HCV-related autoimmune disease. 

Ribavirin is contraindicated in children with unstable cardiopulmonary disease, severe pre-existing anemia or hemoglobinopathy. 

Didanosine combined with ribavirin may lead to increased mitochondrial toxicities; concomitant use is contraindicated. 

Ribavirin and zidovudine both are associated with anemia, and when possible, should not be administered together 
Key to Acronyms: cART = combined antiretroviral therapy; HCV = hepatitis C virus; IFN = interferon; IRIS = immune reconstitution inflammatory syndrome; Peg-IFN = pegylated interferon; SQ = subcutaneous

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