The Dangerous Nexus Between Hepatitis C and HIV
The World Health Organization says a “silent epidemic” of viral hepatitis affects a large part of the world’s population, causing over 1.4 million deaths every year, yet it remains largely unknown or ignored.
It is estimated by the WHO that 240 million people are chronically infected with the hepatitis B virus and more than 185 million people are infected with hepatitis C. These numbers far exceed the number of people living with HIV, estimated at 34 million.
Viral hepatitis co-infection in those living with HIV is now recognized as a major public health problem resulting in increased morbidity and mortality including for those on antiretroviral therapy. Chronic Hepatitis B infection affects 10 percent of HIV sufferers worldwide. By contrast, Hepatitis C affects 20 percent of HIV sufferers, with a majority of them living in low- and middle-income countries.
In countries where intravenous drug use is the biggest risk factor for HIV transmission, as many as 7 out of 10 are co-infected. In countries where sexual behavior is the biggest risk factor for HIV transmission, co-infection is less common, but still a concern, with about 1 in 10 HIV sufferers being co-infected.
Hepatitis C is a blood-borne virus most commonly transmitted through contact with the blood of an infected person, through sharing contaminated needles or drug use equipment and blood transfusion. Less commonly, it is transmitted through sexual contact or through birth to an infected mother. Hepatitis C is a much smaller virus than HIV, so there is a lot of it even in a tiny amount of blood, but unlike HIV, the virus can stay alive on surfaces outside the body for many days. Hepatitis C is 10 times more infectious than HIV.
Experts agree that co-infection makes HIV treatment more complicated. A liver damaged from Hepatitis C may affect HIV medications negatively. Co-infection triples the risk for liver toxicity from HIV medicines. Also, co-infection more than triples the risk for liver disease and liver-related death.
Hepatitis C is hugely complicated, with six different variants with further subdivisions in each genotype. This variability has made it difficult to develop a vaccine that would protect against all strains. However, unlike HIV, Hepatitis C can be cured by treatment. The WHO recommends pegylated and standard interferon in combination with ribavirin.
Persons infected with genotypes 1 and 4 are treated for 48–72 weeks while those infected with genotypes 2 and 3 do not have to have such intensive and long-lasting treatment. The longer treatment durations are recommended for persons co-infected with HIV and those with advanced fibrosis or cirrhosis. Persons with genotype 1 infection and an extended rapid virological response are treated with a shortened course of 24 weeks.
Thus not only the duration of treatment for Hepatitis C for those suffering from HIV is longer, but treatment response is also poorer. Coupled with this is the high cost of treatment (US$ 2,000 in Egypt for 48 weeks), and the high rate of adverse events which require regular monitoring, which prevents most patients from receiving treatment in most low- and middle-income countries.
The field of HCV therapeutics is however evolving rapidly. New oral drugs have the potential to revolutionize treatment, with expected cure rates higher than 90 percent for some genotypes of the disease.
The only deterrent is the prohibitively high price of the drugs, with a 12 week sofosbuvir treatment costing a whopping US$84,000 in the US. At these prices, access in low and middle-income countries is likely to be extremely limited. Moreover the new medicines have yet to be licensed in most countries.
Generic production of drugs for Hepatitis C can reduce the cost drastically, as has happened with anti retrovirals for HIV. A study done at Liverpool University shows that a 12-week course of sofosbuvir as a generic could be as low as $68-$136. But Gourdas Choudhuri, Director and Head of Department of Gastroenterology and Hepatobiliary Sciences at Fortis Healthcare in India, said: “While generics are well established for chemical compounds, where efficacy can be tested, Hepatitis C drugs have to be tested in terms of bio efficacy too, and not just by way of chemical structures. So there will need to be a little more reassurance from companies launching generic interferons about their effectiveness.”
Nonetheless all people living with HIV should be tested for Hepatitis C. A new global resolution endorsed by all 194 member states at the 67th session of WHA in May 2014, has called for enhanced action to improve equitable access to viral hepatitis prevention, diagnosis, and treatment and requested the WHO Secretariat to facilitate access to affordable treatment.
During a press conference at the 19th International AIDS Conference in 2012, Eldred Tellis, Director of the Sankalp Rehabilitation Trust in Mumbai said that, "It makes public health sense to link prevention efforts to HIV programs. Prevention and harm reduction efforts for HIV and Hepatitis C with vulnerable communities should go hand in hand. Unless this is done, HCV infections will rise even though HIV transmission rates reduce, particularly among injecting drug users – the most vulnerable community."
The HIV Program is committed to increase its focus on viral hepatitis and HIV co-infection in 2014–2015. It is hoped that the forthcoming 20th International AIDS Conference in Melbourne will provide renewed impetuous to making timely viral hepatitis diagnosis and treatment affordable and accessible to all those in need of it.