Professor of Medicine
Medical Director, Viral Hepatitis Center
Divisions of Infectious Diseases and Gastroenterology/Hepatology
Johns Hopkins University School of Medicine
Mark S. Sulkowski, MD, has disclosed that he has received consulting fees from AbbVie, Gilead Sciences, and Merck and has received funds for research support from AbbVie, Gilead Sciences, and Proteus Digital Health.
With the availability of highly effective (and, in some regions, inexpensive) direct-acting antivirals (DAAs), global HCV elimination is a hot topic. However, between 2015 and 2016, only 3 million of the estimated 71 million people infected with HCV were treated, and the world is a big, heterogeneous place. This has prompted many experts to focus on microelimination of HCV in specific populations.
Because persons living with HIV (PLWH) tend to have greater access to HCV diagnosis and treatment services, groups around the globe have targeted this population for microelimination. Reports from 2018 recounted spectacular progress toward this goal, including cohort studies in Switzerland (Swiss HIV Cohort Study) and the Netherlands (ATHENA). Progress has also been made in the United States with high rates of successful HCV treatment in many HIV specialty practices.
Despite these remarkable advances, substantial challenges remain. HCV reinfection can be common after cure among persons who inject drugs and men who have sex with men. In addition, not all PLWH have achieved HIV suppression, and many struggle with ongoing linkage to HIV care. This raises an important question: Should HCV treatment be initiated in coinfected patients who have not achieved HIV suppression?
Based on my experience and clinical data, I can say with confidence that high rates of HCV cure can be achieved in PLWH not receiving antiretroviral therapy (ART). This is true even in persons who may struggle with adherence to ART: HCV treatment is short and finite (unlike HIV treatment), and HCV cure is a powerful motivator.
In fact, in my practice, I have seen PLWH with active HCV infection who were not referred for HCV treatment owing to ongoing challenges with their ART adherence. Despite these concerns, these PLWH were able to achieve HCV cure.
What’s the take-home message for HIV/HCV-coinfected persons who are not particularly adherent to HIV care? My approach is to actively engage these individuals in HCV care aimed at delivering cure, which can help to preserve the liver, can prevent HCV transmission to others, and may serve as a “teachable moment” for other health issues such as inadequately treated HIV infection.
The bottom line: All PLWH who are coinfected with HCV should be offered curative HCV treatment. Using this approach, along with enhanced harm reduction after HCV cure, I am confident that we can eliminate HCV in PLWH.
I invite you to share your thoughts and experiences in the comments box.