Clinical Manual for Management of the HIV-Infected ... - myCME.com

pregnancy. Ribavirin is teratogenic, and both women
and men must use contraception consistently during
treatment with ribavirin and for 6 months after
treatment. IFN may cause fetal growth abnormalities,
and is abortifacient in animals.
Treatment of acute HCV
Treatment of acute HCV is associated with a much
higher response rate than treatment during the chronic
phase. However, delaying therapy for 12 weeks to
ascertain whether spontaneous clearance will occur does
not affect treatment response rates. Treatment with
PEG-IFN monotherapy has been associated with viral
eradication in >90% of patients. Treatment for 24 weeks
appears to be sufficient to clear HCV.
Timing of HCV treatment and HIV treatment
The decision of whether and when to treat HCV
among people infected with HIV must be determined
individually. When coinfected patients require
treatment for both infections, some experts begin with
HIV treatment in hope that by improving CD4 counts,
they may enhance the response to HCV therapy, even
though CD4 cell counts by themselves are not firmly
associated with an increased likelihood of a sustained
virologic response. Other experts choose to treat HCV
before initiating ARV therapy (ART) in those with
high CD4 counts and low HIV viral loads to simplify
treatment and improve the tolerability of ART. Consult
with an HCV treatment expert to determine the
appropriateness and timing of HCV treatment.
Some patients with HCV will experience worsening of
hepatic function during ART, and liver function tests
should be monitored closely. Some ARV medications
are hepatotoxic and should be avoided or used
cautiously; these include nevirapine, tipranavir, and
high-dose ritonavir. Numerous other medications (eg,
fluconazole and isoniazid) are hepatotoxic and can pose
problems for people with impaired liver function.
Other Care Issues
Acute hepatitis A or hepatitis B infection in persons
with chronic HCV can cause fulminant liver disease.
All patients with HCV infection should be tested for
immunity to hepatitis A and hepatitis B; patients who
are not immune should be vaccinated.
Persons with HCV infection should be counseled to
avoid exposure to hepatotoxins, including alcohol and
hepatotoxic medications (eg, acetaminophen in large
doses, fluconazole, and isoniazid). All patients should
Section 6—Disease-Specific Treatment | 6–43
be counseled to reduce the risk of transmitting HCV
to others. As appropriate, patients should be advised to
adopt “safer sex” approaches, avoid blood exposures (eg,
from sharing razors or tattoo equipment), practice safe
drug injection techniques, and avoid pregnancy.
Patient Education
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Most patients with HCV will remain asymptomatic
for several years. However, ongoing injury to the
liver occurs during this time and can culminate
in liver failure. Patients can slow the damage by
avoiding alcohol and any medications (including
over-the-counter drugs and recreational drugs)
that may damage the liver. Patients should contact
their pharmacist or health care provider if they have
questions about a specific medication or supplement.
As with HIV, patients must avoid passing HCV to
others. Instruct patients not to share toothbrushes,
dental appliances, razors, sex toys, tattoo equipment,
injection equipment, or personal care items that may
have blood on them. Emphasize the importance of
safer sex to protect themselves and their partner(s).
Tell patients to discuss HCV with their sex
partner(s), and suggest that partner(s) get tested for
HCV.
Pregnant women have a high risk of transmitting
HIV or HCV infection to the baby because each
virus makes it easier to transmit the other. Women
who are pregnant or considering pregnancy should
talk with a specialist in HIV and HCV to discuss
ways to decrease the infection risk for the baby.
HCV medications (ribavirin and interferon)
should not be given during pregnancy. Both men
and women who are taking ribavirin should use
contraception consistently during ribavirin therapy
and for 6 months after completion of treatment.
If children were born after women were infected
with HCV, consider having them tested as well.
Even though their risk is low, they should be
screened for HCV.
Certain ARV drugs are more likely to cause
problems with the liver because of HCV. Advise
patients that if they start an ARV regimen, their liver
function tests should be watched carefully to be sure
that the body is able to process the medicines.
Patients who not been vaccinated against hepatitis
A need to receive 2 vaccinations 6 months apart.