Treating HIV/HCV-Coinfected Patients

Summary and Comment |
February 20, 2015

Treating HIV/HCV-Coinfected Patients

  1. Helmut Albrecht, MD

A sofosbuvir/ribavirin combination cured infections with hepatitis C virus genotypes 1 through 4 in 84% to 89% of HIV-coinfected patients.

  1. Helmut Albrecht, MD

Interferon-based regimens have excessive toxicity and decreased efficacy in patients coinfected with HIV and hepatitis C virus (HCV). New direct-acting anti-HCV drugs, including sofosbuvir, have shown efficacy in this setting, but data are limited. Results from the nonrandomized, open-label PHOTON-2 study have just been published.

In this industry-funded, phase III trial, investigators treated 275 HIV/HCV-coinfected adults in seven European countries with daily sofosbuvir and twice-daily weight-adjusted ribavirin. Sustained virologic response rates 12 weeks following therapy were 85%, 88%, 89%, and 84% for participants with genotype 1, 2, 3, or 4 HCV, respectively. Most treatment failures were due to side effects and patient issues unrelated to the drugs' virologic effects.

Comment

This trial — although already outdated, given the availability of ribavirin-free combination regimens — is important. It will lead to changes in the approved indications for sofosbuvir, making it more difficult for payers to deny HIV/HCV-coinfected patients access to therapies that are more expensive but much more effective. It also negates the notion that HIV-infected patients will not respond well to HCV therapies. I now expect HIV-coinfected patients actually to do better than their monoinfected counterparts on interferon-free study regimens. Because HIV-infected patients included in such trials must show good virologic control, they are used to taking pills daily and adhering to sometimes-complex regimens.

Despite these encouraging findings, treatment of coinfected patients will remain challenging. Clinicians need to stay up to date about complex drug interactions. Knowledge gaps, including how best to treat patients with decompensated cirrhosis, persist but will be closed quickly. HIV disproportionally affects socioeconomically disenfranchised populations, and the price of modern HCV regimens is unfortunate at best and inhumane at worst. At this point, there is no scenario that would make me treat HIV-coinfected patients with interferon-containing regimens. As a matter of fact, ribavirin is about to become obsolete as well.

Editor Disclosures at Time of Publication

  • Disclosures for Helmut Albrecht, MD at time of publication Grant / Research support Health Resources and Services Administration

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