Treatment of chronic hepatitis C in HIV-positive individuals: selection of candidates.

Recent evidence suggests that when HCV therapy is administered adequately (full doses of ribavirin, satisfactory drug compliance, and for at least 12 months irrespective of the HCV genotype) and to the appropriate co-infected candidates, treatment responses may be similar to those seen in HCV mono-infected individuals. The best responders are co-infected individuals under 40 years old with HCV genotypes 2 or 3, low HCV viral load, no cirrhosis, elevated ALT levels, elevated CD4 counts, and low or undetectable plasma HIV-RNA. Treatment should be considered in antiretroviral-naïve co-infected patients with stable HIV infection. In patients already on antiretroviral therapy, HCV therapy should only be administered after replacing ddI by another antiretroviral drug. In patients with evidence of advanced liver fibrosis, HCV therapy should be considered as a priority. However, patients with decompensated cirrhosis should not be treated. In patients with CD4 counts < 200 cells/microl and/or plasma HIV-RNA above 100,000 copies/ml, it may be better to consider suppression of HIV replication before beginning HCV therapy. Individuals with a history of severe neuropsychiatric disorders, people who consume a lot of alcohol and those addicted to illegal drugs generally should not be considered suitable for HCV treatment, and efforts should be concentrated on detoxification programmes.