Controversial aspects of HCV transmission, monitoring, care and treatment

Aspects of care that are currently controversial and which may change as new information becomes available.

Sexual transmission

The risk for sexually transmitted hepatitis C is very low in monogamous, HIV-negative heterosexual couples (in which one partner has HCV), but it is higher for HIV-positive gay men. The mechanism involved with sexual transmission among HIV-positve gay men remains unclear.

New hepatitis C infections in HIV-positive gay men.

Safety of light-to-moderate alcohol intake

Heavy alcohol intake is known to cause liver damage in people who do not have hepatitis C. In people with hepatitis C, alcohol intake of over 50 grams/day (equivalent to 4-5 glasses of wine, bottles of beer, or mixed drinks) accelerates liver damage.

A safe amount of alcohol intake has not been determined for people with hepatitis C. Most doctors advise patients with hepatitis C to abstain from alcohol altogether, or to limit their alcohol intake to one drink on special occasions.

Liver biopsy

Some experts require a biopsy before treating HCV, regardless of HIV status or hepatitis C genotype, since they believe that it is the only reliable way to assess the cause and extent of liver scarring and inflammation. Others only consider a liver biopsy necessary for coinfected people with hepatitis C genotype 1, since treatment is not as effective, and if liver damage is mild, treatment can be delayed.

Some doctors realise that liver biopsy is a big barrier for many people, and have begun to rely on less invasive techniques, such as fibroscan and blood testing.

Liver biopsy and the alternatives.

Access to treatment for drinkers

Guidelines recommend abstaining from alcohol, or limiting your intake to an occasional drink during hepatitis C (HCV) therapy.

Many doctors will not treat people who have not stopped drinking, since alcohol may have a negative impact on adherence and HCV treatment outcomes. The expense of HCV treatment may be a factor as well.

On the other hand, because alcohol makes HCV progress more rapidly, drinkers are at greater risk for developing serious liver damage and should be treated for HCV, as guidelines recommend treatment for people at risk for progression to cirrhosis.

Access to treatment for injecting drug users

Treatment for hepatitis C (HCV) is often withheld from injection drug users, despite medical need, willingness to undergo it and treatment guidelines that recommend making decisions on a case-by-case basis.

Doctors may prefer not to treat people who use drugs because of concerns about psychiatric side effects of HCV therapy, adherence, reinfection, treatment outcomes, and the cost of HCV therapy.

But injecting drug users can be, and have been, treated for HCV, despite ongoing drug use. Successful programs for injecting drug users have provided peer support and education groups, demonstration of safer injection techniques, syringes and/or referral to a syringe exchange program, mental health care, and drug treatment, in tandem with HCV treatment.

How long to treat genotypes 2 and 3

In hepatitis C monoinfection, the duration of treatment depends on genotype, and may be tailored according to individual response. People with genotype 2 or 3 are usually treated for up to six months. HIV coinfected people are usually treated for a year, regardless of their HCV genotype, since higher relapse rates have been reported in coinfected people with genotype 2 or 3 who treated for six months vs. a year.

But six months of treatment may be enough for coinfected people with genotype 2 or 3, if they are rapid virological responders, and their ribavirin dose is weight-based.

Retreatment: consensus interferon

In a small study, about 30% of 61 coinfected people who did not have an early virological response to PEG interferon plus ribavirin had a sustained virological response after switching to daily injections of consensus interferon with weight-based ribavirin for 72 weeks.

Although no one discontinued treatment, flu-like symptoms were common, as were low red and white blood cell counts (anemia and neutropenia). More than half needed treatment with a growth factor for anemia, almost half for neutropenia, and approximately fifteen percent needed treatment for both.

However, consensus interferon has not been approved for use in HIV-positive people.

Earlier access to experimental hepatitis C drugs

Hepatitis C (HCV) drugs are currently always only available in trials for HIV-negative people. This reduces the risk that develpment of a promising HCV drug would be stopped due to negative results related to HIV or HIV drugs. However, HIV-positive people are in urgent need of these treatments, and many cannot wait until drugs are first approved in HIV-negative people, and then studied in people with coinfection.

Researchers and companies need to develop early access programes for promising drugs in a similar way that HIV drugs are made available before they are liscensed in named patient programmes and safety studies.