Hepatitis C treatment: who, how, when

This section focuses on conventional hepatitis C treatment with the current standard of care, which is a combination of pegylated interferon and ribavirin.

Lifestyle-related choices that help your liver are covered in the section Living with coinfection.

One approach to managing hepatitis C (HCV) is to decide first what your priority is. Clearing the virus is the most important goal for many people but not for everyone. In some cases, treatment may be more likely to improve the condition of your liver than to clear the virus. In other cases, treatment may not be necessary right away, or ever.

For some people, deciding whether to start HCV treatment is an easy decision. For most, it isn't. There are a lot of factors to be considered.

I've heard about what happens in families during HCV treatment, people get so depressed, in such a mental state – the husband or wife will say "I hate you"… because people on interferon are so unbearable… it's not worth it! There’s no guarantee you’ll get rid of HCV, or even get better – but your life can be ruined!

I didn’t care about the liver disease, but I needed to be not infectious. I had all the side effects during treatment … the side effects went away as soon as I finished the treatment and I feel pretty much like my old self now.

Who needs treatment?

Treatment guidelines generally agree about when to treat hepatitis C (HCV), and who to treat.

Regardless of HIV status, for all HIV-positive people this is when the benefits of therapy outweigh the risk. Sometimes treatment is recommended for people with coinfection earlier than HIV-negative people.

Treatment is more effective when given during acute infection, and is often recommended for HIV-positive men who have acquired hepatitis C sexually.
People with mild liver disease do not require treatment right away.
Treatment should be offered to people with moderate liver damage, since they are at risk of progression to cirrhosis.
People with compensated cirrhosis can be treated, but treatment is less likely to be effective, and side effects may be worse. Careful monitoring is needed.
People with decompensated cirrhosis cannot be safely treated for hepatitis C. This is when a liver transplant is the only option.

How is hepatitis C treated?

Hepatitis C treatment is a combination of two drugs, pegylated interferon (PEG interferon) and ribavirin (RBV).

PEG interferon

There are two types of PEG interferon:

alpha-2a (manufactured by Roche, trade name Pegasys). Pegasys is a liquid that comes in one vial and is stored in the refrigerator. Everyone uses the same dose of Pegysys, regardless of their weight.
alpha-2b (manufactured by Schering Plough, trade name PegIntron or ViraferonPeg). PegIntron is a powder that has to be reconstituted with purified water, both of which come in separate vials. PegIntron is dosed by weight.

Different formulations have been studied differently in patients with different severity of disease. They have not been compared directly, and so it is difficult to know whether one may be better than another in different circumstances.

What is pegylated interferon?

Interferon is a man-made version of a chemical made by the human body that works against HCV in two ways. It works directly against the virus. It also stimulates the immune system to fight viruses.

Pegylated means that a small molecule has been attached to interferon to keep it in the body longer. This means you only need to inject once a week, and makes it more effective at treating HCV.

Ribavirin

Ribavirin is a nucleoside analogue, from the same family as many HIV drugs, but it does not work against HIV.

On its own, ribavirin is not effective against hepatitis C. It needs to be used with PEG interferon.

Ribavirin is given as pills or capsules, twice daily. It is usually dosed by body weight and by HCV genotype. Brand names for ribavirin include Copegus, Rebetrol and Ribasphere.

Ribavirin, AZT and ddI

Both AZT and ddI increase the toxicity associated with ribavirin. These HIV drugs should not be used during hepatitis C treatment.

How long is hepatitis C treated for?

In HIV-positive people, treatment for hetatitis C is currently recommended for at least a year, for all genotypes, although recently, researchers have looked at tailoring treatment according to individual response.

Some doctors are treating coinfected people with genotypes 2 and 3 for less time if they have an early response to treatment (see Evaluating response to HCV treatment).

Some doctors treat people with genotype 1 and 4 for longer than a year. In particular, people with HIV/ HCV coinfection may require a longer course of treatment, especially people with genotype 1.