be associated with replication of the virus in the brain; however, the causal link between these manifestations and chronic HCV infection is not certain.
66
Natural history of HIVHCV coinfection
Coinfection with HIV adversely affects the course of HCV infection, and coinfected persons have a signiicantly accelerated progression of liver disease to cirrhosis,
decompensated liver cirrhosis and HCC than HCV-monoinfected persons, particularly those with advanced immunodeiciency CD4 count 200 cellsmm
3
.
67-70
In high-income countries, death due to HCV-associated liver disease has become a leading cause of death in people living with HIV in the era of combination ART,
45,71,72
accounting for around 47 of deaths in one series from the United States. It remains unclear whether HCV infection accelerates HIV disease progression, as
determined by AIDS-related events or death.
73
Two large European cohorts have shown that after ART initiation, CD4 recovery was impaired in HIVHCV-coinfected
persons when compared to those infected with HIV alone. HIVHCV-coinfected persons also demonstrated more rapid HIV disease progression compared
to those who were HIV-infected alone, and had an impaired recovery of CD4 cells. However, other studies have shown no such differences in response.
73-77
Assessment of the impact of HCV infection on HIV disease progression may be confounded by the negative health consequences of injecting drug use, which is
strongly linked to HCV infection.
78,79
In persons with HIV infection, HCC tends to occur at a younger age and within a shorter time period.
80
2.4 Prevention of HCV infection
In the absence of a vaccine for hepatitis C, prevention of HCV infection depends upon reducing the risk of exposure to the virus. This is challenging because of
the various routes of transmission and the different populations that are affected. Globally, most HCV infections occur in health-care settings as a result of inadequate
infection control procedures, for example, the reuse of injection equipment. HCV infections in health-care settings also occur through the transfusion of blood that
has not been screened for HCV antibodies. WHO has published guidelines with recommendations to prevent health-care associated HCV infection Table 2.3.
PWID are at great risk of HCV infection through the use of contaminated injection equipment as well as non-injection drug use. WHO, United Nations Ofice on
Drugs and Crime UNODC, and the Joint United Nations Programme on HIV AIDS UNAIDS have developed a set of nine core interventions for the prevention,
care and treatment of HIV infection among PWID Table 2.4. These interventions are also relevant for the prevention and management of viral hepatitis in this
population. In addition, WHO has developed guidelines with recommendations for preventing transmission of viral hepatitis among PWID Table 2.5.
TABLE 2.3
WHO guidance on prevention of HCV infection in health-care settings
TABLE 2.4 WHOUNODCUNAIDS comprehensive package of interventions for HIV
prevention treatment and care in PWID
Focus of guidance documents:
• Hand hygiene: including surgical hand preparation, hand washing and use of gloves
• Safe handling and disposal of sharps and waste
• Safe cleaning of equipment
• Testing of donated blood
• Improved access to safe blood
• Training of health personnel
References
WHO guidelines on hand hygiene in health care. Geneva: World Health Organization; 2009. http: whqlibdoc.who.intpublications20099789241597906_eng.pdf, accessed 20 January 2014.
Safe abortion: technical and policy guidance for health systems. Second edition. Geneva: World Health Organization; 2012. http:apps.who.intirisbitstream106657091419789241548434_
eng.pdf, accessed 20 January 2014. Universal access to safe blood transfusion. Geneva: World Health Organization; 2008. http:www.
who.intbloodsafetypublicationsUniversalAccesstoSafeBT.pdf, accessed 20 January 2014. Blood donor selection: guidelines on assessing donor suitability for blood donation. Geneva: World
Health Organization; 2012. http:www.who.intbloodsafetypublicationsbts_guideline_donor_ suitabilityenindex.html 2012, accessed 20 January 2014.
WHO guidelines on drawing blood: best practices in phlebotomy. Geneva: World Health Organization; 2010. http:www.who.intinjection_safetysigndrawing_blood_bestenindex.html,
accessed 20 January 2014.
Interventions
1. Needle and syringe programmes including other drug-using paraphernalia 2. Opioid substitution therapy and other drug dependence treatment
3. HIV testing and counselling 4. Antiretroviral therapy
5. Prevention and treatment of sexually transmitted infections 6. Condom programmes for people who inject drugs and their sexual partners
7. Targeted information, education and communication for people who inject drugs and
their sexual partners 8. Vaccination, diagnosis and treatment of viral hepatitis
9. Prevention, diagnosis and treatment of tuberculosis.
References
WHO, UNODC, UNAIDS. Technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users. 2012 Revision. Geneva: World Health
Organization; 2012. http:www.drugsandalcohol.ie191901IDU-Technical_Guide_2012_ Revision.pdf accessed 30 January 2014.
TABLE 2.5 WHO recommendations for prevention of HCV infection among people who
inject drugs, in addition to interventions described in Table 2.4
TABLE 2.6
WHO guidance on prevention of sexual transmission of HCV infection
Recommendations
• Offer people who inject drugs the rapid hepatitis B vaccination regimen.
• Offer people who inject drugs incentives to increase uptake and completion of the hepatitis
B vaccination schedule. •
Implement sterile needle and syringe programmes that also provide low dead-space syringes for distribution to people who inject drugs.
• Offer peer interventions to people who inject drugs to reduce the incidence of viral hepatitis.
• Offer opioid substitution therapy to treat opioid dependence; reduce HCV risk behaviour and
transmission through injecting drug use; and increase adherence to HCV treatment. •
Integrate treatment of opioid dependence with medical services for hepatitis.
References
Guidance on prevention of viral hepatitis B and C among people who inject drugs. Geneva: World Health Organization; 2012. http:apps.who.intirisbitstream106657535719789241504041_
eng.pdf, accessed 20 January 2014. WHO guidelines for the psychosocially assisted pharmacological treatment of opioid dependence.
Geneva: World Health Organization; 2009. http:www.who.intsubstance_abusepublications opioid_dependence_guidelines.pdf, accessed 20 January 2014.
Focus of guidance documents:
• Promotion of correct and consistent condom use
• Routine screening of sex workers in high-prevalence settings
• Integrated action to eliminate discrimination and gender violence and to increase access to
medical and social services for vulnerable persons
References
Prevention and treatment of HIV and other sexually transmitted infections for sex workers in low- and middle-income countries: recommendations for a public health approach. Geneva: World Health
Organization; 2012. http:apps.who.intirisbitstream106657774519789241504744_eng.pdf, accessed 20 January 2014.
Prevention and treatment of HIV and other sexually transmitted infections among men who have sex with men and transgender people. Geneva: World Health Organization, Department of HIVAIDS;
2011. http:www.who.inthivpubguidelinesmsm_guidelines2011en, accessed 20 January 2014. The risk of sexual transmission of HCV varies depending on the type of exposure.
The risk is lowest among heterosexual couples and highest among MSM with HIV coinfection. Existing guidelines for prevention of HCV infection through
sexual exposure are listed in Table 2.6.
Prevention of mother-to-child transmission of HCV is dificult as there are no proven interventions to reduce this risk. Neither mode of delivery nor
breastfeeding are reliably linked with transmission. The development of effective drugs against HCV that can be given safely during pregnancy might be a future
option.
2.5 Screening for HCV infection
