New direct-acting antiviral (DAA) medications are highly effective in curing patients with hepatitis C virus (HCV). But these drugs carry a risk of interactions with antiretroviral therapy (ART) used to control HIV. An update on management of drug interactions in patients coinfected with HIV/HCV is presented in The Journal of the Association of Nurses in AIDS Care (JANAC).
“We have the opportunity to cure all patients with chronic HCV, but drug interactions between ART and DAAs pose a clinical challenge in people living with HIV/HCV infection,” write Laura E. Starbird, PhD, RN, of Columbia University and colleagues from Johns Hopkins University, Baltimore. Their article provides knowledge that registered nurses and nurse practitioners need to “identify, mitigate, and manage” potentially toxic interactions between ART and DAAs.
‘Nurses can lead the way’ in minimizing the impact of ART/DAA interactions
It's a “defining moment” for HCV care, when DAAs can cure HCV infection in 8 to 12 weeks for most patients. But the situation is more complex for the many patients who have both HIV and HCV – it is estimated that one in four people living with HIV are coinfected with HCV.
While several factors can make it difficult for people living with HIV to start and succeed with curative treatment for HCV, a major one is the high potential for interactions between ART and DAAs. In one study, about one-third of patients with HIV/HCV coinfection needed to change their ART to safely start DAA therapy.
But switching ART regimens can be a complex process – sometimes taking several months, it can lead to decreased quality of life, increased HIV symptoms, and delays to HCV therapy. “Therefore, identification of ART/DAA drug interactions, including potential ART modifications to minimize barriers to HCV treatment initiation, are urgently needed to smooth the transition for people living with HIV,” Dr Starbird and coauthors write.
Their article introduces the four classes of DAA medications and the mechanisms of their antiviral effects. The goal of treatment is a sustained virologic response (SVR) 12 weeks after completing DAA treatment: “SVR is considered a cure,” according to the authors. Recent clinical trials of DAAs in HCV/HIV-coinfected patients have reported SVR rates of 93 to 100 percent.
The authors summarize the most recent HCV treatment guidelines by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America. They emphasize that the recommendations are continuously revised to reflect the latest evidence – current guidelines can always be found at www.hcvguidelines.org.
Recommended treatment is the same for patients with HIV/HCV coinfection and those with HCV alone – but close attention is needed to avoid interactions. Dr. Starbird and colleagues summarize the risk of interactions between different DAA and ART medication classes, highlighting combinations with lower and higher rates of interactions.
“Although ART/DAA drug interactions are common, it is important to note that ART switches should be avoided if possible, because modifying ART is associated with lower SVR rates,” Dr. Starbird and coauthors write. Yet there is strong clinical evidence in favor of treating HCV, even when the patient's ART needs to be modified. The authors outline the process for switching ART medications before starting DAA treatment, as well as the options for patients who cannot switch.
“Approaches to identify ART/DAA drug interactions that minimize the impact of switching ART are urgently needed,” Dr. Starbird and colleagues conclude. “Nurses can lead the way in addressing this new and major need.”
The Journal of the Association of Nurses in AIDS Care (JANAC) is a peer-reviewed, international nursing journal that covers the full spectrum of the global HIV epidemic, focusing on prevention, evidence-based care management, interprofessional clinical care, research, advocacy, policy, education, social determinants of health, epidemiology, and program development. JANAC functions according to the highest standards of ethical publishing practices and offers innovative publication options, including Open Access and prepublication article posting, where the journal can post articles before they are published with an issue.
About the Association of Nurses in AIDS Care
Since 1987, the Association of Nurses in AIDS Care (ANAC) has been the leading nursing organization responding to HIV/AIDS. The mission of ANAC is to foster the professional development of nurses and others involved in the delivery of healthcare for persons at risk for, living with, and/or affected by the human immunodeficiency virus (HIV) and its co-morbidities. ANAC promotes the health, welfare and rights of people living with HIV around the world.