~Written by Kathleen Lee, MPH Epidemiology, Vanderbilt University Medical Center (Contact: kathleen.g.lee@vanderbilt.edu)
One of the primary goals of public health, epidemiology, in particular, is estimating and examining the burden of disease. The burden in a population, however, is usually not just attributable to one illness or one causative agent. Many disease states carry with them the high likelihood of co-infections or opportunistic infections. Human immunodeficiency virus (HIV) and Hepatitis C (HCV) share at least one common route of transmission and often co-infect individuals. There are an estimated 40 million people worldwide who are infected with HIV and about 60-180 million globally are infected with HCV.1 Understanding the disease process as a whole means taking into consideration not only biological aspects of co-infection, but how this co-infection is propagated, or even mitigated, by patients’ behavior as well as their access to care. An all-inclusive and early detection approach to HIV-HCV treatment can help reduce the burden of disease in the affected population, and can help decrease transmission.
Effective interventions should focus on prevention, or at least early detection and treatment. This is not only good for the patient, but also for the health system. Between 2010 and 2019 it was estimated that HCV expenditures would be $10.7 billion.2 As disease progresses, costs increase (more medications, hospitalizations, etc.). Treatment should not only concentrate on drug therapy, but also address risk behaviors. Interventions, such as needle and syringe exchange programs (NSP) and opiate replacement therapy (ORT) are just some options that public health officials can use (and have used effectively) to curb HCV and HIV transmission in the community. Counseling is not a tool that should be overlooked as many of the co-infected population are affected with mental illness, a known risk factor for HIV acquisition.
Both diseases separately represent a serious health concern, especially among injection drug using populations, but HIV-HCV co-infection introduces additional complications in treatment and disease progression of both conditions. Early interventions, especially during the acute phases of both diseases, can lead to better patient outcomes. Early treatment in co-infected individuals who have not yet been on antiretroviral therapy (ART) do better than those on existing ART regimens. The latter should be considered for treatment regimen changes to ensure minimal side effects and maximum adherence. Alcohol use in both HIV and HCV populations is a contributing factor to liver-related morbidity.3 Inclusion of alcohol and drug rehabilitation programs with drug therapy could decrease liver-related morbidity among co-infected patients. This is incredibly important because liver disease is the leading cause of mortality among co-infected individuals.
Comprehensive interventions are useless if they cannot reach the population. Much has to be done to ensure that the delivery of these interventions captures as wide of an audience as possible. This includes having a well-trained staff of health workers and specialists who are able to support and motivate patients, convenient locations and times that are easily accessible for patients, and pricing should be affordable, if free is not an option.3 Many of the individuals taking advantage of such programs are often low-income, marginalized, and stigmatized by society. Giving these individuals the ability to take control of their condition and be aware of the risk behaviors and prevention strategies available for them could allow for better adherence to treatment, and consequently, better medical outcomes. Much like any other infectious disease that disproportionately affects low-income and vulnerable populations, the distribution and availability of resources are of utmost importance.
All of the above would be futile if there are no set standards to test and screen individuals who are most in need of these treatments. The lack of consensus among public health officials and the government regarding standardized screening among high-risk populations may contribute to the ongoing transmission of HIV and HCV, as well as co-infection. Ensuring sustainability of screening and treatment programs requires engagement and cooperation at all levels, from the patient to the care provider, to the community, to researchers, and even outward to national and international governing bodies.
1. Alter MJ. Epidemiology of viral hepatitis and HIV co-infection. J Hepatol. 2006;44, Supplement 1(0): S6-S9.
2. Wong JB, McQuillan GM, McHutchison JG, Poynard T. Estimating future hepatitis C morbidity, mortality, and costs in the United States. Am J Public Health. 2000;90(10): 1562-
3. Viral Hepatitis: Hepatitis C Treatment. US Department of Veterans Affairs. http://www.hepatitis.va.gov/provider/reviews/HCV-treatments.asp. Page updated December 9, 2013. Accessed October 21, 2014.