Background:  Early treatment of acute hepatitis C virus (HCV) has shortened treatment duration. We hypothesized that regimens adjusted for virologic kinetic response would achieve favorable outcomes in HIV⁺ patients.

Methods:  We studied HIV⁺ patients with acute HCV infection of <6 months duration. Acute HCV was defined as detectable HCV RNA, plus one of the following:  current positive HCV antibody test with negative HCV antibody test <6 months prior; or all of the following: ALT >5-times the upper limits of normal within 6 months and normal ALT within the prior year; and current positive HCV antibody test with most recent HCV antibody test negative at any time in the past; and other causes of acute hepatitis excluded. Patients who did not have spontaneous clearance of HCV infection within 12 weeks were treated with pegylated (PEG) and weight-based ribavirin (RBV). Treatment duration was 24 weeks. RBV was stopped at week 12 in patients who had undetectable HCV RNA, both at week 8 and week 12. PEG was continued for 24 weeks in all patients. HCV viral kinetics were determined by RNA measurements at week 4 (rapid virologic response, RVR), week 12 (early virologic response, EVR), week 24 (end of treatment response, ETR) and 24 weeks after treatment completion (sustained virologic response, SVR).

Results:  Between May 2006 and August 2009, 54 HIV⁺ men were identified with acute HCV infection (38 in San Francisco; 16 in New York). Risk factors for HCV acquisition included men having sex with men (MSM) in 44; injection drug use (IDU) in 3; intranasal drug use in 1; and both MSM and IDU or intranasal drug use in 6; 13 (24%) patients spontaneously cleared HCV infection; 18 declined or were inappropriate for treatment; 2 were treated off protocol; 21 patients (20 HCV genotype 1 and 1 genotype 2) initiated protocol treatment. HCV RNA responses are indicated in the table. Discontinuation of RBV at week 12 did not result in virologic relapse in any patient with RVR. No patient without RVR achieved SVR. G-CSF and epoetin-a were required in 8 and 4 patients. Dose reduction of PEG occurred in 5 patients and RBV in 3. Two patients stopped treatment prematurely due to side effects.

*Includes treatment failures before week 48

Conclusions:  In HIV⁺ patients treated for acute HCV, a tailored, abbreviated course of PEG (24 weeks) plus RBV (12 weeks) achieved SVR in patients with RVR. In patients with slow HCV clearance, longer therapy may be of benefit and requires further study.