Should HIV be treated first?

HIV treatment should be started first if the CD4 count is under 200
cells/mm3. Treatment guidelines recommend starting HIV treatment
when the CD4 cell count is <350 cells/mm3. Some experts
recommend initiating HIV treatment even earlier (CD4 cell count is
<500 cells/mm3) in HIV/HCV coinfected people.
There might be some circumstances perhaps when HCV treatment
is likely to be used soon in someone whose CD4 count is already
falling where HIV treatment may be started earlier. So long as
HCV infection is stable, many people especially if they have
been infected with HCV for a long time will treat their HIV first.
Treating HIV may delay HCV disease progression by maintaining
immune health.

Using HCV treatment depends on:

Your willingness and readiness to start HCV treatment, and
The need for treatment if liver disease is mild, HCV treatment
can be delayed; if moderate to serious, HCV treatment is
recommended.
Detailed information about HIV treatment is available from many
different sources. For example, the i-Base Introduction to Combination
Therapy deals with many questions (see Resources and further
information, page 77).
The most important aspects of HIV treatment are just as relevant in
coinfection as in HIV monoinfection, including choice of treatment,
adherence, side effects, and resistance. The main differences in
considering HIV treatment for someone coinfected with HCV relate
to timing and drug toxicity. Some studies have found that coinfected
people have a blunted CD4 cell response to HIV treatment, and
others suggest that starting HIV treatment earlier may slow liver
disease progression. HIV drugs should be carefully chosen, to
reduce or avoid liver toxicity and damage.
Some HIV drugs are less liver-friendly than others, although it is not
clear whether small increases in liver enzymes increase the risk of
clinical disease. Caution is clearly important; ARVs should be
selected carefully and liver enzyme levels monitored regularly.
(For more information, see HIV drugs and HCV infection,
page 61).

When should HCV be treated first?

In someone whose CD4 count is already strong (above 500 cells/mm 3)
there is no need to use HIV treatment before HCV treatment.
The advantage to treating HCV first if you have a strong immune
system is that you can do this without worrying about drug
interactions or increased risk of side effects from two sets of
treatment.

If you clear HCV, it may also reduce the risk of side effects from HIV
drugs when you use them in the future.
If HCV treatment is necessary, it is possible to treat people on a
stable ARV regimen even if their CD4 count is less than 200
cells/mm3. Studies using an older form on interferon suggested that
HCV treatment is less effective for people with low CD4 counts, but
in more recent studies of pegylated interferon plus ribavirin, CD4
cell count does not seem to be a factor in the success of treatment,
although the overall number of people with less than 200 cells/mm 3
was small.