Successful treatment outcome with pegylated interferon (PEG-IFN) and ribavirin (RBV) lessens as the CD4 cell count declines and although ART slows the progression of liver disease it is still faster than in HCV monoinfection. For these reasons, patients LDK378 with HIV and hepatitis C infection with CD4 cell counts <500 cells/μL should start ART. This should be immediate irrespective of whether HCV treatment is planned or not. For patients with CD4 cell counts between 350 and 500 cells/μL, initiation of anti-HCV treatment

should be delayed until after start of ART unless there is an urgent indication for anti-HCV treatment when ART should be commenced as soon as the patient has been stabilized on HCV therapy. Individuals

with a CD4 cell count greater than 500 cells/μL who defer hepatitis C therapy, should be given the option to commence ART. If they opt to defer, they should be monitored closely for HIV or hepatitis C disease progression, including at least an annual assessment of liver fibrosis. selleck compound We recommend if patients are commencing ART, and DAAs are not being considered, standard first-line ART should be commenced (GPP). We recommend when DAAs are to be used there is careful consideration of possible DDIs (1C) and current or archived HIV resistance. All drug interactions should be checked with an expert source (e.g., www.hiv-druginteractions.org). We recommend if boceprevir is to be used, RAL with TDF plus FTC should be the treatment of choice for those with wild-type HIV (1C): pharmacokinetic data would support ETV, RPV and MVC as alternatives. We recommend if telaprevir is to be used either RAL or standard-dose ATV/r should be used (1C): pharmacokinetic data would support ETV, RPV and MVC as alternatives. EFV may be used but the telaprevir dose needs to be increased to 1125 mg tds. We suggest that if ABC is to be used with ribavirin, the ribavirin should be weight-based dose-adjusted (2C). Among patients receiving DAAs for HCV genotype 1 with ART

for wild type HIV, the percentage on a recommended regimen, i.e. RAL with TDF plus FTC with boceprevir; or RAL or boosted ATV with standard dose telaprevir; or EFV with increased dose 1125 mg tds telaprevir. When DAAs are chosen, Lepirudin some restriction on first-line ARV choice exists due to drug–drug interactions. Boceprevir and telaprevir are currently licensed DAAs for the treatment of hepatitis C genotype 1 infection and are substrates and inhibitors of cytochrome P (CYP) 3A4/5 and p-glycoprotein (p-gp), and therefore interact with several ARVs. Boceprevir is also metabolized by aldo-ketoreductase. Choice of available, safe third agents differs with use of boceprevir and telaprevir. From the limited data and drug–drug interaction studies, we recommend that if boceprevir is to be used, RAL with TDF/FTC should represent first-line ART in the presence of wild-type HIV.