We read with great interest and enthusiasm the updated American Association for the Study of Liver Diseases practice guidelines, “Diagnosis, Management, and Treatment of Hepatitis C” by Strader et al., who comprehensively reviewed the current status and pointed out areas requiring more studies.1 Unfortunately, a group of hepatitis C patients— those with hepatitis B virus (HBV) coinfection—were not addressed at all. In most countries, hepatitis C patients usually have only one hepatotropic virus infection. However, in areas where HBV infection is endemic, such as Southeast Asia, Far East and southern Europe, the number of subjects infected with both hepatitis C and B is substantial.2, 3 More specifically, antibody to hepatitis C virus (anti-HCV) was present in 7% to 11% of patients with HBV-related chronic liver diseases.2, 3 If the prevalence of anti-HCV positivity is around 1% to 2% in the general population, then the number of HCV/HBV coinfection worldwide will be around 3 million to 7 million among the 350 million HBV carriers. Moreover, the HCV- and HBV-coinfected patients have been shown to carry a significantly higher risk of developing cirrhosis or hepatocellular carcinoma than those with HCV or HBV infection alone.4–6 Therefore, patients dually infected with hepatitis C and B need more attention from the medical profession, and they should be urgently treated with effective regimens. At present, unfortunately, hepatitis C and B coinfected patients are frequently neglected.
Nevertheless, some regimens have been used to treat dual chronic hepatitis C and B. A recent study reported that standard interferon 9 million units thrice weekly for 6 months could clear HCV in 31% of these patients.7 We have treated hepatitis C and B dually infected patients in a pilot study by using standard interferon in combination with ribavirin for 6 months.8 We found that a sustained HCV clearance rate in hepatitis C and B dually infected patients could be achieved to an extent comparable to that in hepatitis C alone. After a follow-up of ≥2 years, HCV RNA remained undetectable in 89% of patients, with sustained clearance of serum HCV RNA 6 months posttreatment. To our surprise, 21% of these patients lose serum hepatitis B surface antigen. We anticipate that the efficacy may be enhanced by pegylated interferon, and therefore we propose using pegylated interferon plus ribavirin to treat the dually infected patients. Accordingly, a multicenter clinical trial is being undertaken at present in Taiwan, and we hope our results can culminate in a better treatment for hepatitis C patients coinfected with HBV.