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HCV infection has become more prevalent in the general population and in the HIV-infected population. Overall, approximately 30% of all HIV-positive patients are HCV positive (75, 76). A recent study found a high prevalence of HCV among crystal methamphetamine users (77). Current evidence suggests that in patients treated with combination antiretroviral therapy, HCV infection may not increase HIV replication, but HIV infection appears to increase HCV replication, leading to more patients with coinfection having symptoms and medical illness related to their HCV infection. Studies have also shown that although HCV infection does not significantly change viral load or CD4 parameters in HIV-infected individuals, the survival time of such individuals is shortened (78, 79). Laboratory evidence suggests that HIV may facilitate HCV replication in monocytes, explaining the extrahepatic consequences of HCV in coinfected individuals (80).

Significant rates of HCV are found in patients with psychiatric disorders because of the high lifetime rates of intravenous drug use in the population with severe mental illness (81, 82). Psychiatric disorders are also prevalent in HCV-infected patients, as shown in Figure 1.

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FIGURE 1. Prevalence of DSM-IV-TR Psychiatric Disorders in Patients With Hepatitis C, Compared With U.S. General Population.
Source. Reprinted with permission from Rifai and Rosenstein (83); data from Epidemiologic Catchment Area study (84, 85).
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HIV, HCV, and cognitive impairment

Studies suggest that HCV may be able to replicate in the brain, and HCV has been associated with cognitive impairment independently of hepatic compromise. HCV viral load can be measured in the blood and CSF. HCV can cause cognitive impairment in the absence of systemic illness, elevated liver enzymes, or liver failure, and there appears to be an additive effect of HCV and HIV on cognitive dysfunction (86–88). Several studies have shown HCV infection to be a predictor of impairments in learning, abstraction, and motor skills in the HIV-negative population as well (77, 89, 90). In one study, 46% of HIV-positive/HCV-positive patients met criteria for HIV-associated dementia, as opposed to 10% of HIV-positive/HCV-negative patients; however, 45% of HIV-positive/HCV-negative patients met criteria for minor cognitive-motor disorder, as opposed to 23% of HIV-positive/HCV-positive patients (30). In advanced HCV disease, increasing ammonia levels can also lead to CNS impairment, usually reversible with appropriate treatment (77, 91).

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Management of psychiatric consequences of HCV treatment

Psychiatrists are often asked to evaluate patients who have a current episode or history of mood disorders before the initiation of treatment for HCV. Depression is the most common side effect of interferon treatment with ribavirin for HCV infection. Current evidence of the value of antidepressant treatment in the non-HIV population suggests that antidepressant medication should be continued in those already being treated for depression and should be considered as prophylaxis in those with a prior history of depression (92, 93). A double-blind, randomized, controlled trial of 40 patients with malignant melanoma who received interferon treatment suggested that prophylactic treatment with paroxetine is an effective strategy for minimizing depression induced by interferon (94). A small open-label study suggested citalopram may be effective for depression in patients with HCV infection (95).

FIGURE 1. Prevalence of DSM-IV-TR Psychiatric Disorders in Patients With Hepatitis C, Compared With U.S. General Population.Source. Reprinted with permission from Rifai and Rosenstein (83); data from Epidemiologic Catchment Area study (84, 85).

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