First things first: balancing hepatitis C and human immunodeficiency virus.

Persons who are coinfected with HIV and hepatitis C virus (HCV) and their providers face a number of dilemmas. These include understanding how the natural history of each virus is affected by the presence of the other, balancing the risks and benefits of treating each of these viral infections, deciding on the order and timing of treatment, and understanding how medication toxicity may be modified in patients with coinfection. Previous studies have addressed the natural history of HCV in HIV-infected patients, but given the long natural history of HCV infection, many of these studies were conducted before the widespread use of HAART [1, 2]. Several recent studies have suggested that HCV infection is an independent predictor of mortality in HIV infection [3‐5], possibly by impeding immune reconstitution after the initiation of HAART [6]. The article by Tedaldi and colleagues [7] in this issue of Clinical Infectious Diseases addresses whether HCV infection alters the morbidity and mortality associated with HIV infection in a cohort of patients during a period when HAART was available. This study found that there were proportionately more deaths among HIVHCV‐coinfected patients than there were among patients infected with HIV alone. However, when the authors adjusted for age, baseline CD4 cell count, and duration of HAART, HCV infection was not an independent predictor of survival. Several differences between the HIVHCV‐coinfected group and the HIVmonoinfected group were notable. HIVHCV‐coinfected patients were more likely to have injection drug use as their HIV transmission risk (69.7% vs. 5.4% of those with HIV infection alone); to be nonwhite, older, and less educated; and to receive care with use of public funds. HIV-HCV‐