Hepatitis C Liver Decompensation Remains a Problem for People with HIV Despite Good ART

People with HIV who are coinfected with hepatitis C virus (HCV) continue to have a higher risk for decompensated cirrhosis, or liver failure, even in the era of effective antiretroviral therapy (ART), according to a study published in the March 18 Annals of Internal Medicine. As such, they especially stand to benefit from new interferon-free hepatitis C treatments.

Vincent Lo Re from the University of Pennsylvania and the Philadelphia VA Medical Center and colleagues compared liver disease progression among more than 10,000 HIV/HCV coinfected and HCV monoinfected U.S. veterans receiving combination ART. All had detectable HCV RNA -- indicating current active infection -- and had not been treated for hepatitis C.

The researchers looked at occurrence of liver decompensation -- a potential long-term outcome of liver damage due to viral hepatitis, heavy alcohol use, or other causes -- as indicated by diagnosis of ascites (abdominal fluid accumulation), spontaneous bacterial peritonitis (internal infection), or bleeding esophageal varices (varicose veins).

They found that the incidence of liver decompensation was greater among HIV/HCV coinfected patients compared with HCV monoinfected patients, with rates of 7.4% vs 4.8%, respectively, at 10 years -- a significant difference. Coinfected patients who maintained low or undetectable HIV viral load (>1000 copies/mL) on ART still had higher rates of liver decompensation than monoinfected patients.

"Despite receiving ART, patients coinfected with HIV and HCV had higher rates of hepatic decompensation than HCV monoinfected patients," the researchers concluded. Lo Re suggested that these findings emphasize the urgency of timely hepatitis C treatment for coinfected individuals.

Below is an edited excerpt from a University of Pennsylvania press release describing the research in more detail.

Hepatitis C Remains Major Problem for HIV Patients Despite Antiretroviral Therapy

Patients with HIV and Hepatitis C Had 80 Percent Higher Rates of Serious Liver Disease than Hepatitis C Patients

Philadelphia -- March 17, 2014 -- A new study led by researchers at the Perelman School of Medicine at the University of Pennsylvania has found that the risk of hepatitis C-associated serious liver disease persists in HIV patients otherwise benefitting from antiretroviral therapy (ART) to treat HIV.

It has been suggested that ART slows hepatitis C-associated liver fibrosis; however, whether rates of severe liver complications in patients coinfected with HIV and hepatitis C receiving ART were similar to those with just hepatitis C remained unclear.

The study, published in the March 18 issue of Annals of Internal Medicine, examined electronic medical record data of 4,280 patients infected with both HIV and chronic hepatitis C virus who were receiving ART, and 6,079 hepatitis C-only patients receiving care between 1997 and 2010.

It found that the HIV/hepatitis C coinfected patients had an 80 percent higher rate of decompensated cirrhosis than hepatitis C-only patients. Even when coinfected patients had controlled HIV virus in response to ART, they still had a 60 percent higher rate of serious liver disease compared to those with hepatitis C alone.

"Our results suggest that serious consideration should be given to initiating hepatitis C treatment in patients co-infected with HIV and hepatitis C -- particularly among those with advanced liver fibrosis or cirrhosis -- in order to try to reduce the risk of serious, potentially life-threatening liver complications," said the study’s lead author, Vincent Lo Re III, MD, MSCE, assistant professor of Medicine and Epidemiology in the division of Infectious Diseases and department of Biostatistics and Epidemiology at Penn, and an investigator in the Penn Center for AIDS Research. "By taking action sooner, we may be able to reduce the risk of advanced liver disease in co-infected patients."

This Penn-led study is the largest comparison to date of liver-related complications between antiretroviral-treated HIV/hepatitis C coinfected patients and those with hepatitis C-alone.

Hepatitis C is a treacherous infection of the liver that can remain clinically dormant for years. The U.S. Centers for Disease Control and Prevention has reported that hepatitis C is the leading cause of cirrhosis, liver cancer, and the need for liver transplants in the nation. It is spread through contact with infected blood. Health experts estimate that more Americans die from it each year than HIV. Co-infection with hepatitis C occurs in 20-30 percent of patients with HIV infection, likely due to a shared route of infection.

Liver disease usually occurs in two stages: compensated and decompensated. In the earlier, less severe stage, the liver still can function normally by compensating for the damage. When extensive damage occurs and the liver can no longer function normally, decompensation occurs. The higher rates of serious liver disease found in coinfected patients in the Penn-led study were classified as liver decompensation. 

The authors also found that rates of decompensation were higher for coinfected patients with advanced liver fibrosis, severe anemia, diabetes, and non-black race.

In addition to Dr. Lo Re, other Penn co-authors include Michael J. Kallan, MS; A. Russell Localio, PhD; K. Rajender Reddy, MD; and Jay R. Kostman, MD. Brian L. Strom MD, MPH, formerly Executive Vice Dean for Institutional Affairs at Penn and now Chancellor of Rutgers Biomedical and Health Sciences, also participated in the investigation.

The study was funded primarily by the National Institute of Allergy and Infectious Diseases.

3/21/14

Reference

V Lo Re, MJ Kallan, JP Tate, et al. Hepatic Decompensation in Antiretroviral-Treated Patients Co-Infected With HIV and Hepatitis C Virus Compared With Hepatitis C Virus–Monoinfected Patients: A Cohort Study. Annals of Internal Medicine 160(6):369-379. March 18, 2014.

Other Source

University of Pennsylvania. Penn Study: Hepatitis C Remains Major Problem for HIV Patients Despite Antiretroviral Therapy. Press release. March 17, 2014.