Many HIV-HCV Coinfected Patients Are Not Evaluated for Hepatitis C Management

By Liz Highleyman

Many factors influence decisions about whether to start treatment for chronic hepatitis C virus (HCV) infection, including extent of liver disease, co-existing medical and mental health conditions, and the likelihood of good adherence to therapy.

Due to overlapping routes of transmission, many individuals are coinfected with both HCV and HIV. The coinfection rate is particularly high among injection drug users, who are often infected with both viruses through sharing contaminated injection equipment.

Because they are perceived as being unsuitable candidates, many coinfected individuals do not receive timely evaluation for hepatitis C treatment ranging from interferon-based therapy to liver transplantation. However, numerous studies have shown that many coinfected patients can achieve sustained virological response to pegylated interferon plus ribavirin, albeit at a somewhat lower rate than HCV monoinfected individuals.

In a study presented at the Digestive Disease Week (DDW) 2008 conference this week in San Diego, researchers evaluated factors that influenced referral of HIV-HCV coinfected patients for liver disease management at a Southern California HIV/AIDS tertiary care center.

The analysis included 538 consecutive coinfected patients seen at the HIV clinic between January 2003 and December 2006. Most (82%) were men, the mean age was 46 years, 51% were Caucasian, 25% were Hispanic, 20% were African American, and 4% were of another race/ethnicity.

The mean CD4 count was 396 cells/mm3 and the median HIV viral load was 400 copies/mL (range 0-1,160,000). The median HCV viral load was 700,000 IU/mL. The mean AST and ALT levels were 88 and 114 IU/L, respectively.

Factors potentially associated with non-adherence to clinic visits were analyzed in the categories of demographics, medical factors, psychosocial factors, and lifestyle factors.

Results

• 308 coinfected patients (57.1%) were referred to the liver clinic for HCV evaluation by their HIV care provider.

• Despite referral, 84 patients (27%) did not attend their liver clinic appointment (Group A), while 224 patients (73%) attended the liver clinic at least once (Group B).

• There were no statistically significant differences between the 2 groups with regard to demographics, except for age, with patients in Group A being significantly younger (43 vs 46 years, respectively; P < 0.01).

• Potential factors related to liver clinic non-attendance that were significantly different between Group A and Group B included:

• Current alcohol use (23% vs 12%; P = 0.02);

• Current crystal methamphetamine use (36% vs 17%; P < 0.01);

• Non-adherence to HIV medication and/or HIV clinic visits (23% vs 9%; P < 0.01);

• History of incarceration (31% vs 13%; P < 0.01).

• Patients with depression or anxiety were not deterred from pursuing liver disease evaluation (46% of Group A vs 59% of Group B).

Conclusion

Based on these findings, the investigators concluded that in a tertiary clinic setting, referral for HCV management occurred in only 57% of coinfected patients, and despite referral, 27% did not pursue evaluation of HCV.

They added that, "factors influencing management of HCV included active alcohol and drug use, non-adherence to HIV management, and younger age."

These observations, they suggested, "underscore the importance of supporting HIV-HCV coinfected patients and their health providers with education on the importance of management of liver disease and substance use."

5/20/08

Reference
R Pozza, F Barakat, E Barber, and others. Factors contributing to the low rate of HCV evaluation in HIV/HCV co-infected cohort. Digestive Disease Week (DDW) 2008. San Diego, CA. May 17-22, 2008. Abstract W1873.