European Study Finds More than Half of HIV/HCV Coinfected Patients Do Not Receive Treatment despite Advanced Fibrosis

		SUMMARY: A majority of HIV positive individuals with chronic hepatitis C virus (HCV) coinfection are not treated for hepatitis C for a variety of reasons ranging from patient choice to provider concerns about adherence, active substance use, or mental illness, according to a study presented at the 45th Annual Meeting of the European Association for the Study of the Liver (EASL 2010) last month in Vienna. The researchers noted, however, that studies demonstrate acceptable treatment success for such patients in real-life clinical practice.

By Liz Highleyman

European investigators carried out a multicenter study of 1033 HIV/HCV coinfected patients diagnosed since 2001 at 14 centers in Berlin, Hamburg, and Vienna.

HCV coinfection represents a significant risk factor for increased illness and death of HIV positive people, the researchers noted as background; according to current guidelines, hepatitis C treatment should be considered a priority for coinfected patients.

About three-quarters of patients in this analysis were men and the average age was 43 years; the current CD4 cell count was high, at nearly 500 cells/mm3, but the nadir (lowest-ever) count was 255 cells/mm3. A majority (62%) had HCV genotype 1, followed by genotypes 3 (2%), 4 (9%), and 2 (5%). Liver biopsy data available for 146 patients showed a mean Metavir fibrosis stage of 3 (on a scale of 0-4), indicating advanced fibrosis requiring treatment.

Results

	416 patients (40%) received hepatitis C treatment, while 617 (60%) remained untreated.
	The main reasons for lack of treatment were:
	Patient choice (20%); Concerns about adherence (19%); Active injection drug use (14%); Psychiatric illness (9%); Other co-existing conditions (9%); Advanced immune deficiency or AIDS (9%); Other or unknown reasons: 22%.
	Patients who started hepatitis C treatment had less advanced HIV disease, with a higher average CD4 count and a lower average HIV viral load than untreated individuals.
	Interesting, treated patients had significantly less advanced fibrosis than untreated patients (average fibrosis stage F2 vs F4), but they had higher ALT levels on average (113 vs 75 IU/mL).
	HCV genotype and HCV viral load -- both established predictors of treatment response -- did not influence treatment decisions.
	Age, hemoglobin level (an indicator of anemia), platelet count, and white blood cell count also did not significantly affect treatment decisions.
	Among the 305 treated patients with sufficient data, the overall sustained virological response (SVR) rate was 51% (38% for genotype 1 and 75% for genotype 3).

According to the investigators, "This large cohort study provides evidence for considerable under-treatment of chronic HCV infection in HIV patients."

"Despite acceptable treatment success in this real-life setting, HCV remains untreated in the majority of cases and often due to reason that should not be considered as absolute contraindications to antiviral therapy," they continued.

The SVR rates seen in this study are within the range typically seen in trials of treatment HIV/HCV coinfected individuals, and the cure rate for genotype 3 matched the usual rate for HIV negative people with hepatitis C alone.

These findings led the researchers to conclude, "Strategies to enhance adherence and medical advice for the HIV-HCV coinfected population are urgently needed."

Internal Medicine III, Div. of Gastroenterology & Hepatology, Medical University Vienna, Vienna, Austria; Medical Laboratory Berg, Berlin, Germany; Praxis Dupke/Carganico/Baumgarten, Berlin, Germany; Dermatology, Div. of Immunology, Allergy & Infectious Diseases, Medical University Vienna, Vienna, Austria.

5/11/10

Reference
T Reiberger, M Obermeier, BA Payer, and others. Evidence for considerable undertreatment of chronic hepatitis C infection in HIV-HCV coinfected patients. 45th Annual Meeting of the European Association for the Study of the Liver (EASL 2010). Vienna, Austria. April 14-18, 2010. (Abstract).