Coinfection

HIV/HBV Coinfected Patients Respond to ART as well as HIV Monoinfected

HIV positive people coinfected with hepatitis B virus (HBV) respond as well to combination antiretroviral therapy (ART) as individuals with HIV alone, but they are more likely to die due to non-AIDS-related causes, according to a study published in the September 10, 2009 issue of AIDS.

Due to overlapping routes of infection, many people are coinfected with both HIV and HBV, and an estimated 5% to 10% have chronic coinfection. Some commonly used antiretroviral drugs -- including tenofovir (Viread, also in the Truvada and Atripla combination pills), emtricitabine (Emtriva), and lamivudine (3TC, Epivir) -- are active against both viruses. But long-term ART outcomes in this group have not been extensively studied.

Christopher Hoffmann from Johns Hopkins Medical School and colleagues retrospectively analyzed data from participants in the Multicenter AIDS Cohort Study (MACS), a longitudinal study of men who have sex with men in Baltimore, Chicago, Pittsburgh, and Los Angeles.

Study participants were classified according to hepatitis B status based on serology findings at the time of combination ART initiation. Of 816 men followed for a median of 7 years on ART, 350 were never infected with HBV, 357 had evidence of past infection, 45 had chronic hepatitis B, and 64 were only hepatitis B core antibody (HBcAb) positive.

The investigators used regression analysis to determine associations between chronic hepatitis B and HIV suppression, CD4 cell gain, AIDS-defining illnesses, and mortality.

Results

• Overall, 87 patients died while on combination ART, for a mortality rate of 17 deaths per 1000 person-years (PY).
• Despite being on ART, AIDS-related illness was the most common cause of death (8 deaths per 1000 PY).
• The AIDS-related mortality rate was highest among patients with chronic hepatitis B (17 per 1000 PY).
• Patients with past HBV infection had an intermediate AIDS-related mortality rate (14 per 1000 PY).
• The AIDS-related death rate was lowest among people who had never been infected with HBV (3 per 1000 PY).
• In a multivariable model adjusting for potential confounding factors including time of ART initiation and history of injection drug use, patients with chronic hepatitis B had a 2.7-fold higher rate of AIDS-related mortality than those who were never infected, a difference that did not reach statistical significance (P = 0.08).
• The rate of non-AIDS-related mortality also was highest among participants with chronic hepatitis B (22 per 1000 PY), primarily due to liver disease, and this was significant (adjusted hazard ratio 4.1; P = 0.04).
• The non-AIDS death rate was likewise lowest for individuals never infected with HBV (2 per 1000 person-years).
• 4 of the 6 non-AIDS deaths in the chronic hepatitis B group were liver-related, a rate of 17 per 1000 PY.
• There were no significant differences in HIV viral load suppression, CD4 cell increases, or AIDS-defining events.

"In HIV-infected patients receiving long-term HAART, HBV status did not influence HIV suppression or CD4 cell increase," the investigators concluded. "However, mortality was highest among those with chronic hepatitis B and was mostly due to liver disease despite HBV-active HAART."

Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; University of New Mexico School of Medicine, Albuquerque, NM; David Geffen School of Medicine at UCLA, Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA; Department of Infectious Diseases and Microbiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA; Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL.

9/04/09

Reference

CJ Hoffmann, EC Seaberg, S Young, and others. Hepatitis B and long-term HIV outcomes in coinfected HAART recipients. AIDS 23(14): 1881-1889. September 10, 2009.