Coinfection

Antiretroviral Therapy Reduces Liver Decompensation Risk in HIV/HCV Coinfected Patients

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HIV positive people with hepatitis C coinfection who start combination antiretroviral therapy (ART) are less likely to develop decompensated liver disease, or liver failure, according to a study published in the March 1, 2014, edition of Clinical Infectious Diseases. These findings offer further support for early ART initiation for people with viral hepatitis.

Over years or decades, chronic hepatitis C can lead to serious liver disease including cirrhosis and liver cancer. HIV/HCV coinfected people experience faster liver disease progression, on average, than people with hepatitis C alone, but having well-controlled HIV may help keep it in check.

Jeffrey Anderson from Harvard School of Public Health and colleagues evaluated the likelihood of liver decompensation and its association with initiation of combination ART in a population of HIV/HCV coinfected veterans.

The analysis included10,090 coinfected men in the Veterans Aging Cohort Study (VACS) Virtual Cohort who had not yet started ART at entry into the cohort. The researchers looked for incident or new cases of liver decompensation occurring between 1996 and 2010. About 60% were black and the median age was 47 years. About one-third had a low baseline CD4 T-cell count below 200 cells/mm3.

ART was defined as filling a prescription for a regimen containing at least 3 drugs from at least 2 antiretroviral classes. During a median 3.1 years of follow-up, 69% started ART and 36% started interferon-based hepatitis C treatment. Liver decompensation was defined as the first occurrence of 1 hospital discharge diagnosis or 2 outpatient diagnoses for ascites (abdominal swelling), spontaneous bacterial peritonitis, or esophageal variceal hemorrhage (bleeding veins in the throat).

Results

  • A total of645 liver decompensation events occurred during 46,444 person-years of follow-up (6% of particpants).
  • The incidence rate of liver decompensation was 1.4 cases per 100 person-years.
  • Coinfected participants who initiated ART had a significantly lower rate of liver decompensation compared with those who did not start antiretrovirals (hazard ratio 0.72, or a 28% risk reduction).
  • Looking only at people with HIV viral load >400 copies/mL at baseline (assuming those with lower levels might have been on unreported ART), the risk reduction was more pronounced (hazard ratio 0.59, or 41% reduction).

"Initiation of ART significantly reduced the rate of hepatic decompensation by 28%-41% on average," the study authors concluded. "These results suggest that ART should be administered to HIV/HCV coinfected patients to lower the risk of end-stage liver disease."

U.S. treatment guidelines now recommend ART for all people with HIV regardless of CD4 cell count, but the recommendation is particularly strong for people with HCV coinfection. European guidelines list people with hepatitis C as one group that should consider earlier ART.

2/20/14

Reference

JP Anderson, EJ Tchetgen Tchetgen, V Lo Re, et al. Antiretroviral Therapy Reduces the Rate of Hepatic Decompensation Among HIV- and Hepatitis C Virus-Coinfected Veterans. Clinical Infectious Diseases 58(5):719-727. March 1, 2014.