IAS 2015: Fatty Liver May Contribute to Higher Risk of Death for HIV/HCV Coinfected People


About a quarter of HIV and hepatitis C virus (HCV) coinfected people in a New York City cohort died over a 10-year follow-up period -- a "strikingly low" survival rate -- according to a poster presented at the 8th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention last month in Vancouver. Researchers saw trends toward an association between steatosis (fatty liver) and cardiovascular disease, diabetes, and overall survival.

HIV/HCV coinfected individuals typically experience more aggressive liver disease progression than those with HIV or HCV alone, and they are more likely to develop steatosis (fat accumulation in the liver) and fibrosis (build-up of scar tissue). Non-alcoholic fatty liver disease and non-alcoholic steatohepatitis (NAFLD and NASH) are growing causes of cirrhosis, liver cancer, and the need for liver transplantation.

Carrie Down from Weill Cornell New York Presbyterian Hospital and colleagues explored the impact of steatosis on fibrosis progression, cardiovascular disease, and survival over time in HIV/HCV coinfected people.

This single-center retrospective cohort study analyzed clinical outcomes among 105 coinfected patients who initially received liver biopsies between 1998 and 2003 for the evaluation of HCV-related liver disease. The research team evaluated this group in 2005 and continued follow-up for 10 years. Of note, the earliest patients received biopsies during the first years after the advent of effective combination antiretroviral therapy (ART) for HIV, and follow-up ended just as interferon-free direct-acting antiviral therapy for hepatitis C started to become widely available.

A majority of participants (70%) were men and the mean age was 45 years. Most (84%) had HCV genotype 1; 39% had absent or mild (grade 0-1) fibrosis, 38% had moderate (grade 2) fibrosis, and 23% had advanced fibrosis or cirrhosis (grade 3-4). Most (88%) were on ART, 61% had undetectable HIV viral load, the median CD4 T-cell count was 410 cells/mm3, and about 60% had an AIDS diagnosis. The mean body mass index was 26.3 (25 and 30 being the cutoffs for overweight and obesity, respectively), 10% had diabetes, and 20% had hypertension (high blood pressure).

The researchers looked at clinical outcomes including cardiac events, liver function, and survival over 10 years. Liver fibrosis was assessed using FIB-4 and APRI scores, calculated using common laboratory biomarkers (ALT and AST liver enzyme levels and platelet count).


  • 59 participants (56%) showed evidence of steatosis; this was mostly mild (grade 1), but 7% had moderate (grade 2) and 2% had advanced steatosis (grade 3).
  • People with steatosis were more likely to be male, overweight or obese, and to drink alcohol, but were equally likely to have elevated blood lipids (8%).
  • Over 10 years there were trends towards greater risk of several conditions in the steatosis group compared to patients without steatosis, but the differences did not reach statistical significance:

o   Diabetes: 22% vs 11%;

o   Decompensated liver disease: 19% vs 15%;

o   Coronary artery disease: 5% vs 4%;

o   Peripheral vascular disease: 5% vs 4%;

o   Myocardial infarction: 5% vs 2%.

  • 30 people (29%) died during follow-up, with liver disease being the most common cause, accounting for 10 deaths (8 people had an unknown cause of death).
  • Survival analysis showed that patients with steatosis had decreased survival compared to those without steatosis at 5 years (88% vs 93%) and at 10 years (65% vs 73%), though these differences were also not significant.
  • People with steatosis had higher mean FIB-4 and APRI scores at the time of initial biopsy and at 10 years of follow-up.
  • Changes in FIB-4 and APRI over time were both significantly associated with increased mortality (unadjusted hazard ratio 1.08 and 1.15, respectively).
  • A multivariate analysis showed that diabetes, obesity, elevated blood lipids, alcohol use, and HIV and HCV viral load were not significant predictors of survival.

"This retrospective cohort study did not detect a significant association of steatosis with overall survival or cardiovascular or diabetic events," the researchers concluded. "However, the data trended toward an increased rate of cardiovascular events, diabetes, and decreased survival in patients with steatosis."

"The overall survival in this HIV/HCV coinfected cohort studied was strikingly low (25% mortality), given [the] age and demographics at time of enrollment," they continued. "Low survival rate and association between liver disease markers and survival in this cohort underscore the importance of HCV treatment in HIV/HCV coinfected individuals."



C Down, N Mehta, and K Marks. The risk of cardiovascular disease and death over 10 years in HIV/HCV co-infected patients with and without steatosis. 8th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention. Vancouver, July 19-22, 2015. Abstract TUPEB246.