Coinfection

Hepatitis B Linked to More HIV+ Deaths than Hepatitis C, Risk High for People with AIDS

HIV positive men who are coinfected with hepatitis B virus (HBV) are more likely to die than those with hepatitis C virus (HCV) coinfection, according to research published in the April 20, 2012, advance online edition of Clinical Infectious Diseases. A related study, however, found that liver-related mortality was quite high for HIV/HCV coinfected people with a diagnosis of AIDS.

Since the advent of effective antiretroviral therapy, liver disease has become a leading cause of death among people with HIV. Over years or decades, chronic hepatitis B or C can progress to severe liver disease including cirrhosis, hepatocellular carcinoma, and end-stage liver failure; evidence indicates that progression may happen faster in HIV positive people.

Oluwaseun Falade-Nwuliaand Chloe Thio from Johns Hopkins University and colleagues compared rates of liver-related mortality among participants in the Multicenter AIDS Cohort Study (MACS) -- an ongoing prospective study of the natural history and HIV treatment outcomes of gay and bisexual men in U.S. cities -- who had chronic hepatitis B or C.

The analysis included 680 men, 69% of whom were HIV positive. 337 men had chronic hepatitis B, including 229 with HIV/HBV coinfected; 343 had chronic hepatitis C, including 243 with HIV/HCV coinfection. About 75% were white and the median age was 35 years.

Participants were prospectively followed until death, their last follow-up visit, or March 30, 2010 (whichever came first), for a median of about 7 years. The researchers obtained causes of death from death certificates and compared rates of liver-related and all-cause mortality in the hepatitis B and C patients after adjusting for potential confounding factors.

Results

• There were a total of 293 deaths from all causes during 6728 person-years (PY) of follow-up, for a rate of 43.5 deaths per 1000 PY:
• 51 deaths were due to liver-related causes, a rate of 7.6 per 1000 PY.
• All-cause mortality rates were similar between participants with chronic hepatitis B and chronic hepatitis C.
• Liver-related mortality, however, was significantly higher among those with chronic hepatitis B (9.6 vs 5.0 per 1000 PY, respectively).
• 46 liver-related deaths -- or 90.2% -- occurred in people with HIV.
• Among coinfected people, the liver-related mortality rate remained significantly higher for those with HIV/HBV compared with HIV/HCV in an adjusted analysis (IRR 2.2, or about twice as high).
• Among people with HIV, having a CD4 T-cell count < 200 cells/mm³ was associated with a 16.2-fold increased risk of liver-related death compared with counts > 350 cells/mm³.

Based on these findings, the researchers concluded, "Chronic hepatitis B carries a higher risk of death from liver disease than does chronic hepatitis C especially in HIV-infected men with greater immunosuppression."

These results, they added, underscore the need for expanded HBV screening, hepatitis B vaccination, and treatment of HIV/HBV coinfected patients with drugs that are active against both viruses.

HIV/HCV Mortality

In a related study described in the April 24, 2012, advance edition of Clinical Infectious Diseases, Andrea Branch from Mt. Sinai School of Medicine and colleagues retrospectively analyzed deaths among participants in the Longitudinal Studies of the Ocular Complications of AIDS. The researchers tested stored plasma samples from 2025 patients with CDC-defined AIDS for HCV RNA and antibodies.

Results

• 337 patients, or 17%, had detectable HCV RNA (indicating chronic infection); 91, or 4%, had HCV antibodies and no HCV RNA (indicating cleared infection); and the rest had no HCV markers.
• Median CD4 counts were 200 cells/mm³ in the chronic HCV group, 193 cells/mm³ in the cleared HCV group, and 175 cells/mm³ in the no HCV group.
• A total of 558 deaths occurred during the study period.
• Over a median follow-up period of about 6 years, patients with chronic hepatitis C had a 50% higher risk of death compared to those with no HCV markers (relative risk 1.5 after adjusting for known risk factors.
• Mortality was not significantly increased, however, when looking only at patients with cleared HCV infection (relative risk 0.9).
• 20.4% of deaths among patients with chronic hepatitis C were liver-related, compared with 3.8% of deaths among people without HCV.

"Chronic HCV infection is independently associated with a 50% increase in mortality among patients with a diagnosis of AIDS, despite competing risks," the researchers concluded. "Effective HCV treatment may benefit HIV/HCV co-infected patients with AIDS."

6/12/12

References

O Falade-Nwulia, EC Seaberg, CR Rinaldo, CL Thio, et al. Comparative Risk of Liver-Related Mortality from Chronic Hepatitis B Versus Chronic Hepatitis C Virus Infection. Clinical Infectious Diseases. April 20, 2012 (Epub ahead of print).

AD Branch, ML Van Natta, ML Vachon, et al (for the Studies of the Ocular Complications of AIDS Research Group). Mortality in HCV-infected Patients with a Diagnosis of AIDS in the Era of Combination Anti-retroviral Therapy. Clinical Infectious Diseases. April 24, 2012 (Epub ahead of print).