People with HIV and HCV co-infection experience more rapid liver disease
progression, on average, than HIV-negative people with hepatitis C, though the
reasons for this are not fully understood. As effective antiretroviral therapy (ART)
has dramatically reduced the risk of AIDS-related conditions, liver disease has
become a leading cause of illness and death for people with HIV.
P Nasta of Spedali Civili in
Brescia, Italy, and colleagues looked at the association between liver
fibrosis and mortality among people with HIV and HCV co-infection on ART.
This analysis included
3338 participants with co-infection in the Italian MASTER cohort. Liver
fibrosis was estimated using the FIB-4 score, a biomarker index based on age,
platelet count, and ALT and AST liver enzyme levels. People with hepatitis B
triple infection or severe liver enzyme abnormalities at baseline were
excluded.
A total of 291
participants (8.7%) died during the course of more than 45,000 patient-years
of follow-up. Death rates rose with increasing fibrosis severity. About 40% of
people who died had FIB-4 scores suggesting advanced fibrosis, compared with
16% of those who survived. People with high FIB-4 scores were not only more
likely to die from liver-related causes, as expected, but they were also more
likely to die due to any cause.
People with a FIB-4
score above 3.25 (indicating advanced fibrosis) had a twofold higher risk of
all-cause death, while those with scores below 1.44 (indicating absent or mild
fibrosis) reduced their risk of death by about half. Having clinical AIDS at
baseline was also an independent risk factor for all-cause death, while HCV
clearance was associated with reduced mortality.
Based on these findings,
the researchers concluded that advanced fibrosis is independently associated
with all-cause and liver-related mortality in people with HIV and HCV co-infection
and that FIB-4 can be used to determine if liver disease is progressing and when
hepatitis C treatment is needed.
In a related study, V
Berthaud of Meharry Medical College in Nashville and colleagues looked at
factors predicting survival among people with HIV at a clinic in Tennessee, in
the US 'deep south'.
The researchers
analysed medical records of 745 people living with HIV seen at the clinic from
2004 through 2014. Most (80%) were African American, 35% were women, 16% had a
history of injecting drugs and 14% were homeless. Overall 24% had HCV
co-infection, but the rate rose to 54% among patients who died, according to
the study abstract.
Just over
three-quarters of participants were retained in care, 76% were prescribed
antiretroviral therapy and 64% achieved undetectable HIV viral load. Hepatitis
C treatment was less common: about a quarter of people with co-infection
received interferon-based therapy, with a cure rate of 68%.
Shorter survival was
associated with HIV and HCV co-infection, fewer clinic visits, last viral load
measurement >75 copies/ml, CD4 count <200 cells/mm3 and older
age. The researchers concluded that HCV co-infection plays a major role in
survival of people with HIV – perhaps even more so than detectable HIV viral
load.
"In the context of
HIV plasma viral load suppression, scale-up of hepatitis C treatment will
further reduce mortality among medically underserved minority communities
disproportionately impacted by HIV/HCV co-infection in the Deep South,"
they concluded.