A recent study (Lo Re & Vincent (L&J)) presents disquieting findings regarding the relative risk of severe liver complications in HIV/Hepatitis C co-infected patients.
Hepatitis C (HCV) has received particular attention in STIs recently on account of its strong association with HIV sero-positivity in MSM (Yaphe & Klein (STIs)) and because of its growing incidence in some MSM populations (Giraudon & Barton (STIs)). As for the outcomes of HCV in co-infected patients, there have been studies suggesting the benefit of ART in slowing progression of liver complications; but, L&J claim, theirs is the first to have established a significant difference in the outcomes of HIV co-infected patients.
L&J is a retrospective cohort study involving the records of 10,359 patients receiving care between 1997 and 2010 through the US Veterans Health Administration. It establishes a relatively higher risk of hepatic decompensation for HCV co-infected, as opposed to HCV mono-infected patients: HR 1.83 or HR 1.56 (depending on whether death is treated as a “competing risk”). Cumulative incidence of decompensation at ten years for co-infected and mono-infected was, respectively, 7.4% and 4.8%.
The study also gives an indication of the impact of levels of ART success (in terms of maintenance of HIV RNA levels) on rates of hepatic decompensation in co-infected patients. Co-infected patients who maintained HIV RNA levels at less than 1000 copies/mL had lower rates of hepatic decompensation than patients who did not, but these rates were still considerably higher than for mono-infected patients: HR 1.44. Cumulative incidence of decompensation at ten years for co-infected with HIV RNA ≥ 1000 copies/mL was 7.6%.
In addition, the study examined various characteristics associated with higher levels of decompensation in co-infected patients – most interestingly, perhaps CD4 count at the study baseline. Cumulative incidence of decompensation at ten years for co-infected patients with CD4 <200×106 was 8.1%, as against 6.9% for co-infected with CD4 ≥200×106.
The authors conclude that the considerably greater risk of decompensation in co-infected patients is only somewhat alleviated by effective ART. They point out that their findings strongly support current guidelines for the earliest possible initiation of ART in co-infected patients, regardless of CD4 count, and may prompt earlier consideration of initiation of HCV to reduce the risk of liver complications