A quarter of
HIV-positive people in the EuroSIDA cohort with chronic hepatitis C virus
(HCV) co-infection have received HCV therapy, a study published in HIV Medicine shows. The proportion of
people treated increased significantly between 1998 and 2007 but then fell,
possibly because patients and doctors were awaiting for the arrival of new
direct-acting anti-HCV drugs.
the study showed that only 36% of treated people had significant fibrosis and
that a fifth of untreated people had liver damage serious enough to warrant
patients, including some with significant fibrosis, who have not been exposed
to anti-HCV treatment,” comment the authors.
proportion of HIV-positive people are co-infected with HCV. Liver disease
caused by this co-infection is now an important cause of death in these
HCV can be treated
and cured. Guidelines recommend that HIV-positive people with significant
liver fibrosis (stage F2 or above) should receive HCV therapy. People with
well-controlled HIV infection (a CD4 cell count above 350 cells/mm3)
are also a priority group for treatment.
recommendations, little is known about the uptake of HCV therapy among
the EuroSIDA cohort study therefore analysed data collected between 1998 and
2010 to see if rates of treatment were increasing, the factors associated with
starting therapy, and if patients prioritised by guidelines were receiving
The EuroSIDA cohort comprises
approximately 18,300 HIV-positive people in Europe, Israel and Argentina. A
total of 4224 of these people have antibodies to HCV. HCV viral load
measurements were available for 2663 of these participants and 2008 (76%) were found
to be HCV RNA positive. Some 1984 of these people were HCV-treatment naive at
baseline and eligible for inclusion in the study.
people contributed 18,303 person-years of follow-up. During this time, 501
(25%) started HCV treatment, a rate of 2.74 per 100 person-years of follow-up.
incidence of treatment increased over time from just 0.33 per 100 person-years
of follow-up in 1998 to 5.93 per 100 person-years of follow-up in 2007.
Between 1998 and
2007, the incidence of treatment uptake increased by a significant 26% each year
(p < 0.0001).
uptake of anti-HCV therapy probably reflects the introduction of peg-IFN
[pegylated interferon], with cure rates of approximately 70% for HCV genotype 2
or 3 and 35% for genotype 1 or 4,” suggest the authors.
2007, treatment uptake fell. In 2009 it was 3.74 per 100 person-years of
follow-up. “The trend of decreasing treatment uptake seen after a peak in 2007
is explained by different patient characteristics and possibly treatment
saturation of the easy-to-treat patients,” write the authors. An alternative explanation
offered by the authors is that patients and doctors were “choosing to wait for
the first generation of directly acting agents”.
Southern Europe were especially likely to start treatment, as were gay men. The
investigators believe that the higher treatment rates in Southern Europe could
be due to greater physician experience. Many of the infections among gay men
have been detected during the acute phase, and therapy has an especially high
success rate when administered at this time.
characteristics were also associated with the receipt of therapy. These
included a suppressed HIV viral load (p = 0.012), a higher HCV viral load (p =
0.049) and elevations in ALT levels (p < 0.0001).
liver fibrosis was available for 800 participants (40%). People with significant
fibrosis were 60% more likely (p < 0.0065) to have received therapy compared
to people with less severe liver damage.
However, only 36%
of individuals of treated patients had F2 fibrosis or above, and 22% of patients
with severe fibrosis were still waiting to start therapy.
“We have reported
an increase in the incidence of treatment for HCV infection in EuroSIDA, with
those selected for treatment mostly aligned with current guidelines,” conclude
the authors. However, they express concern that a significant proportion of
people with serious liver fibrosis remain untreated. “Future studies of the
reasons for this are warranted.”