Does HIV affect hepatitis C?

Research shows that HIV hastens the process of liver damage due to hepatitis C. Consequently, co-infected people are more likely to develop severe liver disease, and to do so more rapidly. A major meta-analysis from 2002 showed that HIV/HCV co-infected people had a two-fold greater risk of cirrhosis and a six-fold greater risk of ESLD than those with HCV alone.1 Other studies from the UK and other countries have shown comparable results.2 3

Various studies have shown that in co-infected people, the average time to liver disease progression is 15 to 25 years, compared to an average of 30 years or more in people with HCV alone.4 5 In another study, HIV co-infection significantly shortened the survival time of people with HCV-related ESLD.6 

Although the likelihood of liver disease progression seems to be highest for co-infected people with advanced HIV disease and heavily compromised immune systems, even those with high CD4 cell counts may be at greater risk of liver damage. Another study found that co-infected patients experienced faster than expected fibrosis progression, even if they showed minimal scarring on initial biopsy.7

There is also evidence that progression to HCC is faster in co-infected people.8,9 and that co-infected individuals have twice the risk of ESLD for each decade of HCV infection.10

Although most evidence indicates that HIV accelerates HCV-associated liver disease, some studies have not found this to be the case.11,12 There is also some evidence that liver function markers and HCV viral load may not be higher in co-infected individuals.13 Many studies were conducted before the widespread adoption of HAART; some later research suggests that patients who are receiving effective antiretroviral therapy and who have well-controlled HIV disease may fare about as well as people with HCV alone.14 Co-infected people with lower CD4 counts (below 50, 100, 200, or 500 cells/mm3 in different studies) are more likely to experience severe liver disease progression and death than those with less compromised immune systems.4,15

One caution when considering studies of co-infected individuals is the lack of attention to alcohol use when assessing the results. Studies that do not control for alcohol use should be treated with caution, since alcohol use is an independent risk factor for liver damage in co-infected individuals. Another problem is that it can be difficult to measure exactly how long people have been infected with HCV, which can lead to false estimates of the speed of HCV disease progression.

HIV/HCV co-infection has been associated with greater risk of hepatic steatosis, which can impair response to anti-HCV therapy,16,17 although one study found that steatosis was lower in co-infected individuals than in patients with HCV alone.18 Steatosis risk may also call for caution in use of ddI (didanosine) and d4T (stavudine) in co-infected patients.19

HIV/HCV co-infection has been associated with higher levels of HCV RNA in the blood and reduced response to interferon-based HCV treatment.20

References

  1. National Institutes of Health Management of Hepatitis C, 2002. NIH Consensus and State-of-the-Science Statements. 19 (3), 2002
  2. Lesens O et al. Hepatitis C virus is related to progressive liver disease in HIV-positive hemophiliacs and should be treated as an opportunistic infection. Journal of Infectious Diseases 179(5): 1254-1258, 1999
  3. Soto B et al. Human immunodeficiency virus infection modifies the natural history of chronic parenterally-acquired hepatitis C with an unusually rapid progression to cirrhosis. J Hepatol 26: 1-5, 1997
  4. Benhamou Y et al. Liver fibrosis progression in human immunodeficiency virus and hepatitis C virus co-infected patients. The Multivirc Group. Hepatology 30: 1054-1058, 1999
  5. Mohsen AH et al. Impact of human immunodeficiency virus (HIV) infection on the progression of liver fibrosis in hepatitis C virus infected patients. Gut 52: 1035-1040, 2003
  6. Pineda J et al. HIV coinfection shortens the survival of patients with hepatitis C virus-related decompensated cirrhosis. Hepatol 41(4): 779-789, 2005
  7. Sulkowski M et al. Unexpected significant liver disease among HIV/HCV-co-infected persons with minimal fibrosis on initial liver biopsy. Twelfth Conference on Retroviruses and Opportunistic Infections, Boston, abstract 121, 2005
  8. Bräu N et al. Hepatocellular carcinoma in 40 HIV/HCV-coinfected versus 50 HCV-monoinfected patients: North American HCC in HIV Study Group. Third IAS Conference on HIV Pathogenesis and Treatment, Rio de Janeiro, abstract TuPe1.1C17, 2005
  9. Garcia-Samaniego J et al. Hepatocellular carcinoma in HIV-infected patients with chronic hepatitis C. Am J of Gastroenterol 96: 179-183, 2001
  10. Ragni MV et al. Impact of human immunodeficiency virus infection on progression to end-stage liver disease in individuals with hemophilia and hepatitis C virus infection. J Infect Dis 183: 1112-1115, 2001
  11. Puoti M et al. Liver fibrosis progression is related to CD4 cell depletion in patients coinfected with hepatitis C virus and human immunodeficiency virus. J Infect Dis 183: 134-137, 2001
  12. Tor J et al. Chronic hepatitis C in HIV-infected patients: effects of coinfection and HAART. Eighth Conference on Retroviruses and Opportunistic Infections, Chicago, abstract 566, 2001
  13. Sterling RK et al. The clinical spectrum of hepatitis C virus in HIV coinfection. J Acquir Immune Defic Syndr 32: 30-37, 2003
  14. Kramer JR et al. The effect of HIV coinfection on the risk of cirrhosis and hepatocellular carcinoma in US veterans with Hepatitis C. Am J Gastroenterol. 100(1):56-63, 2005
  15. Fultz S et al. Survival in patients coinfected with HIV and hepatitis C in the HAART era. 15th International AIDS Conference, Bangkok, abstract MoPeB3318, 2004
  16. Sulkowski M et al. Hepatic steatosis and antiretroviral drug use among adults coinfected with HIV and hepatitis C virus. AIDS 19: 585-592, 2005
  17. Thomopoulos K et al. Liver steatosis is an independent risk factor for treatment failure in patients with chronic hepatitis C. Eur J Gastroenterol & Hepatol 17(2): 149-154, 2005
  18. Monto A et al. Hepatic steatosis in HIV/hepatitis C coinfection: Prevalence and significance compared with hepatitis C monoinfection. Hepatol 42(2): 310-316, 2005
  19. McGovern BH et al. Hepatic steatosis is associated with fibrosis, nucleoside analogue use, and hepatitis C virus genotype 3 infection in HIV-seropositive patients. Clin Infect Dis 43: 365-372, 2006
  20. Di Martino V et al. HIV coinfection does not compromise liver histological response to interferon therapy in patients with chronic hepatitis C. AIDS 16: 441-445, 2002
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