Co-infection with HIV and viral hepatitis
is associated with a more aggressive disease course for liver cancer, according
to research conducted in London and presented to the recent EASL Monothematic
Conference: HIV and the Liver.
The investigators found that liver cancer
developed at an early age in co-infected people, that there was a high
dropout rate when waiting for liver transplant, and that overall survival was
The research has implications for HIV care,
with the investigators calling for more surveillance of liver cancer in
Large numbers of people with HIV are
co-infected with hepatitis B and/or hepatitis C. Liver disease is now a leading
cause of illness and death in those co-infected people. An important manifestation
of liver disease in this group is hepatocellular carcinoma (HCC). Research
conducted in Spain recently found increased rates of HCC in HIV-positive people, especially in the context of hepatitis C co-infection.
Investigators from King’s College Hospital, London, wished to establish a clear
understanding of HCC in their HIV-positive patients.
They therefore conducted a case-controlled
study. Individuals who developed HCC between 2003 and 2010 were identified from
hospital records and matched with HIV-negative controls who also developed HCC.
A total of 20 cases of HCC involving
people with HIV were identified; 13 cases of HCC were diagnosed in people
co-infected with hepatitis C, and seven cases were diagnosed in hepatitis
Almost all (n = 19) the participants were men and
their median CD4 cell count was 249 cells/mm3. The majority (n= 19)
were taking antiretroviral therapy. Most had well-controlled HIV infection, and
viral load was undetectable in 18 participants (80%).
HCC developed at a younger age in the
HIV-positive people compared to the controls (46 vs 58 years; p <
The malignancy was diagnosed as part of
routine care for twelve of the co-infected people. Almost all (n = 18) the
HIV-positive participants had liver cirrhosis at the time their HCC was detected.
Staging of liver disease and HCC at the
time of diagnosis did not differ significantly between the patients and the
There were a number of differences between
the participants co-infected with hepatitis B compared to those co-infected with
People co-infected with HIV and hepatitis
C had lower CD4 cell counts than those with HIV and hepatitis B (180 vs 430
cells/mm3; p = 0.06), and also had more advanced portal hypertension
(spleen size: 15 vs 11 cm; p = 0.02).
Comparison between HIV-positive and
HIV-negative people with hepatitis C infection showed that individuals with
HIV were significantly less likely to have undergone a course of hepatitis C
therapy (14 vs 73%; p = 0.006).
Management of HCC did not differ
significantly between the HIV-positive and the HIV-negative participants.
However, although six of the co-infected
patients were referred for liver transplant, only three individuals actually underwent
Survival was poorer in the participants with
HIV than the controls. Only 17% of the co-infected individuals were alive five
years after the diagnosis of HCC; this compared to a 41% survival rate in the
The 24-month survival rate was
significantly poorer in the HIV/hepatitis B co-infected patients compared to the
hepatitis B-monoinfected controls (39 vs 61%; p = 0.03).
Mortality rates twelve months after
diagnosis of HCC among the participants with hepatitis C were poor in both
co-infected and monoinfected individuals (43 vs 32%).
“HIV-positive patients with HCC present at
younger age, have a high drop-out rate for liver transplant and appear to have
a more aggressive disease course,” conclude the investigators. “Heightened HCC
surveillance may be warranted.”