HIV-positive patients who are not screened for infection with hepatitis C virus have an increased risk of death, according to French research published in the September edition of the Journal of Viral Hepatitis. The investigators from Lyon found that only older age and a low CD4 cell count had a greater association with death. However the investigators do not think that suboptimal care was the reason why unscreened patients had a greater risk of death. They suggest that the poor health of unscreened patients at baseline made hepatitis C infection less of a priority for their doctors.
Treatment guidelines recommend that all HIV-positive individuals should be tested soon after diagnosis for infection with hepatitis C virus. The guidelines of the British HIV Association (BHIVA) further recommend that individuals with an ongoing risk of infection with hepatitis C should be regularly screened for the infection.
HIV-positive patients who are coinfected with hepatitis C have a poorer prognosis, but there are limited data regarding the characteristics and survival of patients who have not been screened for the infection.
Investigators from Lyon therefore analysed data for 3,244 patients who received HIV care in the city between 1992 and 2005. The data were collected prospectively and entered onto the French Hospital Database on HIV.
At baseline, information on gender, age, presumed mode of HIV infection, AIDS at the time of HIV diagnosis, and CD4 cell count were collected. The investigators also gathered data on hepatitis C screening, the duration of follow-up, and the use of potent antiretroviral therapy.
A total of 14,631 person years of follow-up were available for the investigators’ analysis. The patients had a mean age of 37 years on enrolment, and mean CD4 cell count at baseline was 354 cells/mm3.
The hepatitis C infection status of 299 patients (9%) was unknown. The investigators found that these unscreened patients were less likely to have acquired HIV through either homosexual or heterosexual sex and to have an unknown mode of HIV infection (p = 0.041), to have a CD4 cell count below 50 cells/mm3 or an unknown baseline CD4 cell count (p = 0.009), to have a shorter mean duration of follow-up (40 months vs. 56 months, p < 0.001), to have a greater number of mean hospital visits per year (13 vs. eight, p < 0.001), to have an AIDS diagnosis at baseline (24% vs. 15%, p < 0.001), and to have taken potent antiretroviral therapy during follow-up (29% vs. 20%, p < 0.001).
Significantly more unscreened patients than screened patients died during follow-up (17% vs. 11%, p < 0.001) and the investigators calculated that unscreened patients had an incidence rate of death of 52 per 1,000 patient years compared to an incidence of 24 per 1,000 patient years for screened patients. This rate of progression to death was statistically significant (p < 0.001) and persisted after the investigators controlled for the use of antiretroviral therapy (p = 0.015).
In multivariate analysis, the investigators found that, after controlling for possible confounding factors, being unscreened for hepatitis C infection remained a significant predictor of death (hazard ratio [HR] 2.48; 95% CI, 1.83 – 3.35, p < 0.001). Only age over 56 years (HR 3.37; 95% CI, 1.90 – 5.97, p < 0.001) and baseline CD4 cell counts below 50 cells/mm3 (HR 13.71; 95% CI, 9.63 – 19.50, p < 0.001) and 199 cells/mm3 (HR 5.62; 95% CI, 3.97 – 7.97, p < 0.001), had a stronger association with death.
“We observed that the progression to death was higher for patients with unknown HCV status vs. the patients with known HCV status after adjusting of potentially confounding factors”, comment the predictors.
Although the investigators initially speculated that suboptimal care might be associated with lack of hepatitis C screening and poorer survival, they emphasise that there is good evidence to believe that this was not the case. They write “the missing data on HCV status do not seem to be associated with poor adherence or access to care because these individuals accessed highly active antiretroviral therapy more often...and the mean number of visits was higher in the group not screened for HCV.”
As unscreened patients often had AIDS or a low CD4 cell count at baseline, the investigators speculate that their advanced HIV disease meant that hepatitis C status was less of “a priority to their medical practitioners.” However, they emphasise that “guidelines clearly recommend that HIV-infected persons be screened for HCV infection with HCV antibody test[s].”