HIV/HCV coinfected patients more prone to end-stage liver disease without treatment

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Individuals coinfected with HIV and hepatitis C virus are more likely to develop end-stage liver disease (ESLD) compared to patients with hepatitis C virus, alone, according to a study presented at the Sixteenth International AIDS Conference in Toronto on August 15th. However, the investigators found that coinfected patients who achieved a sustained response to hepatitis C therapy were no more likely to progress to end-stage liver disease than their hepatitis C monoinfected peers.

Most studies show that coinfected individuals experience more rapid liver fibrosis progression than those with hepatitis C alone, although this may be less likely if they have well-controlled HIV. Coinfected patients are also less likely to respond to interferon-based therapy.

Firouzé Bani-Sadr from INSERM presented data from a study of liver disease progression among co-infected patients in France. The researchers prospectively followed 248 HIV and hepatitis C coinfected participants who received pegylated or conventional interferon, both with ribavirin, for 48 weeks in the RIBAVIC trial. Overall, 29% achieved sustained virological response, or continued undetectable hepatitis C viral load, 24 weeks after the completion of therapy.

Glossary

end-stage disease

Final period or phase in the course of a disease leading to a person's death.

fibrosis

Thickening and scarring of connective tissue. Often refers to fibrosis of the liver, which can be caused by an inflammatory reaction to long-term hepatitis infection. See also ‘cirrhosis’, which is more severe scarring.

cirrhosis

Severe fibrosis, or scarring of organs. The structure of the organs is altered, and their function diminished. The term cirrhosis is often used in relation to the liver. 

p-value

The result of a statistical test which tells us whether the results of a study are likely to be due to chance and would not be confirmed if the study was repeated. All p-values are between 0 and 1; the most reliable studies have p-values very close to 0. A p-value of 0.001 means that there is a 1 in 1000 probability that the results are due to chance and do not reflect a real difference. A p-value of 0.05 means there is a 1 in 20 probability that the results are due to chance. When a p-value is 0.05 or below, the result is considered to be ‘statistically significant’. Confidence intervals give similar information to p-values but are easier to interpret. 

hepatic

To do with the liver.

The average age of the patients was 42 years, 75% were men, and 59% had hard-to-treat hepatitis C genotypes 1 or 4. Most (81%) were taking potent anti-HIV therapy, about half had HIV viral loads below 200 copies/mL, and the average CD4 cell count was 567 cells/mm3. At the start of the study, 35% already had severe liver fibrosis or cirrhosis.

After an average follow-up period of 33 months, 17 events indicative of end-stage liver disease occurred in nine patients (4%). These events included liver decompensation (with symptoms such as severely elevated bilirubin, ascites, hepatic encephalopathy, or bleeding esophageal varices), hepatocellular carcinoma, need for liver transplant, and liver-related death. Six patients died of liver-related causes and two of other causes.

All cases of end-stage liver disease occurred in patients who did not achieve sustained response to hepatitis C treatment, and all but one occurred in individuals who had advanced fibrosis at the start of the study. End-stage liver disease did not occur in patients with severe fibrosis who permanently cleared hepatitis C with treatment. Among non-responders, end-stage liver disease was more common among patients with advanced fibrosis who also had lower CD4 cell counts.

In a stratified analysis, the only independent risk factors for end-stage liver disease were cirrhosis or severe fibrosis at the start of the study (p3 (p=0.022), and lack of sustained virological response to anti-hepatitis C therapy (p=0.068).

In conclusion, the researchers stated, “Our study confirms that the rate of spontaneous hepatic decompensation in coinfected patients with asymptomatic cirrhosis is higher (7.4% per year) than in hepatitis C monoinfected patients (3-4% per year).”

They recommended that, “clinicians should consider the evidence that sustained virological response seems associated with a reduction in long-term morbidity and mortality related to hepatitis C” when discussing treatment options with patients.

References

Carrat F et al. Three years assessment of the risk of end-stage liver disease in HIV/HCV co-infected patients treated for a chronic HCV infection. Sixteenth International AIDS Conference, Toronto, abstract TUAB0301, 2006.