Just 18% of people with hepatitis/HIV co-infection and cirrhosis are screened for liver cancer as often as recommended

There is a “strikingly low adherence” to clinical guidelines for ultrasound screening for hepatocellular carcinoma in western Europe, researchers report in the Journal of Viral Hepatitis.

Over years or decades, chronic hepatitis B or C can cause serious liver disease including both cirrhosis and liver cancer (hepatocellular carcinoma, HCC). The risk of HCC is elevated in people with cirrhosis and also in people with hepatitis/HIV co-infection.

HCC treatment is more likely to be successful if the cancer is diagnosed promptly. Clinical guidelines from the European Association for the Study of the Liver (EASL), American Association for the Study of Liver Diseases (AASLD) and European AIDS Clinical Society (EACS) therefore all recommend that adults with cirrhosis should be screened with ultrasound scans for HCC every six months.



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. 


A doctor, nurse or other healthcare professional who is active in looking after patients.


A type of cancer that starts in the cells of the skin or the tissues that cover and line the body cavities and organs. At least 80% of all cancers are carcinomas.


An alternative term for ‘adherence’.


The study of the causes of a disease, its distribution within a population, and measures for control and prevention. Epidemiology focuses on groups rather than individuals.

Although the screening interval is the same, regardless of co-infection, previous US studies have shown low adherence to the guideline, with between 13 and 51% of people with hepatitis monoinfection screened every six months. 

Dr Sophie Willemse and colleagues pooled data from the Collaboration of Observational HIV Epidemiological Research in Europe (COHERE). Their aim was to assess compliance with HCC screening guidelines in a large European cohort of HIV-positive people with hepatitis B or C co-infection and cirrhosis.

A total of 646 people were included in the analysis, with data collected between 2005 and 2015. Only the four participating cohorts which routinely record document ultrasound results were included, reflecting practice in the Netherlands, France, Austria and Italy.

Participants had co-infection with hepatitis B (13%), hepatitis C (80%) or both (7%). They had been diagnosed with cirrhosis for a median of five years and 93% were taking antiretroviral therapy. Probable HIV transmission routes were injecting drug use (57%), sex between men (20%) and sex between men and women (12%).

The proportion of participants screened within the previous six months varied between 5.4% in 2005, 18.4% in 2008 and 14.2% in 2014.

Figures for screening within the previous 12 months were not much better: 7%, 26% and 30% respectively.

There was better adherence to guidelines for people with more frequent clinic visits. Those diagnosed with cirrhosis for a longer period of time had somewhat better screening, possibly reflecting a more stable situation where both patient and clinician are aware of the importance of regular follow-up.

The authors say multiple factors may contribute, including limited clinician awareness of guidelines and the absence of systems to schedule and follow up screening visits. “This finding warrants urgent action to ensure better implementation of HCC screening guidelines,” they say.


Willemse S et al. Low compliance with hepatocellular carcinoma screening guidelines in hepatitis B/C virus co-infected HIV-patients with cirrhosis. Journal of Viral Hepatitis, online ahead of print, 28 May 2019. (Full text freely available).