Decompensated cirrhosis increases risk of liver cancer for people with HIV and viral hepatitis co-infection

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There is a relatively low incidence of hepatocellular carcinoma (HCC) among people living with HIV who have liver cirrhosis, results of a prospective Spanish study published in the online edition of the Journal of Acquired Immune Deficiency Syndromes show. During five years of follow-up, the overall incidence was 6.72 per 1000 person-years. But incidence was significantly higher among the participants with decompensated cirrhosis at the start of the study compared to participants with compensated cirrhosis. All the study participants had hepatitis C virus (HCV) and/or hepatitis B virus (HBV) co-infection.

“An important finding of our study was a clear trend towards a higher incidence of HCC among patients with decompensated cirrhosis as compared with those with compensated cirrhosis,” comment the authors.

Large numbers of people living with HIV have HBV and/or HCV co-infection. These co-infections can cause liver cirrhosis. Liver disease, including HCC, is now an important cause of serious illness and death in this group.



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. 

hepatitis B virus (HBV)

The hepatitis B virus can be spread through sexual contact, sharing of contaminated needles and syringes, needlestick injuries and during childbirth. Hepatitis B infection may be either short-lived and rapidly cleared in less than six months by the immune system (acute infection) or lifelong (chronic). The infection can lead to serious illnesses such as cirrhosis and liver cancer. A vaccine is available to prevent the infection.

decompensated cirrhosis

The later stage of cirrhosis, during which the liver cannot perform some vital functions and complications occur. 

prospective study

A type of longitudinal study in which people join the study and information is then collected on them for several weeks, months or years. 

compensated cirrhosis

The earlier stage of cirrhosis, during which the liver is damaged but still able to perform most of its functions. 

Information on the risk of HCC for people living with HIV who have liver cirrhosis is largely derived from retrospective studies involving people taking sub-optimal antiretroviral therapy.

Investigators in Spain wanted to gain a clearer understanding of rates and risk factors for HCC during the era of modern HIV medicine. They therefore designed a prospective study involving people living with HIV who had cirrhosis; were receiving care at hospitals across Spain between 2004 and 2005; and who continue to be monitored. The investigators examined incidence of HCC, its epidemiological characteristics, clinical presentation and outcome.

Participants were followed every six months. In the present study, the investigators examined five-year follow-up data.

The study cohort comprised 371 patients. Most (95%) had HCV co-infection and HBV was present in 5%. Approximately three-quarters of participants were diagnosed with cirrhosis three years before their enrolment in the present study. Just over a quarter of individuals (26%) had decompensated cirrhosis at the time of their recruitment to the cohort. At baseline, 90% were taking HIV therapy and 60% had an undetectable viral load.

The participants in the study were followed for a median of 60 months. During this time, ten were diagnosed with HCC. Nine of these individuals had HCV co-infection and one had HBV. At the clinic visit before HCC diagnosis, all the participants had a CD4 cell count above 100 cells/mm3 and were taking antiretroviral therapy, 90% had an undetectable viral load.

Six people died after the diagnosis of HCC. Two people underwent liver transplantation.

The overall incidence of HCC was 6.72 per 1000 person-years and the cumulative incidence rate was 2.7%.

Incidence rates were significantly higher among people with decompensated cirrhosis at baseline (20 per 1000 person-years) than in people with compensated cirrhosis (4 per 1000 patient-years).

Incidence was similar in people with and without HCV co-infection, HBV co-infection and triple infection with HIV, HCV and HBV.

The overall probability of developing HCC after six years of follow-up was 3%. The probability was higher for people with decompensated cirrhosis at baseline compared to those with compensated disease (5.8 vs 2%).

The probability of progressing to HCC for people with baseline compensated cirrhosis was 1% at two years and 2% at years four and six. This compared to a probability of 2% at year two and 5.8% at years four and six for the people with decompensated cirrhosis.

“Our prospective cohort of cirrhotic patients with adequate control of HIV infection shows a relatively low probability of developing HCC,” write the authors. “Incidence of HCC is…higher in patients with decompensated liver disease at baseline.”

Follow-up of the participants will continue and the investigators are hopeful this will provide evidence of “changing trends in the incidence of HCC in HIV-infected patients with liver cirrhosis and viral hepatitis co-infection.”


Ramirez MLM et al. Incidence of hepatocellular carcinoma in HIV-infected patients with cirrhosis: a prospective study. The “GESIDA Cirrhosis Study Group”. J Acquir Immune Defic Syndr, online edition. DOI: 10.1097/QAI.0b013e3182a685dc, 2013.