Coinfection

Hepatitis B and C Coinfection among HIV Positive People in the U.S.

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Liver disease and coinfection with hepatitis B or C are common among people with HIV, according to a recent analysis, leading researchers to recommend that viral hepatitis screening, vaccination, and treatment should be considered a priority for HIV positive individuals.

Since the advent of effective antiretroviral therapy (ART), liver disease -- often related to hepatitis B virus (HBV) or hepatitis C virus (HCV) coinfection -- has become a leading cause of illness and death among people with HIV.

As described in the April 14, 2011, World Journal of Gastroenterology, Susan Buskin from the Seattle and King County Department of Public Health and colleagues evaluated trends and risk factors for liver disease and viral hepatitis among HIV positive people age 13 and older.

The analysis included 29,490 participants in the Adult/Adolescent Spectrum of HIV-related Diseases Project, a multicenter review sponsored by the Centers for Disease Control and Prevention (CDC) that looked at medical records of HIV patients at more than 100 medical facilities in Atlanta, Dallas, Denver, Detroit, Houston, Los Angeles, New Orleans, New York City, Puerto Rico, San Antonio, and Seattle.

The project started collecting information in 1990, but the present analysis was restricted to data obtained data between 1998 and 2004 (not long after the widespread adoption of combination ART).

Every 6 months researchers collected data about presentation, treatment, and outcomes of HIV disease and associated conditions, including presence of liver disease, hepatitis screening, and hepatitis diagnosis. Participants were followed for 2.4 years on average, contributing a total 69,487 person-years of observation.

Results

  • Overall, 3% of cohort participants were diagnosed with liver disease, 8% with chronic hepatitis B, and 19% with hepatitis C; 2% had both hepatitis B and C.
  • 25% had a liver disease diagnosis at baseline (first record examined), while 75% developed new liver disease during follow-up.
  • The rate of chronic hepatitis B diagnosis showed a small but significant rise, from 7% in 1998 to 9% in 2004.
  • The rate of hepatitis C diagnosis nearly tripled over the same period, from 9% to 24%.
  • 832 participants diagnosed with liver disease had the following conditions:
    • 31% with non-alcoholic cirrhosis (or alcohol not specified as a cause);
    • 20% with alcoholic cirrhosis;
    • 3% with a primary liver cancer;
    • 3% with liver failure not otherwise specified;
    • 29% with other liver disease.
  • Over the course of follow-up, the rate of new or incident liver disease was 0.9 cases per 100 person-years.
  • The incidence of chronic hepatitis B was 1.8 per 100 person-years, and the rate for hepatitis C was 4.7 per 100 person-years.
  • Significant risk factors for new chronic hepatitis B diagnosis included male sex, men having sex with men, lower nadir (lowest-ever) CD4 T-cell count, injection drug use, alcohol use, and triple infection with HCV.
  • Significant risk factors for new hepatitis C diagnosis included male sex, older age, white or Latino race/ethnicity, triple infection with HBV, injection drug use (4.7-fold higher risk), and hemophilia (7-fold higher).
  • In a multivariate analysis, independent predictors of liver disease included:
    • Older age, history of injection drug users, heavy alcohol consumption, and diagnosis of AIDS (CD4 T-cell count < 200 cells/mm3) was associated with greater risk.
    • Black patients had a lower rate than other racial/ethnic groups.
    • Neither ART use overall nor use of specific antiretroviral drugs was positively or negatively associated with liver disease after controlling for other factors including HBV and HCV.
  • 25 participants were diagnosed with liver cancer, including 15 with hepatocellular carcinoma; 2 of these patients were lost to follow-up and the rest died.
  • 13 patients with liver cancer had HCV and 10 had chronic HBV (including 2 people with both).
  • Mortality was much higher among people diagnosed with liver disease, 57% compared with 15% for the study population overall.
  • 10% of all deaths occurred among participants with liver disease.
  • An estimated 1% of all deaths may have had liver disease as a cause or contributing factor, rising to 2% among people with HBV or HCV.
  • The likelihood of HBV and HCV screening increased significantly during the study period -- from less than 20% to more than 60% -- but repeat screening was uncommon, even for people with ongoing risk of infection.
  • Less than one-third of people without prior hepatitis B had a record of HBV vaccination, although this increased from 10% to 28% during the study period.

The researchers noted that despite care guidelines calling for HBV vaccination and hepatitis B and C screening for people with HIV, these were not universally performed (or if done, were not documented).

Based on these findings, they concluded, "Due to high rates of incident liver disease, viral hepatitis screening, vaccination, and treatment among HIV-infected individuals should be a priority."

"Although HBV vaccination rates have improved and screening rates for HBV and HCV have climbed steadily, they are still inadequate, and efforts are needed to improve vaccination and screening rates," they elaborated in their discussion.

"The high rates of incident HCV (5/100 person-years) indicate that individuals at risk should be screened and while remaining at risk, re-screened on a regular basis. Similarly, a sizable HBV incidence (2/100 person-years) supports improved screening and vaccination," they continued.

"Until better data are available, annual screenings for HCV and HBV vaccination discussions are suggested," they recommended. "Treatment of HBV and HCV should be considered for all HIV co-infected individuals."

Investigator affiliations: Public Health, Seattle and King County, WA; University of Washington, Seattle, WA; Harborview Medical Center, Seattle, WA; Virginia Mason Medical Center, Seattle, WA.

9/13/11

Reference

SE Buskin, EA Barash, JD Scott, et al. Hepatitis B and C infection and liver disease trends among human immunodeficiency virus-infected individuals. World Journal of Gastroenterology 17(14):1807-1816 (full text). April 14, 2011.