Coinfection

EASL 2013: HIV/HCV Coinfected at Risk for Decompensation, May Need Prompt Treatment

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HIV positive people with hepatitis C coinfection may experience liver decompensation with advanced fibrosis, even before they progress to cirrhosis, and may therefore benefit from earlier antiviral treatment, researchers reported at the EASL International Liver Congress (EASL 2013) last month in Amsterdam.

The advent of direct-acting antivirals (DAAs) has changed the treatment paradigm for hepatitis C. The first HCV protease inhibitors -- boceprevir (Victrelis) or telaprevir (Incivek or Incivo) -- improve cure rates compared with pegylated interferon and ribavirin alone, but their high cost and added side effects limit their use.

More effective and better-tolerated second-generation agents are in the pipeline, with the first expected to emerge by the end of 2013. While many patients and providers are awaiting all-oral DAA regimens without interferon, many people with advanced liver disease need treatment now and cannot wait. HIV/HCV coinfected patients experience faster disease progression than those with HCV alone, and therefore may be candidates for earlier therapy.

Juan Macias from Hospital Universitario de Valme in Seville and colleagues assessed the risk of hepatic decompensation among HIV positive people with chronic hepatitis C coinfection who had advanced fibrosis or cirrhosis.

The researchers presented findings from 2 retrospective cohorts of coinfected patients, one with liver disease stage determined by traditional biopsies (n=317), the other estimated using liver stiffness measurements, or FibroScan (n=575). In both cohorts most participants were men, about 85% had a history of injection drug use, the median age was about 43 years, and about 60% had HCV genotype 1. At baseline the median CD4 T-cell count was 450 cells/mm3, most were on antiretroviral therapy, and a majority had suppressed HIV viral load. While 45% had previously been treated for hepatitis C, about 40% were prior null responders. In the biopsy cohort, 47% had advanced fibrosis (Metavir stage F3) and 53% had cirrhosis (stage F4). In the FibroScan cohort, the median liver stiffness was 15.4 kiloPascals (kPa).

Results

  • In the biopsy cohort, the incidence of decompensation was 1.4 per 100 person-years for people with stage F3 fibrosis and 3.1 per 100 person-years for those with stage F4 cirrhosis.
  • Among patients with F3 fibrosis, the probability of decompensation was 1% at 1 year, 2% at 3 years, and 5% at 5 years.
  • Among patients with cirrhosis, the corresponding probabilities were 4%, 13%, and 23%.
  • In the FibroScan cohort, the incidence of decompensation was 0.9 per 100 person-years for people with liver stiffness measurements of 9.5-14.5 kPa and 4.0 per 100 person-years for those with >14.6 kPa.
  • Among patients with 9.5-14.5 kPa, the probability of decompensation was 1% at 1 year, 3% at 3 years, and 4% at 5 years.
  • Among patients with >14.6 kPa, the probabilities were 7%, 17%, and 27%, respectively.
  • In a multivariate analysis of the biopsy cohort, having stage F4 cirrhosis vs F3 fibrosis was the only significant predictor of decompensation.
  • In the FibroScan cohort, both low platelet count and liver stiffness above the 14.6 kPa cutoff predicted decompensation.

"As in patients with cirrhosis, immediate therapy against HCV is warranted for patients with pre-cirrhosis and HIV coinfection, as they are at risk of liver decompensations soon after the diagnosis of advanced fibrosis," the investigators advised.

5/15/13

Reference

J Macias, A Camacho, MA von Wichmann, et al. Advanced fibrosis and the risk of liver decompensation among HIV/HCV-coinfected individuals: consequences for the timing of therapy against HCV. 48th Annual Meeting of the European Association for the Study of the Liver (EASL 2013). Amsterdam. April 24-28, 2013. Abstract 474.