Antiretrovirals Reduce Liver Decompensation in HIV/HCV Coinfected


Starting antiretroviral therapy (ART) reduces the likelihood that HIV positive people coinfected with hepatitis C virus (HCV) will develop decompensated liver disease, according to a report published in the November 27, 2013, advance edition of Clinical Infectious Diseases.

Over years or decades, chronic HCV infection can lead to serious liver disease including cirrhosis, hepatocellular carcinoma, liver failure, and death. HIV/HCV coinfected people experienced more rapid liver disease progression, on average, than people with HCV alone and do not respond as well to interferon-based hepatitis C treatment.

Jeffrey Anderson from Harvard School of Public Health and colleagues conducted a study to evaluate the effect of combination ART on HCV-associated liver failure in coinfected patients.

The analysis included 10,090 HIV/HCV coinfected men in the Veterans Aging Cohort Study Virtual Cohort who had not yet started ART at enrollment. About 60% were black, the median age was 47 years, and 8% had triple-infection with hepatitis B virus. Most (82%) had detectable HIV viral load and about one-third had a low CD4 T-cell count below 200 cells/mm3 at study entry.

The researchers collected data on incidence of liver decompensation between 1996 and 2010. Hepatic decompensation was defined as the first occurrence of 1 hospital discharge diagnosis or 2 outpatient diagnoses for ascites (abdominal fluid accumulation), spontaneous bacterial peritonitis (abdominal infection), or esophageal variceal hemorrhage (bleeding veins in the throat).

A majority of participants (69%) started ART during the study, defined as filling a prescription for at least 3 drugs from at least 2 antiretroviral classes for the first time. About one-third started interferon-based therapy for hepatitis C. The median follow-up period was about 3 years.


  • A total of 645 liver decompensation events were observed over 46,444 person-years of follow-up.
  • The incidence rate of decompensation was 1.4 per 100 person-years.
  • HIV/HCV coinfected patients who started ART had a significantly lower rate of liver decompensation compared with those who did not start (hazard ratio 0.72, or nearly 30% lower risk).
  • After omitting 1876 patients with low HIV RNA (<400 copies/mL) at baseline -- suggesting they might actually have been on unreported ART -- the hazard ratio was even more pronounced (HR 0.59, or 41% risk reduction).

"Initiation of ART significantly reduced the rate of hepatic decompensation by 28%-41% on average," the study authors concluded. "These results suggest that ART should be administered to HIV/HCV coinfected patients to lower the risk of end-stage liver disease."

"Taken together with the body of available literature, our results suggest a significant benefit of ART for coinfected patients, and serve to inform therapeutic strategies as caregivers face the continuing challenges of chronic hepatitis in HIV-infected individuals," they added in their discussion.

Current U.S. antiretroviral treatment guidelines recommend that everyone who tests HIV positive should consider starting ART regardless of CD4 T-cell count. European guidelines still maintain a treatment initiation threshold of 350 cells/mm3, but add that people with a number of comorbid conditions -- including HIV/HCV coinfection -- should start antiretroviral treatment sooner.



JP Anderson, EJ Tchetgen Tchetgen, V Lo Re, AC Justice, et al. Antiretroviral Therapy Reduces the Rate of Hepatic Decompensation Among HIV- and Hepatitis C Virus–Coinfected Veterans. Clinical Infectious Diseases. November 27, 2013 (Epub ahead of print).