Co-infection with hepatitis C increases mortality risk by 50% for patients with AIDS

Co-infection with hepatitis C increases the risk of death for patients with AIDS by 50%, according to the results of a large study published in the online edition of Clinical Infectious Diseases. A fifth of these deaths were attributable to liver-related causes, five times the rate seen in people with AIDS who were not co-infected.

The investigators also found that a third of co-infected patients were unaware of their hepatitis C infection.

“The negative impact of liver disease on survival emphasises the need for patients with AIDS to be aware of their HCV [hepatitis C virus] status so that they can fully participate in their health care and risk reduction,” comment the authors. “Heightened HCV awareness may increase the proportion of patients seeking treatment and achieving a SVR [sustained virological response].”

Few deaths in HIV-positive people were attributable to liver disease in the period before effective antiretroviral treatment became available. However, large numbers of people with HIV are co-infected with hepatitis C virus and liver disease caused by this infection is now an increasingly important cause of death among these co-infected people.

A meta-analysis of studies has shown that coinfection increases the risk of death by around 35% in people with HIV and hepatitis C. Nevertheless, it remains unclear if hepatitis C increases the risk of death for patients who have progressed to AIDS and who continue to have an elevated risk of death due to HIV-related causes. 35,000 people were diagnosed with AIDS in 2009 in the United States alone, so this remains a pressing question even for developed countries, due to high rates of late diagnosis and poor access to care for marginalised populations.

To gain a clearer understanding of this issue, a team of US investigators analysed mortality records for 2026 AIDS patients who received care between 1998 and 2009.

Blood samples obtained from the patients on entry to the study were tested for hepatitis C antibodies and viral load

A total of 421 patients (21%) had evidence of past or current hepatitis C infection. This included 91 patients (21%) who had apparently cleared the infection.

There were 558 deaths during a median of 6.1 years of follow-up.

After adjusting for other risk factors, the results showed that chronic hepatitis C co-infection increased the risk of death by 50% (RR = 1.5; 95% CI, 1.2-1.9; p = 0.001). Prior infection with hepatitis C did not increase the risk of death.

Of the 113 deaths in people co-infected with chronic hepatitis C, some 20% were attributed to liver-related causes. This compared to just 4% of deaths in people who did not have hepatitis C.

“Patients with chronic infection were more than five times more likely to die of liver-related causes than patients with no markers of HCV (p < 0.0001),” note the authors.

Questioning of patients revealed that almost third of individuals with chronic hepatitis C were unaware of their infection.

“Research is needed to determine whether the failure to accurately report positive HCV status reflected failure of physicians to test for HCV, lack of communication, miscommunication, or denial,” write the researchers.

The research may also have implications for hepatitis C screening strategies. The results showed that 7% of patients with chronic infection would have been undiagnosed had they relied on hepatitis B antibody tests.  

“Our results underscore the urgency of efforts to screen AIDS patients for HCV and to make sure that the test results and their implications are clearly communicated,” conclude the investigators. “Broader screening and more patient education are needed to maximize the benefits of new [HCV] treatments and to lower liver-related mortality.”

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