Since the introduction of HAART in the late 1990s study after study has shown that people with HIV are living longer, healthier lives. However, a study conducted by investigators at Johns Hopkins University in Baltimore has revealed evidence that between 1995 and 2000 the rate of hospitalisation amongst individuals coinfected with HIV and hepatitis C virus (HCV) increased significantly. The study is published in the October 1st edition of the Journal of Acquired Immune Deficiency Syndromes.
Johhs Hopkins University provides HIV treatment and care to an overwhelming poor, African-American patient population in east Baltimore. In common with other HIV cohorts with access to HAART, rates of hospitalisation in the Johns Hopkins cohort fell with the introduction of HAART in 1995-96. Doctors, however, noted stabilisation in the number of hospitalisations between 1996 and 1998 and an increase in the overall number of admissions from 1998 and 2000. Liver related causes were hypothesised to be the cause of this increase in earlier published studies.
In a prospective cohort study, which longitudinally followed 3750 patients between 1995 and 2000 investigators from Johns Hopkins sought to examine trends in hospital and intensive care admissions over time, to examine if any clinical or demographic characteristics emerged. They stratified their results according to HCV status.
A total of 9,275 person years of follow-up were contributed to the study. The overwhelming majority of patients included in the cohort were African American (76.9%), male (67.5%) and had injecting drug use as their HIV risk activity (47.4%). A substantial minority of the cohort (42.8%) was coinfected with HCV.
Causes of hospitalisation were placed into one of four mutually exclusive categories: HIV opportunistic infection; injecting drug use-related; liver related; and other.
Patients who were coinfected with HCV were more likely to be injecting drug users, but there were no statistically significant demographic differences between the HCV-positive and uninfected members of the cohort.
Amongst HCV-negative patients, hospitalisation rates fell by a third between 1995 and 1996 (60 per 100 patient years of follow-up to 48 per 100 patient years) and then remained constant at approximately 40 per 100 patient years of follow-up between 1997 and 2000. Of particular note was the dramatic and sustained fall in hospitalisations due to HIV-related opportunistic infections from 35.5 per 100 patient years to 12 per 100 patient years during this interval. There was a slight, but not statistically significant increase in injecting drug use-related hospitalisations amongst HCV-negative patients from 4.6 per 100 patient years in 1995 to 6.8 per 100 patient years in 2000 (p=0.78).
By contrast, hospitalisation rates amongst the HCV-positive patients increased significantly from 55.4 per 100 patient years in 1995 to 62.9 in 2000. There was a significant increase in hospitalisations due to drug-related causes between 1995 and 2000 from 13.6 to 18.4 per 100 patient years. Admissions for liver-related causes increased five-fold (5.4 – 26.7 per 100 patient years) over the study period amongst the coinfected patients.
Mean duration of hospitalisation was seven days for both the HCV-positive and HCV-negative patients.
In multivariate analysis admission to hospital was associated with being HCV-positive (incidence rate ratio [IRR] 1.75, 95% CI: 1.47 – 2.07); female gender (IRR 1.75, 95% CI: 1.32 – 1.85); African American race (IRR 1.30, 95% CI: 1.05 – 1.61); age under 37 years (IRR 1.19, 95% CI: 1.01 – 1.41); and, a CD4 cell count below 200 cells/mm3 in 1998 (IRR 1.32, 95% CI: 1.07 – 1.63). A viral load below 100,000 copies/mL was found to be protective against admission (p
Intensive care was used by 7.3% of all admissions, and there was a non-significant trend (p=0.07) for HCV-positive patients to need more intensive care than HCV-negative individuals between 1998 and 2000.
The Johns Hopkins investigators conclude: “Our data suggest that overall hospitalization rates decreased significantly between 1995 and 1996 corresponding to the introduction of HAART; however our results are intriguing in that they show an increase in overall hospitalization rates between 1998 and 2000 compared to the nadir from 1996 to 1997 in our HCV-coinfected patients. The results suggest that there should be increased efforts to prevent the spread of HCV and perhaps to treat HIV/HCV coinfected patients. The rates of hospitalization have important implications for the potential costs of medical care in HIV/HCV-coinfected patients”.
Further information on this website
Hepatitis C - overview
Hepatitis C - factsheet
HIV and hepatitis - booklet in the information for HIV-positive people series (pdf)
HIV/HCV coinfected patients at increased risk of death and hospitalisation in the HAART-era - news story
AIDS deaths in the HAART era examined at Paris conference - news story
AIDS deaths down, but new causes of death at largest UK HIV clinic -new story
Gebo KA et al. Hospitalization rates differ by hepatitis C status in an urban HIV cohort. JAIDS 34: 165 – 173, 2003.