Liver disease now the major cause of death amongst HIV-positive men with haemophilia in UK

Less than a quarter of HIV-positive men with haemophilia in the United Kingdom are still alive 20-25 years after infection with HIV, report investigators from the Royal Free Hospital in the September 16^th online edition of the British Medical Journal. The investigators also note that since effective anti-HIV treatment became available, liver disease has become the major cause of death amongst HIV-positive men with haemophilia.

It is thought that the first case of HIV infection in a man with haemophilia occurred in 1979. After HIV was identified, measures were taken to protect the UK’s blood supply from HIV and no new HIV infections via the blood supply have occurred in the UK since these precautions were introduced. Therefore all the men in the Royal Free cohort were infected with HIV 25 – 20 years ago.

The Royal Free Hospital is the leading UK centre for the treatment of haemophilia and HIV and has provided treatment and care to 111 HIV-positive men with haemophilia since the early 1980s. All the men also have hepatitis C virus coinfection. Although the majority of patients died before effective anti-HIV therapy became available in 1996, doctors from the Royal Free undertook a review of those individuals still alive “to determine their long term outcomes and to assess the impact of coinfection with hepatitis C virus.”

Follow-up was calculated to the time of death, last clinic visit or the end of 2004. The median duration of follow-up was 14 years. By December 31^st 2004, 53% of the entire cohort had developed AIDS and 67% had died.

Since 1996 there were six new AIDS diagnoses in the cohort, but 20 deaths. This compared to 53 AIDS diagnoses and 54 deaths before the introduction of potent HIV treatment.

Liver disease has been the main cause of death since 1996 (seven cases), with five deaths attributed to HIV, five to non-HIV-related causes and three to unknown causes. This represents a significant shift in cause of death compared to the era before effective HIV treatment, when 78% of deaths were attributable to HIV and only 9% to liver-related causes.

At the end of 2004, a total of 23 individuals were still receiving care at the Royal Free and 20 were taking anti-HIV treatment. Even though most had started antiretroviral therapy before potent therapy became available (the median duration of treatment being ten years) and had taken a median of seven anti-HIV drugs, all had a viral load below 50 copies/ml and the median CD4 cell was 326 cells/mm³.

“A small proportion of haemophilic men infected with HIV 20 – 25 years ago remain alive and well”, comment the investigators. They note the beneficial effects of anti-HIV therapy in the cohort, but emphasise that “hepatitis C virus continues to cause deaths” and that “continued development of new antiviral agents for both HIV and hepatitis C virus are essential to maintain the health of these patients.”