Starting antiretroviral therapy significantly reduces the risk of decompensated liver disease for men with HIV/HCV co-infection

Starting antiretroviral therapy (ART) significantly reduces the risk of serious liver disease for people with HIV and hepatitis C virus (HCV) co-infection, results of a large US study published in the online edition of Clinical Infectious Diseases show.

Initiating HIV therapy reduced the risk of decompensated liver disease by between 28 and 41%.

The findings support current US treatment guidelines that recommend antiretroviral therapy for all patients with HIV and hepatitis C co-infection.

“Our results favor treatment of HIV in patients coinfected with HCV,” write the authors, who assert their findings “provide direct evidence to support recent clinical guidelines recommending consideration of ART initiation in HIV/HCV coinfected individuals, regardless of CD4 cell count.”

Between a quarter and a third of people living with HIV in the US have hepatitis C co-infection. HIV can accelerate hepatitis C disease progression and liver disease is now a leading cause of death in people with this co-infection.

The benefits of starting antiretroviral therapy in terms of hepatitis C disease progression are unclear. Some cross-sectional studies have suggested that HIV treatment can slow the course of hepatitis C disease, but there are also concerns in some quarters that antiretroviral therapy could lead to immune reconstitution illness, increasing the risk of decompensated liver disease.

To further elucidate the benefits or HIV treatment for people with HIV and hepatitis C, investigators from the Veterans Aging Cohort Study Virtual Cohort (VACS VC) designed a longitudinal study involving approximately 10,000 people with HIV and hepatitis C co-infection. All received care between 1996 and the present day and were antiretroviral naive when they entered the cohort.

The risk of hepatic decompensation (hospital admission with this diagnosis or the presence of two or more outpatient diagnoses for ascites, spontaneous bacterial peritonitis or oesophageal variceal haemorrhage) was compared between people who started HIV therapy and those who remained treatment naive.

All the study participants were men and none were documented as having received HIV therapy at baseline. A little under two-thirds (61%) were black and the median age on entry to the cohort was 47 years. Chronic hepatitis B infection was present in 8% of individuals. Over a third (36%) of patients had a baseline CD4 cell count below 200 cells/mm³ and 82% had a detectable baseline viral load.

The participants were followed for a median of 3.1 years and contributed 46,444 person years of follow-up. During this time, 36% of individuals initiated interferon-based hepatitis C treatment. A total of 6935 people (69%) started HIV therapy over the course of the study.

Hepatic decompensation was recorded in 645 individuals (6%), an incidence rate of 1.4 per 100 person-years.

Overall, starting HIV therapy reduced the risk of hepatic decompensation by 28% (HR = 0.72; 95% CI, 0.54-0.94).  

The investigators excluded the 1876 individuals who had a viral load below 400 copies/ml at baseline despite no documented HIV therapy. Analysis of this population showed that initiating ART reduced the risk of decompensated liver disease by 41% (HR = 0.59; 95% CI, 0.43-0.82).

“We have demonstrated an average 28-41% reduction in the rate of hepatic decompensation for ART initiators relative to non-initiators in our study population of HIV/HCV-coinfected male veterans,” conclude the authors. “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.”