Men infected with both HIV and hepatitis B are nineteen times more likely to die of liver related causes than men infected only with hepatitis B, and eight times more likely to die of liver disease than men who are only infected with HIV. This is the core finding of a study conducted in the long-running Multicenter AIDS Cohort Study (MACS) by investigators at Johns Hopkins University and published in the 14th December 2002 edition of The Lancet.
The investigators recruited 5293 men to the study from participants in MACS. A total of 213 men were found to be coinfected with HIV and hepatitis B, and 139 men were infected with hepatitis B alone. Just under 5,000 men in the study did not have hepatitis B and of these, 47% (2,346) were HIV-positive. The HIV/hepatitis B coinfected and hepatitis B monoinfected groups shared similar background characteristics, including age, number of sexual partners, ethnic origin, and amount of alcohol consumed each week. However, the investigators found that coinfected patients were more likely to have injected drugs and to have had lower nadir CD4 counts.
Follow-up was every six months for an average of 10.5 years. During the study 62 patients died of liver-related causes. Of these, 61 were coinfected. CD4 count below 100 cells/mm3 was associated with an increased risk of liver related death, and the investigators also noted that deaths from liver disease doubled after the introduction of HAART in 1996.
Investigators also looked at the impact of 3TC (lamivudine) use on mortality. 3TC is active against both HIV and hepatitis B. The investigators found no relationship between 3TC use and the risk of death, nor was any relationship found between discontinuation of 3TC use and liver related death, but the researchers acknowledged “sparse” data.
The hepatitis C status of patients in the study was also available for 60 of the coinfected men who died of liver disease. Of these 12 tested positive for hepatitis C.
Possible reasons for the increase in liver-related deaths since the introduction of HAART were suggested by the authors, including drug toxicity; stopping 3TC treatment (although insufficient data were available to reach a conclusion on this); living longer with hepatitis B because of the success of HAART at extending HIV life expectancy; and HAART-induced immune responses to hepatitis B.
The authors also warn that higher rates of death from liver disease may ultimately be seen in the hepatitis B monoinfected patients, as “it is likely that these men acquired HBV infection as adults”, adding “it is possible that too little time had passed for death from liver failure to occur.”
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Thio CL et al HIV-1, hepatitis B virus, and the risk of liver related mortality in the Multicenter Cohort Study. The Lancet, 360: 1921-1926, 2002.