Hepatotoxicity associated with nevirapine or efavirenz-containing antiretroviral therapy: role of hepatitis C and B infections

Liver function tests, CD4+ counts, and viral load among people living with HIV on dolutegravir compared to efavirenz-based cART; a comparative cross-sectional study

Background

Recently, dolutegravir-based therapy has become the first-line treatment when compared to others. However, dolutegravir-associated side effects in the liver and levels of efficacy haven't been addressed yet in underdeveloped countries such as Ethiopia.

Objective

The purpose of this study was to compare liver function tests, CD4+ counts, and viral load among people living with HIV on dolutegravir and efavirenz-based antiretroviral regimens at Debre Markos Comprehensive Specialized Hospital in Northwest Ethiopia.

Methods

An institutional-based comparative cross-sectional study was carried out from May 20 to July 10, 2020. An equal number of dolutegravir and efavirenz-prescribed patients (n = 53 each) for 6 months and above were included, and a judgmental sampling technique was used. A comparison of categorical and continuous parameters was analyzed with chi-square and an independent t-test, respectively, using SPSS version 26. A multivariable logistic regression was conducted and considered statistically significant at a p-value of <0.05.

Results

The magnitude of liver enzyme (AST/ALT) abnormalities was 22.4 % (12/53) and 30.2 % (16/53) among dolutegravir- and efavirenz-prescribed patients, respectively. The dolutegravir group had significantly higher mean CD4+ counts than the efavirenz group (589.40 ± 244.38 vs. 450.64 ± 203.54 cell/mm3; p = 0.002). The efavirenz group had a significantly higher mean viral load than the dolutegravir group (783.83 ± 476.82 vs. 997.98 ± 439.11 cp/ml; p = 0.032). There was a statistically insignificant difference in AST (p = 0.709) or ALT (p = 0.687) between dolutegravir and efavirenz-based regimens. The multivariable logistic regression analysis revealed that BMI ≥25 kg/m2 was associated with liver enzyme abnormalities (AOR = 6.60, 95 % CI: 1.17, 42.82).

Conclusion

A dolutegravir-based regimen was more likely to result in patients achieving higher efficacy for viral suppression and a CD4+ count increase. Although the differences were statistically insignificant, the mean AST and ALT levels were marginally higher in efavirenz-treated groups than in dolutegravir-treated groups.

Chronic Liver Enzyme Elevation and Use of Contemporary ARVs Among People With HIV

Background

While use of some older antiretroviral drugs (ARVs) is associated with chronic liver enzyme elevation (cLEE), the impact of newer ARVs remains unknown.

Methods

People with HIV enrolled in the RESPOND cohort who started an ARV after January 1, 2012 were included (baseline). The primary outcome was first cLEE individuals were censored at first of cLEE, last visit, death, or December 31, 2021. Incidence rates (IRs; events/1000 person-years) were calculated for each ARV overall and by ARV exposure (6-12 months, 1-2 years, and 2+ years). Poisson regression was used to estimate the incidence rate ratio (IRR) of cLEE and its association with individual ARVs and ARV class.

Results

Of 17 106 individuals included contributing 87 924 person-years of follow-up, 1932 (11.3%) experienced cLEE (incidence rate [IR], 22.0; 95% CI, 21.0-23.0). There was no evidence of a cumulative ARV effect on cLEE incidence, (6-12 months: IR, 45.8; 95% CI, 41.4-50.19; 1-2 years: IR, 34.3; 95% CI, 31.5-37.4; and 2+ years: IR, 18.5; 95% CI, 17.4-19.7). Any use (vs no prior use) of non-nucleoside reverse transcriptase inhibitors (NNRTIs) as a class and tenofovir disoproxil fumarate (TDF) was independently associated with an increased IRR of cLEE, and any use of darunavir (DRV) was associated with a decreased risk of cLEE.

Conclusions

cLEE is common and more frequent during the first year after initiating new ARVs. With a >5-year median follow-up, we found no short-term liver safety concerns with the use of INSTIs. Use of NNRTIs and TDF was associated with an increased cLEE risk, while DRV was associated with lower risk.

Time to develop adverse drug reactions and associated factors among children HIV positive patients on antiretroviral treatment in North West Amhara Specialized Hospitals: Retrospective cohort study, 2022

Introduction

Adverse drug reactions (ADRs) are harmful and unintended reactions to medicines given at standard doses through a proper route of administration for the purpose of prophylaxis, diagnosis, or treatment.

Objective

The objective of this research paper was to assess median time to development of ADRs and associated factors among children HIV positive patients on antiretroviral treatment (ART) in North West Amhara Specialized Hospitals.

Methods

The adverse drug effect survival time was estimated using the Kaplan-Meier survival method and log-rank test curves was applied for analyze "time-to-event" data. Cox regression model was used to identify the associated factors. Adjusted hazard ratios with their respective 95% confidence intervals (CIs) were estimated and a value of p less than 0.05 was used to declare the presence of a significant association.

Result

The overall incidence of ADRs was 0.67 (95% CI: 3.74-4.44) per 10,000 person-year observation, with a median of 57 months. Adults are presenting with opportunistic Infections (OIs) experiences, baseline CD4 < 200 cells/µL counts, 1e, tenofovir disoproxil fumarate-lamivudine-efavirenz ART regimen, bedridden baseline functional status, World Health Organization (WHO) clinical stage II and III were notably associated with the incidence of ADRs development.

Conclusion

ADRs were uncommon in this study. predictors, such as OIs experiences, a low CD4 count, ART regimen, an advanced WHO stage, and bedridden functional status were significantly associated with ADRs.

A possible case of bictegravir-associated severe unconjugated hyperbilirubinemia

BACKGROUND

Bictegravir (BIC) co-formulated with emtricitabine (FTC) and tenofovir alafenamide (TAF) is approved by Federal Food and Drug Administration in 2018 for both treatment-naïve and experienced persons living with HIV (PLWH).

CASE PRESENTATION

A young man with recently diagnosed human immunodeficiency virus (HIV) infection presented with jaundice. Blood work was significant for mild anemia and grade 4 unconjugated hyperbilirubinemia. A comprehensive evaluation for hemolytic anemia failed to reveal any etiology. Other causes of hyperbilirubinemia were negative. Four months prior, patient was started on antiretroviral therapy with a single tablet regimen containing bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF), brand name Biktarvy®, and the medication was suspected to be the cause. The medication was held, and the hyperbilirubinemia improved.

CONCLUSION

Severe hyperbilirubinemia can be found in the patient using BIC/FTC/TAF. The data for this adverse reaction is scarce, and more studies are needed on this possible side effect. The mechanism of unconjugated hyperbilirubinemia by INSTI remains undefined.

Factors associated with high alanine aminotransferase (ALT) and cirrhosis in people living with HIV on combination antiretroviral treatment (cART) in the Asia-Pacific

Liver disease is a growing burden among people living with HIV (PLHIV) in resource-limited settings. As an indicator of liver disease, risk factors of high alanine aminotransferase (ALT) and cirrhosis were assessed among PLHIV in the TREAT Asia HIV Observational Database (TAHOD). Patients on combination antiretroviral therapy (cART) with a pre-cART ALT measurement and at least one follow-up ALT measurement were included. Factors associated with high ALT (ALT levels > 5 times its upper limit of normal) were analyzed using repeated measure logistic regression over a 10-year follow-up period. Liver cirrhosis was defined as having an AST to Platelet Ratio Index score > 1.5, fibrosis-4 score > 3.25, or a clinical diagnosis of cirrhosis. Cox regression analysis stratified by site was used to analyze factors associated with cirrhosis among those in follow-up after 2015. Of 5182 patients, 101 patients (1.9%) had high ALT levels with hepatitis C virus (HCV) antibody positive (odds ratio [OR]: 4.98, 95% confidence interval [CI]: 2.82-8.77, p < 0.001) and ever high alcohol consumption (OR: 2.33, 95% CI: 1.00-5.46, p = 0.050) as likely factors. Among 6318 PLHIV in the liver cirrhosis analysis, 151 (2%) developed cirrhosis (incidence rate = 0.82 per 100 person-years). Those HCV-antibody positive (hazard ratio [HR]: 5.54, 95% CI: 3.75-8.18, p < 0.001) and had high alcohol consumption (HR: 2.06, 95% CI: 1.23-3.45, p = 0.006) were associated with liver cirrhosis. HCV-antibody positive and high alcohol consumption are factors associated with high ALT. With raised ALT levels as a known factor associated with liver cirrhosis, greater efforts are required in managing ALT levels and reducing the risk of developing liver cirrhosis among those positive for HCV-antibody and those who consume alcohol.

Incidence and risk factors of drug-induced liver injury

The epidemiology and aetiology of drug-induced liver injury (DILI) vary across different countries and populations. Overall, DILI is rare in the general population but has become more prevalent in hospitalized patients, especially among patients with unexplained liver conditions. In addition, drugs implicated in DILI differ between Western and Eastern countries. Antibiotics are the leading drugs implicated in DILI in the West, whereas traditional Chinese medicine is the primary cause implicated in DILI in the East. The incidence of herbal and dietary supplements-induced hepatotoxicity is increasing globally. Several genetic and nongenetic risk factors associated with DILI have been described in the literature; however, there are no confirmed risk factors for all-cause DILI. Some factors may contribute to the risk of DILI in a drug-specific manner.

Factors Associated with Liver Enzyme Abnormalities in HIV-HBV and/or HCV Co-infected Patients in Kinshasa, Democratic Republic of the Congo: Multicenter Cross-sectional Study

BACKGROUND AND OBJECTIVE

Liver enzyme abnormalities (LEA) are extremely common and sometimes severe in individuals infected with human immunodeficiency virus (HIV), but data for this disorder are lacking in the developing countries. The objective of this study was to identify factors associated with LEA in HIV-hepatitis B virus (HBV)/hepatitis C virus (HCV) co-infected patients in Kinshasa, Democratic Republic of the Congo.

METHODS

This cross-sectional analytical study included 180 people living with HIV (PLWHIV) mono-infected or co-infected with HBV/HCV between November 10, 2013 and January 10, 2014 in Kinshasa. Sociodemographic, clinical, biological, serological, and immunological data were analyzed. Levels of serum glutamate oxaloacetate transferase (SGOT) and serum glutamate pyruvate transaminase (SGPT) were determined. Antibody levels were determined using enzyme-linked immunosorbent assay (ELISA).

RESULTS

The mean age of patients was 44.2±11.0 years; female sex was predominant (76.7%). Co-infection, mainly with HBV, but also HCV, was found in 43 (23.9%) patients. Elevated liver enzymes were found in 77 (42.8%) of the patients. No difference was found in the rate of liver enzyme abnormalities between patients with HIV mono-infection or HIV co-infection (46.7% versus 30.2%, respectively; P=0.08). Factors associated with LEA were age ≥50 years (adjusted odds ratio [OR] 2.7; 95% CI 1.4-5.5), duration of HIV infection >3 years (adjusted OR 2.7; 95% CI 1.4-5.5), and CD4 T cells count ≤303 cells/mm³ (adjusted OR 2.2; 95% CI 1.1-4.5).

CONCLUSIONS

Liver enzyme abnormalities are frequent in patients co-infected with HIV-HBV/HCV as well as in HIV patients without co-infection. Diagnosis is determined based on age, immunodeficiency, and length of illness.

Longitudinal analysis of new-onset non-AIDS-defining diseases among people living with HIV: A real-world observational study

OBJECTIVES

We aimed to analyze the incidence rates of new-onset diabetes, hypertriglyceridemia, hypercholesterolemia, liver injury, and renal injury during antiretroviral therapy (ART) among people living with HIV (PLWH) and determine the associated risk factors.

METHODS

This study included PLWH enrolled from Beijing Ditan Hospital from November 11, 2004, to December 29, 2018. The incidence rates of new-onset diabetes, hypertriglyceridemia, hypercholesterolemia, liver injury, and renal injury were calculated and stratified based on ART regimen, CD4 count, and HIV-RNA. Risk factors were determined using Cox regression analysis.

RESULTS

Overall, 6747 participants were included. Moreover, 4.5%, 43.3%, 25.4%, 11.2%, and 6.2% of patients developed new-onset diabetes, hypertriglyceridemia, hypercholesterolemia, liver injury, and renal injury, respectively, with incidence rates of 1.7, 26.9, 10.2, 3.9, and 5.5 per 100 person-years, respectively. Longitudinally, the incidence rates and percentages of these outcomes were highest in the first year of ART. The percentage of dyslipidemia was significantly higher in protease inhibitor (PI)-based regimen than in non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimen. However, the percentage of liver injury was significantly higher in NNRTI-based regimen than in PI-based regimen. In multivariate Cox regression analysis, low CD4 count (<200 cells/µL, adjusted hazard ratio [aHR] = 1.34, 95% confidence interval [CI] 1.15-1.57) and high HIV-RNA (>10⁵ copies/mL, aHR = 1.26, 95% CI 1.08-1.48) were risk factors for hypertriglyceridemia.

CONCLUSIONS

Clinical outcomes, including new-onset diabetes, dyslipidemia, and liver and renal injuries, are common in PLWH. Regular glucose, lipid, liver, and renal function monitoring is required during ART, especially in high-risk patients.

Non-Alcoholic Fatty Liver Disease in HIV/HBV Patients - a Metabolic Imbalance Aggravated by Antiretroviral Therapy and Perpetuated by the Hepatokine/Adipokine Axis Breakdown

Non-alcoholic fatty liver disease (NAFLD) is strongly associated with the metabolic syndrome and is one of the most prevalent comorbidities in HIV and HBV infected patients. HIV plays an early and direct role in the development of metabolic syndrome by disrupting the mechanism of adipogenesis and synthesis of adipokines. Adipokines, molecules that regulate the lipid metabolism, also contribute to the progression of NAFLD either directly or via hepatic organokines (hepatokines). Most hepatokines play a direct role in lipid homeostasis and liver inflammation but their role in the evolution of NAFLD is not well defined. The role of HBV in the pathogenesis of NAFLD is controversial. HBV has been previously associated with a decreased level of triglycerides and with a protective role against the development of steatosis and metabolic syndrome. At the same time HBV displays a high fibrogenetic and oncogenetic potential. In the HIV/HBV co-infection, the metabolic changes are initiated by mitochondrial dysfunction as well as by the fatty overload of the liver, two interconnected mechanisms. The evolution of NAFLD is further perpetuated by the inflammatory response to these viral agents and by the variable toxicity of the antiretroviral therapy. The current article discusses the pathogenic changes and the contribution of the hepatokine/adipokine axis in the development of NAFLD as well as the implications of HIV and HBV infection in the breakdown of the hepatokine/adipokine axis and NAFLD progression.

Immune response to hepatitis B vaccination in human immunodeficiency virus-positive patients in China: A 2-year retrospective study

Currently, the studies focused on the immune response to hepatitis B vaccination in Chinese human immunodeficiency virus (HIV)-positive patients are limited. In this study, the participants with an initial hepatitis B surface antibody (HBsAb) titer <10 mIU/ml were assigned to Cohort 1 to receive a standard dose of recombinant hepatitis B vaccine, and participants with an initial HBsAb titer between 10 and 100 mIU/ml were assigned to Cohort 2 to receive a single reinforced recombinant vaccine. In Cohort 1, the immune and high response rates in HIV-positive patients were 93.4%/81.4%, 87.4%/51.5%, and 83.2%/40.7% at 1-3 months, 1 year, and 2 years postvaccination. Multivariate analysis showed that only age and HIV RNA status at baseline were independent factors related to sustained immune response at 2 years postvaccination. In Cohort 2, the high immune response rates in HIV-positive patients were 78.8%, 60.6%, and 51.5% at 1-3 months, 1 year, and 2 years postvaccination. The immune or high response rates did not differ between HIV-positive patients and healthy controls at 1-3 months postvaccination in these two cohorts; however, HBsAb titers were significantly lower in HIV-positive patients. This study summarized the 2-year data of immune response to hepatitis B vaccination and analyzed the factors related to sustained immune response at 2 years postvaccination in Chinese HIV-positive patients.

Protease inhibitor-based direct-acting antivirals are associated with increased risk of aminotransferase elevations but not hepatic dysfunction or decompensation

BACKGROUND & AIMS

Cases of acute liver injury (ALI) have been reported among chronic HCV-infected patients receiving protease inhibitor (PI)-based direct-acting antiviral (DAA) regimens, but no analyses have compared the risk of ALI in patients receiving PI- vs. non-PI-based DAAs. Thus, we compared the risk of 3 ALI outcomes between patients (by baseline Fibrosis-4 [FIB-4] group) receiving PI-based or non-PI-based DAAs.

METHODS

We conducted a cohort study of 18,498 patients receiving PI-based DAA therapy (paritaprevir/ritonavir/ombitasvir±dasabuvir, elbasvir/grazoprevir, glecaprevir/pibrentasvir) matched 1:1 on propensity score to those receiving non-PI-based DAAs (sofosbuvir/ledipasvir, sofosbuvir/velpatasvir) in the 1945-1965 Veterans Birth Cohort (2014-2019). During exposure to DAA therapy, we determined development of: i) alanine aminotransferase (ALT) >200 U/L, ii) severe hepatic dysfunction (coagulopathy with hyperbilirubinemia), and iii) hepatic decompensation. We used Cox regression to determine hazard ratios (HRs) with 95% CIs for each ALI outcome within groups defined by baseline FIB-4 (≤3.25; >3.25).

RESULTS

Among patients with baseline FIB-4 ≤3.25, those receiving PIs had a higher risk of ALT >200 U/L (HR 3.98; 95% CI 2.37-6.68), but not severe hepatic dysfunction (HR 0.67; 95% CI 0.19-2.39) or hepatic decompensation (HR 1.01; 95% CI 0.29-3.49), compared to those receiving non-PI-based regimens. For those with baseline FIB-4 >3.25, those receiving PIs had a higher risk of ALT >200 U/L (HR, 2.15; 95% CI 1.09-4.26), but not severe hepatic dysfunction (HR, 1.23 [0.64-2.38]) or hepatic decompensation (HR, 0.87; 95% CI 0.41-1.87), compared to those receiving non-PI-based regimens CONCLUSION: While risk of incident ALT elevations was increased in those receiving PI-based DAAs in both FIB-4 groups, the risk of severe hepatic dysfunction and hepatic decompensation did not differ between patients receiving PI- or non-PI-based DAAs in either FIB-4 group.

LAY SUMMARY

Cases of liver injury have been reported among patients treated with protease inhibitor-based direct-acting antivirals for hepatitis C infection, but it is not clear if the risk of liver injury among people starting these drugs is increased compared to those starting non-protease inhibitor-based therapy. In this study, patients receiving protease inhibitor-based treatment had a higher risk of liver inflammation than those receiving a non-protease inhibitor-based treatment, regardless of the presence of pre-treatment advanced liver fibrosis/cirrhosis. However, the risk of severe liver dysfunction and decompensation were not higher for patients treated with protease inhibitor-based regimens.

Hepatotoxicity and Liver-Related Mortality in Women of Childbearing Potential Living With Human Immunodeficiency Virus and High CD4 Cell Counts Initiating Efavirenz-Containing Regimens

BACKGROUND

Severe hepatotoxicity in people with human immunodeficiency virus (HIV) receiving efavirenz (EFV) has been reported. We assessed the incidence and risk factors of hepatotoxicity in women of childbearing age initiating EFV-containing regimens.

METHODS

In the Promoting Maternal and Infant Survival Everywhere (PROMISE) trial, ART-naive pregnant women with HIV and CD4 count ≥ 350 cells/μL and alanine aminotransferase ≤ 2.5 the upper limit of normal were randomized during the antepartum and postpartum periods to antiretroviral therapy (ART) strategies to assess HIV vertical transmission, safety, and maternal disease progression. Hepatotoxicity was defined per the Division of AIDS Toxicity Tables. Cox proportional hazards models were constructed with covariates including participant characteristics, ART regimens, and timing of EFV initiation.

RESULTS

Among 3576 women, 2435 (68%) initiated EFV at a median 121.1 weeks post delivery. After EFV initiation, 2.5% (61/2435) had severe (grade 3 or higher) hepatotoxicity with an incidence of 2.3 (95% confidence interval [CI], 2.0-2.6) per 100 person-years. Events occurred between 1 and 132 weeks postpartum. Of those with severe hepatotoxicity, 8.2% (5/61) were symptomatic, and 3.3% (2/61) of those with severe hepatotoxicity died from EFV-related hepatotoxicity, 1 of whom was symptomatic. The incidence of liver-related mortality was 0.07 (95% CI, .06-.08) per 100 person-years. In multivariable analysis, older age was associated with severe hepatotoxicity (adjusted hazard ratio per 5 years, 1.35 [95% CI, 1.06-1.70]).

CONCLUSIONS

Severe hepatotoxicity after EFV initiation occurred in 2.5% of women and liver-related mortality occurred in 3% of those with severe hepatotoxicity. The occurrence of fatal events underscores the need for safer treatments for women of childbearing age.

Hepatotoxicity of Contemporary Antiretroviral Drugs: A Review and Evaluation of Published Clinical Data

Contemporary antiretroviral agents afford enhanced potency and safety for patients living with HIV. Newer antiretroviral drugs are often better tolerated than those initially approved in the early stages of the HIV epidemic. While the safety profile has improved, adverse drug reactions still occur. We have segregated the antiretroviral agents used in contemporary practice into class groupings based on their mechanism of antiviral activity (non-nucleoside reverse transcriptase inhibitors, nucleoside reverse transcriptase inhibitors, integrase inhibitors, protease inhibitors, and entry inhibitors) while providing a review and discussion of the hepatoxicity seen in the most relevant clinical literature published to date. Clinical literature for individual agents is discussed and agent comparisons afforded within each group in tabular format. Our review will provide a summative overview of the incidence and medications associated with hepatic adverse reactions linked to the use of contemporary antiretroviral drugs.

Drug-induced liver injury: Asia Pacific Association of Study of Liver consensus guidelines

Idiosyncratic drug-induced liver injury mimics acute and chronic liver disease. It is under recognized and underrecognised because of the lack of pathognomonic diagnostic serological markers. Its consequences may vary from being asymptomatic to self-limiting illness to severe liver injury leading to acute liver failure. Its incidence is likely to be more common in Asia than other parts of the world, mainly because of hepatotoxicity resulting from the treatment of tuberculosis disease and the ubiquitous use of traditional and complimentary medicines in Asian countries. This APASL consensus guidelines on DILI is a concise account of the various aspects including current evidence-based information on DILI with special emphasis on DILI due to antituberculosis agents and traditional and complementary medicine use in Asia.

Risk Factors Associated With Chronic Liver Enzyme Elevation in Persons With HIV Without Hepatitis B or C Coinfection in the Combination Antiretroviral Therapy Era

Background

As morbidity due to viral coinfections declines among HIV-infected persons, changes in liver-related morbidity are anticipated. We examined data from the US Military HIV Natural History Study (NHS), a cohort of military beneficiaries, to evaluate incidence and risk factors associated with chronic liver enzyme elevation (cLEE) in HIV-monoinfected patients in the combination antiretroviral therapy (cART) era.

Methods

Participants who were hepatitis B virus and hepatitis C virus seronegative with follow-up after 1996 were included. We defined chronic liver enzyme elevation (cLEE) as alanine aminotransferase elevations ≥1.25 times the upper limit of normal on at least 2 visits, for a duration of ≥6 months within 2 years. We used multivariate Cox proportional hazards models to examine risk factors for cLEE.

Results

Of 2779 participants, 309 (11%) met criteria for cLEE for an incidence of 1.28/100 PYFU (1.28–1.29/100 PYFU). In an adjusted model, cLEE was associated with Hispanic/other ethnicity (reference Caucasian: hazard ratio [HR], 1.744; 95% CI, 1.270–2.395), non–nucleoside reverse transcriptase inhibitor–based cART (reference boosted protease inhibitors: HR, 2.232; 95% CI, 1.378–3.616), being cART naïve (HR, 6.046; 95% CI, 3.686–9.915), or having cART interruptions (HR, 8.671; 95% CI, 4.651–16.164). African American race (HR, 0.669; 95% CI, 0.510–0.877) and integrase strand transfer inhibitor (INSTI)–based cART (HR, 0.222; 95% CI, 0.104–0.474) were protective.

Conclusions

Our findings demonstrate that initiation and continued use of cART are protective against cLEE and support the hypothesis that HIV infection directly impacts the liver. INSTI-based regimens were protective and could be considered in persons with cLEE.

Apoptosis of Hepatocytes: Relevance for HIV-Infected Patients under Treatment

Due to medical advances over the past few decades, human immunodeficiency virus (HIV) infection, once a devastatingly mortal pandemic, has become a manageable chronic condition. However, available antiretroviral treatments (cART) cannot fully restore immune health and, consequently, a number of inflammation-associated and/or immunodeficiency complications have manifested themselves in treated HIV-infected patients. Among these chronic, non-AIDS (acquired immune deficiency syndrome)-related conditions, liver disease is one of the deadliest, proving to be fatal for 15–17% of these individuals. Aside from the presence of liver-related comorbidities, including metabolic disturbances and co-infections, HIV itself and the adverse effects of cART are the main factors that contribute to hepatic cell injury, inflammation, and fibrosis. Among the molecular mechanisms that are activated in the liver during HIV infection, apoptotic cell death of hepatocytes stands out as a key pathogenic player. In this review, we will discuss the evidence and potential mechanisms involved in the apoptosis of hepatocytes induced by HIV, HIV-encoded proteins, or cART. Some antiretroviral drugs, especially the older generation, can induce apoptosis of hepatic cells, which occurs through a variety of mechanisms, such as mitochondrial dysfunction, increased production of reactive oxygen species (ROS), and induction of endoplasmic reticulum (ER) stress and unfolded protein response (UPR), all of which ultimately lead to caspase activation and cell death.

Higher Mortality and Intensive Care Unit Admissions in COVID-19 Patients with Liver Enzyme Elevations

The aim of the present study is to evaluate if an independent association exists between liver enzyme elevations (LEE) and the risk of mortality or intensive care unit (ICU) admissions in patients with COVID-19. This was a single-center observational study, recruiting all consecutive adults with COVID-19. The elevation of aspartate aminotransferase (AST) or alanine aminotransferase (ALT) to the highest level between COVID-19 diagnosis and hospital discharge was categorized according to a standardized toxicity grade scale. In total, 799 patients were included in this study, 39% of which were female, with a mean age of 69.9 (±16.0) years. Of these patients, 225 (28.1%) developed LEE of grade ≥2 after a median of three days (interquartile range (IQR): 0–8 days) from the diagnosis of COVID-19, and they were estimated to have a higher hazard of death or ICU admission (adjusted hazard ratio (aHR): 1.46, 95% confidence interval (CI): 1.14–1.88). The clinical and laboratory variables associated with the development of LEE were male sex, higher respiratory rate, higher gamma glutamyl transpeptidase (GGT) and lower albumin levels at baseline. Among the analyzed treatments, steroids, tocilizumab and darunavir/ritonavir correlated with LEE. In conclusion, LEE were associated with mortality and ICU admission among COVID-19 patients. While the origin of LEE is probably multifactorial, LEE evaluation could add information to the clinical and laboratory variables that are commonly evaluated during the course of COVID-19.

Improving Medication-Related Outcomes in Chronic Liver Disease

Patients with chronic liver disease (CLD) are becoming increasingly complex due to the rising prevalence of multimorbidity and polypharmacy. Medications are often essential to manage the underlying liver disease, complications of cirrhosis and portal hypertension, and comorbidities. However, medication-related problems (MRPs) have been associated with adverse patient outcomes, including hospitalization and mortality. Factors that can contribute to MRPs in people with CLD are variable and often entwined. This narrative literature review discusses key barriers and opportunities to modify risk factors and improve medication-related outcomes for people with CLD.

Incidence and risk factors for liver enzyme elevation among naive HIV-1-infected patients receiving ART in the ICONA cohort

OBJECTIVES

To evaluate the incidence and risk factors for liver enzyme elevations (LEE) in patients initiating first-line ART in the ICONA prospective observational cohort, between June 2009 and December 2017.

PATIENTS AND METHODS

In total, 6575 ART-naive patients were selected, initiating two NRTIs with the third drug being a boosted PI (n=2436; 37.0%), an NNRTI (n=2384; 36.3%) or an integrase strand transfer inhibitor (INSTI) (n=1755; 26.7%). HBV surface antigen and HCV RNA were detected in 3.9% and 5.8% of the study population. Inverse probability weighted Cox regression analysis was used to calculate the HRs, according to first-line regimen, for LEE, defined as ALT or AST increases of ≥2.5× upper limit of normal (ULN) for patients with normal baseline values or ≥2.5× baseline for patients with higher baseline values.

RESULTS

One hundred and eighty-three LEE occurred over 20722 patient-years of follow-up. After adjusting for the main confounders, the risk of LEE halved with INSTIs compared with NNRTIs (HR 0.46, 95% CI 0.25-0.86), with a significant reduction in the raltegravir group (HR 0.11, 95% CI 0.02-0.84 using the NNRTI class as reference). HRs for LEE were significantly higher in subjects with HBV or HCV coinfection, in patients with poorly controlled HIV infection and in those who acquired HIV through homosexual transmission.

CONCLUSIONS

In our study, INSTI use almost halved the risk of LEE compared with other regimens. This finding could be particularly important for choosing ART in patients with risk factors for liver toxicity such as HCV and HBV coinfections.

Semen Extracellular Vesicles From HIV-1-Infected Individuals Inhibit HIV-1 Replication In Vitro, and Extracellular Vesicles Carry Antiretroviral Drugs In Vivo

BACKGROUND

Extracellular vesicles (EVs) are cell-derived vesicles with diverse functions in intercellular communication including disease and infection, and EVs seem to influence HIV-1 pathogenesis. EVs isolated from HIV-1-uninfected semen (SE), but not blood (BE), contain factors that interfere with HIV-1 infection and replication in target cells. The reason for this dichotomy is unknown. Furthermore, the effect of HIV-1 infection and antiretroviral (ARV) drugs on the anti-HIV-1 effects of SE and BE is unknown. Here, we characterize EVs and EV-free plasma isolated from HIV-infected donor semen and blood and their effects on HIV infection.

METHODS

EVs and EV-free plasma were purified from autologous blood and semen of HIV-negative, HIV-infected antiretroviral therapy (ART)-naïve, and HIV-infected ART-treated participants. HIV infection was assessed in a TZM-bl cell reporter system. ARV concentrations were analyzed using liquid chromatography-mass spectrometry.

RESULTS

SE isolated from both HIV-negative and HIV-infected, ART-naïve donors inhibited HIV-1 infection, but BE and semen and blood EV-free plasma did not. By contrast, BE, SE, and EV-free plasma from HIV-infected, ART-treated donors inhibited HIV-1. Importantly, exosomes isolated from ART-treated donors contained concentrations of ARV drugs (ART-EVs) at biologically relevant inhibitory levels.

CONCLUSIONS

The HIV-1-inhibitory phenotype of SE is independent of donor HIV-1 or ART status, and ARV drugs and their metabolites are SE- and BE-associated in vivo.

Low serum 25-hydroxyvitamin D levels are associated with liver injury markers in the US adult population

OBJECTIVE

To examine the associations between serum 25-hydroxyvitamin D (25(OH)D) levels and serum liver enzymes in a representative sample of US adults.

DESIGN

The cross-sectional study sample consisted of 24 229 adults with data on serum 25(OH)D levels and serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP) and gamma-glutamyl transaminase (GGT) concentrations, in addition to data on other potential confounders. Multivariate logistic regression and linear regression were applied to assess the associations between serum 25(OH)D levels and ALT, AST, ALP and GGT concentrations.

SETTING

The National Health and Nutrition Examination Survey, 2001-2006.

PARTICIPANTS

The cross-sectional study sample consisted of 24 229 adults.

RESULTS

We found a significant association between low serum 25(OH)D levels (<30 nmol/l) and ALP levels in all participants (OR 2·67; 95 % CI 1·98, 3·59; P < 0·001), a confirmed healthy population (OR 3·02; 95 % CI 2·25, 4·07; P < 0·001) and individuals with viral hepatitis (OR 2·87; 95 % CI 1·52, 5·44; P = 0·006) compared with those who had normal 25(OH)D levels (>50 nmol/l). Moreover, in both the logistic regression and linear regression, the associations between 25(OH)D levels and ALP levels were stronger in the subgroups with obesity. No association was present between ALT, AST or GGT levels and serum 25(OH)D levels in this population.

CONCLUSIONS

The results of the present study provide epidemiological evidence that vitamin D deficiency is associated with liver ALP levels in humans. This finding suggests a potential adverse effect of low 25(OH)D levels on human liver function. However, the underlying mechanisms still need further investigation.

HCV infection status and care seeking among people living with HIV who use drugs in Vietnam

HCV co-infection is widespread among people living with HIV who use drugs (PLHWUD). However, HCV testing was inconsistently implemented among PLHWUD. The low infection awareness and mental health challenges together impede PLHWUD's treatment-seeking. The study used baseline data of a randomized controlled trial conducted in Vietnam. HCV infection status was collected through self-report and medical record review. A linear mixed-effects regression model was used to examine the relationships between PLHWUD's perceived barriers to seeking healthcare, their depressive symptoms, and the consistencies in HCV status reports. Among the 181 PLHWUD in the study, one-third (64; 35.4%) had inconsistent self-reports and medical records of HIV infection status. The agreement between the two records was fair (Kappa statistics = 0.43). PLHWUD with consistent HCV infection confirmed by both medical records and self-reports perceived lower levels of healthcare-seeking barriers than those with discrepant HCV reports (estimated difference = -1.59, SE = 0.71, P = 0.027). Depressive symptoms were significantly correlated with healthcare-seeking barriers among those with discrepant HCV results (estimate = 0.17, SE = 0.06, P = 0.007). There is an urgent need to extend HCV screening efforts and increase HCV awareness among PLHWUD. Explicit HCV result notification and integrated mental health support are recommended to facilitate patients' access to needed care.

Antiretroviral switching and bedaquiline treatment of drug-resistant tuberculosis HIV co-infection

Bedaquiline, a potent new therapy for drug-resistant tuberculosis, results in improved survival including in HIV patients with multidrug and extensively drug-resistant tuberculosis. In line with WHO recommendations, in South Africa and other low-income and middle-income settings, antiretroviral therapy is switched from generic fixed-dose combination efavirenz-containing regimens to twice-daily nevirapine with separate companion pills because of interactions between efavirenz and bedaquiline. Early data suggest a signal for low antiretroviral therapy adherence after this antiretroviral therapy switch. Mortality and other tuberculosis-specific benefits noted with bedaquiline treatment in multidrug and extensively drug-resistant tuberculosis HIV might be compromised by HIV viral failure, and emergent antiretroviral resistance. Programmatic responses, such as adherence support and dual pharmacovigilance, should be instituted; antiretroviral therapy initiation with fixed-dose combinations without bedaquiline drug interactions should be strongly considered.

Epidemiology, Predisposing Factors, and Outcomes of Drug-Induced Liver Injury

Idiosyncratic drug-induced liver injury (DILI) is an underreported and underestimated adverse drug reaction. A recent population-based study found a crude incidence of approximately 19 cases per 100,000 a year. Amoxicillin-clavulanate continues to be the most commonly implicated agent in most Western countries, reported to occur in approximately 1 of 2300 users. In patients with drug-induced autoimmune hepatitis, liver tests often do not normalize with cessation of the drugs and require corticosteroids. DILI associated with jaundice can lead to death from liver failure or require liver transplantation in at least 10% of cases.

Antiretroviral treatment for HIV infection: Swedish recommendations 2019

The Swedish Reference Group for Antiviral Therapy (RAV) published recommendations for the treatment of HIV infection in this journal most recently in 2017. An expert group under the guidance of RAV here provides updated recommendations. The most important updates in the present guidelines are the following: (a) The risk of HIV transmission through condomless sex from individuals with fully suppressed HIV viral load is effectively zero. (b) Pre-exposure prophylaxis (PrEP) is recommended for groups with a high risk of HIV infection. (c) Since the last update, two new substances have been registered: bictegravir and doravirine. (d) Dual treatment may be an alternative in selected patients, using lamivudine + dolutegravir or lamivudine + boosted darunavir/atazanavir. As with previous publications, recommendations are evidence-graded in accordance with the Oxford Centre for Evidence Based Medicine. This document does not cover treatment of opportunistic infections and tumours.

Liver enzyme elevation in patients taking HAART compared with treatment naïve controls at Debre Berhan Referral Hospital: a comparative cross-sectional study, Northeast Ethiopia

Objective

HAART had significantly improved the quality of life of HIV patients. However, it results different adverse effects such as: hepatotoxicity, nephrotoxicity, lipodystrophy, anemia, diarrhea, psychiatric disorder and others. Therefore, this comparative cross sectional study was designed to investigate liver enzyme elevation in patients taking HAART compared with treatment naïve controls at Debre Berhan Referral Hospital.

Result

A total of 152 individuals (76 cases and 76 controls) were included in this study. The mean ages of treatment and control groups were 37.37 and 36.38 respectively. The mean values of liver enzymes (ALT, AST and ALP), total bilirubin and direct bilirubin were significantly higher (p < 0.05) while, total protein and creatinine were significantly lower in patients taking HAART compared with treatment naïve controls. In this study, about 19 (25%) of clients in HAART treated groups and 7 (9.2%) of treatment naïve controls had showed liver enzyme changes. Moreover, 23.7% and 1.3% of the HAART treated groups developed mild and moderate liver enzyme elevation or hepatotoxicity, respectively. In this study, significant difference was observed in liver enzyme elevation between ART and pre-ART patients. As a result, regular clinical and laboratory monitoring of liver function will be necessary to prevent severe form of liver injury.

Drug hypersensitivity in HIV infection

PURPOSE OF REVIEW

Immune-mediated adverse drug reactions (IM-ADRs) are many times more common in HIV-infected patients. Usual offending drugs include antiretroviral and antiinfectives, but the burden of specific drug IM-ADRs is population-specific; changing as new and fixed dose combinations enter the market, and drug-resistance patterns demand. This review considers recent literature on epidemiology, mechanisms, clinical management and prevention of IM-ADRs amongst persons living with HIV/AIDS.

RECENT FINDINGS

Epidemiological studies continue to describe high rates of delayed hypersensitivity to known offenders, as well as similar reactions in preexposure prophylaxis. IM-ADRs to oral and injectable integrase strand transfer inhibitors are reported with expanding use. The clinical spectrum and management of IM-ADRs occurring in HIV-infected populations is similar to uninfected; with exceptions such as a recently described severe delayed efavirenz DILI with high mortality. Furthermore, the context can be unique, such as the lower than expected mortality in a Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) cohort from a HIV/TB high burden setting. Programmatic data showing the near complete elimination of Abacavir drug hypersensitivity syndrome following implementation of HLA-B57:01 screening is a stellar example of how prevention is possible with mechanistic insight.

SUMMARY

IM-ADRs remain a challenge in persons living with HIV. The complexities posed by polypharmacy, overlapping drug toxicities, drug interactions, overlap of IM-ADRs with other diseases, limited alternative drugs, and vulnerable patients with advanced immunosuppression with high mortality, necessitate increased use of drug provocation testing, treat-through and desensitization strategies. There is an urgent need for improved diagnostics and predictive biomarkers for prevention, or to guide treat-through, rechallenge and desensitization approaches.

Rilpivirine as a potential candidate for the treatment of HIV-associated neurocognitive disorders (HAND)

As the HIV epidemic continues to contribute to global morbidity and mortality, the prevalence of HIV-associated neurological disorders (HAND) also continues to be a major concern in infected individuals, despite the widespread use of combination antiretroviral therapy. Therefore, current antiretroviral drugs should be able to reach therapeutic levels in the brain for the treatment of HAND. The brain distribution of the next-generation non-nucleoside reverse transcriptase inhibitor, rilpivirine (RPV) was investigated in healthy female Sprague-Dawley (SD) rats. The presented study involves the use of liquid chromatography-tandem mass spectrometry (LC-MS/MS) to estimate the concentrations of RPV in plasma and brain homogenate samples. The use of matrix-assisted laser desorption/ionization mass spectrometry imaging (MALDI-MSI) provided regional spatial distribution of RPV in brain tissue sections. The localization of RPV was found to be relatively high in the hypothalamus, thalamus and corpus callosum, brain regions known to be associated with neurodegeneration during HAND (including the cerebral cortex). This study has shown that RPV has an excellent blood-brain barrier penetrability. Thus, in combination with other antiretroviral drugs, better central nervous system (CNS) protection against HAND can possibly be achieved.

Drug-Induced Liver Injuries (Clinical Guidelines for Physicians)

Aim.Clinical guidelines for the management of adult patients suffering from drug-induced liver injuries (DILI) are intended for all medical specialists, who treat such patients in their clinical practice.

Key findings.The presented recommendations contain information about the epidemiological data, terminology, diagnostic principles, classification, prognosis and management of patients with DILI. The recommendations list pharmacological agents that most commonly cause DILI, including its fatal cases. Dose-dependent and predictable (hepatotoxic), as well as dose-independent and unpredictable (idiosyncratic) DILI forms are described in detail, which information has a particular practical significance. The criteria and types of DILI are described in detail, with the most reliable diagnostic and prognostic scales and indices being provided. The pathogenesis and risk factors for the development of DILI are considered. The clinical and morphological forms (phenotypes) of DILI are described. The diseases that are included into the differential diagnosis of DILI, as well as the principles of its implementation, are given. The role and significance of various diagnostic methods for examining a patient with suspected DILI is described, with the liver biopsy role being discussed. Clinical situations, in which DILI can acquire a chronic course, are described. A section on the assessment of causal relationships in the diagnosis of DILI is presented; the practical value of using the CIOMS-RUCAM scale is shown. All possible therapeutic measures and pharmacological approaches to the treatment of patients with various DILI phenotypes are investigated in detail. A particular attention is paid to the use of glucocorticosteroids in the treatment of DILI.

Conclusion.The presented clinical recommendations are important for improving the quality of medical care in the field of hepatology.

Risk Factors for Alanine Aminotransferase Elevations in a Prospective Cohort of HIV-Infected Tanzanian Adults Initiating Antiretroviral Therapy

INTRODUCTION

Serum alanine aminotransferase (ALT) elevations are common among HIV-infected patients on combination antiretroviral therapy (cART).

APPROACH

We conducted a prospective cohort study of 3023 HIV-infected Tanzanian adults initiating cART. We assessed risk factors for mild/moderate ALT elevations >40 IU/L and severe ALT elevations >200 IU/L.

RESULTS

We found that over a median follow-up of 32.5 months (interquartile range: 19.4-41.5), 44.8% of participants had at least 1 incident ALT elevation >40 IU/L of which 50.1% were persistent elevations. Risk factors for incident ALT elevation >40 IU/L included male sex, CD4 count <100 cells/μL, d4T+3TC+NVP cART, and triglycerides ≥150 mg/dL (P values <.05). Hepatitis B coinfection and alcohol consumption increased the risk of severe ALT elevations >200 IU/L (P values: <.05).

CONCLUSION

Incident mild and moderate ALT elevations are common among Tanzanians initiating cART, and the clinical and demographic information can identify patients at increased risk.

Environmental fate and ecotoxicological effects of antiretrovirals: A current global status and future perspectives

The therapeutic efficacy of antiretroviral drugs as well as challenges and side effects against the human immunodeficiency virus is well documented and reviewed. Evidence is available in literature indication that antiretrovirals are only partially transformed and become completely excreted from the human body in their original form and/or as metabolites in urine and feces. The possibility of massive release of antiretrovirals through human excreta that enters surface water through surface runoff and wastewater treatment plant effluents is now of environmental concern because the public might be experiencing chronic exposure to antiretrovirals. The primary concern of this review is limited data concerning environmental fate and ecotoxicity of antiretrovirals and their metabolites. The review aims to provide a comprehensive insight into the evaluation of antiretrovirals in environmental samples. The objective is therefore to assess the extent of analysis of antiretrovirals in environmental samples and also look at strategies including instrumentation and predictive models that have been reported in literature on the fate and ecotoxicological effects due to presence of antiretrovirals in different environmental compartments. The review also looks at current challenges and offers possible areas of exploration that could help minimize the presence of antiretrovirals in the environment.

Acute Liver Failure among Patients on Efavirenz-Based Antiretroviral Therapy

Objectives

To describe the clinical characteristics of patients presenting with fulminant liver failure after varying periods of exposure to Efavirenz containing antiretroviral medications.

Methods

We report a series of 4 patients with human immunodeficiency virus (HIV) infection who were admitted with acute liver failure (ALF) over a 6-month period. All these patients had been treated with a range of Efavirenz containing antiretroviral regimens and were negative for hepatitis A, B, and C infections as well as other opportunistic infections, all were negative for autoimmune hepatitis, and none had evidence of chronic liver disease or use of alcohol or herbal medications. Information on patient clinical characteristics, current antiretroviral regimen, CD4 count, HIV-1 RNA levels, and clinical chemistry parameters was collected. Informed consent was provided.

Results

During a 6-month period, four patients without other known risk factors for acute hepatitis presented with symptomatic drug-induced liver injury with varying symptoms and outcomes. The pattern of liver injury was hepatocellular for all the 4 cases. Liver biopsies were done for all the four cases and the results showed a heavy mixed inflammatory cell infiltrate with eosinophils. For three patients withdrawal of Efavirenz from their antiretroviral regimen was sufficient to restore transaminase levels to normal and led to improvement of clinical symptoms. For one patient his clinical course was characterized by fulminant liver failure and fluctuating episodes of hepatic encephalopathy which ultimately resulted in his death.

Conclusion

Hepatotoxicity of Efavirenz is not as rare as previously described in the literature and does actually present with fatal outcomes. The key message to note is that frequent monitoring of liver enzymes should be done at initiation of antiretroviral therapy and should continue throughout the treatment period.

Increased MMAB level in mitochondria as a novel biomarker of hepatotoxicity induced by Efavirenz

Background

Efavirenz (EFV), a non-nucleoside reverse transcriptase inhibitor (NNRTI), has been widely used in the therapy of human immunodeficiency virus (HIV) infection. Some of its toxic effects on hepatic cells have been reported to display features of mitochondrial dysfunction through bioenergetic stress and autophagy, etc. However, alteration of protein levels, especially mitochondrial protein levels, in hepatic cells during treatment of EFV has not been fully investigated.

Methods

We built a cell model of EFV-induced liver toxicity through treating Huh-7 cells with different concentrations of EFV for different time followed by the analysis of cell viability using cell counting kit -8 (CCK8) and reactive oxygen species (ROS) using 2',7'-dichlorodihydrofluorescein diacetate (DCFH-DA) and MitoSox dye. Proteomic profiles in the mitochondria of Huh-7 cells stimulated by EFV were analyzed. Four differentially expressed proteins were quantified by real time RT-PCR. We also detected the expression of mitochondrial precursor Cob(I)yrinic acid a,c-diamide adenosyltransferase (MMAB) by immunohistochemistry analysis in clinical samples. The expression levels of MMAB and ROS were detected in EFV-treated Huh-7 cells with and without shRNA used to knock down MMAB, and in primary hepatocytes (PHC). The effects of other anti-HIV drugs (nevirapine (NVP) and tenofovirdisoproxil (TDF)), and hydrogen peroxide (H₂O₂) were also tested. Amino acid analysis and fatty aldehyde dehydrogenase (ALDH3A2) expression after MMAB expression knock-down with shRNA was used to investigate the metabolic effect of MMAB in Huh-7 cells.

Results

EFV treatment inhibited cell viability and increased ROS production with time- and concentration-dependence. Proteomic study was performed at 2 hours after EFV treatment. After treated Huh-7 cells with EFV (2.5mg/L or 10 mg/L) for 2 h, fifteen differentially expressed protein spots from purified mitochondrion that included four mitochondria proteins were detected in EFV-treated Huh-7 cells compared to controls. Consistent with protein expression levels, mRNA expression levels of mitochondrial protein MMAB were also increased by EFV treatment. In addition, the liver of EFV-treated HIV infected patients showed substantially higher levels of MMAB expression compared to the livers of untreated or protease inhibitor (PI)-treated HIV-infected patients. Furthermore, ROS were found to be decreased in Huh-7 cells treated with shMMAB compared with empty plasmid treated with EFV at the concentration of 2.5 or 10 mg/L. MMAB was increased in EFV-treated Huh-7 cells and primary hepatocytes. However, no change in MMAB expression was detected after treatment of Huh-7 cells and primary hepatocytes with anti-HIV drugs nevirapine (NVP) and tenofovirdisoproxil (TDF), or hydrogen peroxide (H₂O₂), although ROS was increased in these cells. Finally, knockdown of MMAB by shRNA induced increases in the β-Alanine (β-Ala) production levels and decrease in ALDH3A2 expression.

Conclusions

A mitochondrial proteomic study was performed to study the proteins related to EFV-inducted liver toxicity. MMAB might be a target and potential biomarker of hepatotoxicity in EFV-induced liver toxicity.

Coinfections with hepatitis B and C virus and syphilis among HIV-infected clients in Southern Ethiopia: a cross-sectional study

Introduction

Hepatitis B virus (HBV) and hepatitis C virus (HCV) are hepatotropic viruses of public health significance worldwide. Despite their severe clinical impact in HIV-infected patients, there is inadequate information regarding the epidemiology of hepatitis/HIV coinfections in Ethiopia. Thus, this study aimed to determine the prevalence of HBV and HCV infections among HIV-infected patients at a tertiary hospital in Southern Ethiopia.

Methods

Stored sera, which were originally collected for the investigation of syphilis among HIV-infected clients, were analyzed in this study. Samples were tested for hepatitis B surface antigen (HBsAg) and antibody to hepatitis B core antigen using rapid diagnostic tests. Those samples that tested positive for HBsAg were further analyzed for hepatitis B e antigen. All sera were tested for antibody to HCV infection using rapid diagnostic test.

Results

HBsAg was positive for 6.3% of the participants; of whom, 10% were positive for hepatitis B e antigen. The exposure rates to HBV (antibody to hepatitis B core antigen) and HCV (anti-HCV) infections were 22.4 and 3.1%, respectively. The rates of coinfections with HBV-syphilis, HCV-syphilis, and HBV-HCV were found to be 3.1, 0.6, and 1.3%, respectively. HBV exposure rate was significantly higher among participants in the age range 40–49 years (adjusted odds ratio [AOR], 1.98; 95% CI, 1.01–3.88) and those who had a CD4+ T cell count <200 cells/μL (AOR, 2.40; 95% CI, 1.13–5.10) and 200–349 cells/μL (AOR, 2.36; 95% CI, 1.28–4.35).

Conclusion

The rates of HBV and HCV infections were found to be similar to other subpopulations in Ethiopia. Age and CD4+ T cell level influenced the rate of HBV exposure. As human immunodeficiency virus-hepatitis coinfections are clinically consequential in people living with human immunodeficiency virus/acquired immunodeficiency syndrome, the need to screen this population for HBV and HCV infections is critically important.

HBV, HCV, and HBV/HCV co-infection among HIV-positive patients in Hunan province, China: Regimen selection, hepatotoxicity, and antiretroviral therapy outcome

Co-infection with hepatitis B (HBV) and C (HCV) is common among people living with HIV (PLHIV). This study investigates the impacts of hepatitis co-infection on antiretroviral therapy (ART) outcomes and hepatotoxicity in PLHIV. The cohort study included 1984 PLHIV. Hepatotoxicity was defined by elevated alanine aminotransferase (ALT) levels. ART outcomes were measured by CD4 cell counts, viral load, and mortality rate in patients. Among 1984 PLHIV, 184 (9.3%) were co-infected with HBV and 198 (10.0%) with HCV and 54 (2.7%) were co-infected with HBV and HCV. Of these patients, 156 (7.9%) had ALT elevation ≥ grade 1 at baseline. During the course of ART, the mortality rate and its adjusted hazard ratio (AHR) in PLHIV who were co-infected with HCV (2.6/100 person-years [py], AHR = 2.3, 95%CI 1.1-4.7) was higher than for patients with mono-infected HIV, as it was for those with an elevated ALT (4.4/100 py, AHR = 3.8, [1.7-8.2]) at baseline compared to those with normal ALT. After 6-12 months of ART, the incidence of hepatotoxicity among all the patients was 3.7/100 py. The risk of hepatotoxicity was higher in HCV co-infected (18.6/100 py, adjusted odds ratio [AOR] = 12.4, [8.1-18.2]) than HIV mono-infected patients, and for all regimens (nevirapine: 30.0/100 py, 34.2, 7.3-47.9; zidovudine/stavudine: 24.7/100 py, 22.1, 7.1-25.5; efavirenz: 14.5/100 py, 9.4, 3.5-19.2; lopinavir/ritonavir: 40.1/100 py, 52.2, 9.5-88.2) except tenofovir (4.3/100 py, 4.9, 0.8-9.5). Patients with HBV/HCV co-infected had high hepatotoxicity (10.0/100 py, 6.3, 1.2-23.3) over the same period. Patients with HCV co-infection and HBV/HCV co-infection demonstrated higher hepatotoxicity rate compared with HIV mono-infected patients in China.

Current treatment status and barriers for patients with chronic HCV infection in mainland China: A national multicenter cross-sectional survey in 56 hospitals

Chronic hepatitis C virus (HCV) infection is a serious public health problem worldwide. China, as the country with the largest number of HCV infections in the world, plays a significant role in eliminating hepatitis C. Due to different financial situations and education background, hepatitis C patients take different actions for their disease treatment and management. Therefore, antiviral treatment status should be attached great importance to learn the medical demand of patients. A nationwide, multicenter survey was conducted from July 2015 to June 2016. Of 1798 inpatients and outpatients with chronic HCV from 56 hospitals participated in the survey. Each patient completed the questionnaire with questions about his/her antiviral therapy status, perception of treatment barriers, and expectations for future treatment. In total 1622 patients, including 1241 with chronic hepatitis C, 344 with cirrhosis, and 37 patients with hepatocellular carcinoma, fulfilled data collection requirements and finally were included in analysis. Overall, up to 30.7% of the patients had not or currently does not intend to receive antiviral therapy. The main reason was expecting more potent and well-tolerance medication (31.5%), followed by the fear of interferon related side effects (27.5%). Multiple regression analysis showed that the patient's annual income, the severity of HCV, and comorbidity were independent predictors of not receiving antiviral therapy. The whole patients were expecting more potent and well tolerance medication available soon. In summary, Peg-IFN/RBV treatment regimen cannot meet the need of patients well, and safe and efficient direct-acting antivirals are urgently needed in mainland China.

Prevalence and Clinical Spectrum of Liver Disease in Nepalese HIV-Sero-Positive Patients Undergoing Antiretroviral Therapy: A Cross-Sectional Hospital Based Study

Introduction

Liver enzyme abnormalities are common in HIV patients, and the prevalence varies across the nations. In Nepal, however, prevalence of liver enzyme disorder and the spectrum of these populations are lacking.

Objective

The present study sheds light on prevalence and clinical spectrum of liver disease in Nepalese HIV-sero-positive patients.

Methods

This cross-sectional study was conducted at OPD/ART, Clinic of Bir Hospital, NAMS. One hundred and forty-four HIV positive patients were enrolled consecutively and their clinical profiles of liver injury were investigated.

Results

Of 144 recruited patients, liver enzyme injury was observed in 82 (56.9%). Majority 61 (42.4%) of these cases had hepatocellular type of liver injury. Opportunistic infections were reported in 18 cases, with 9 (6.2%) TB and 8 (5.6%) HCV. Test for significance of liver injury confirmed the absence of any tendency towards an association with coinfection, CD4 cells, ART regimen, and alcohol consumption (P > 0.05). However, gender significantly linked with liver injury as well as the pattern of liver injury (P < 0.05).

Conclusion

The study revealed high rate of liver injury in a substantial proportion of HIV individuals, stressing that a regular clinic follow-up is necessary for the HIV individuals who are undergoing ART.

Idiosyncratic drug-induced liver injury: A short review

Idiosyncratic drug‐induced liver injury (iDILI) is a rare adverse drug reaction that occasionally leads to acute liver failure or even death. An aging population that uses more drugs, a constant influx of newly developed drugs, and a growing risk from herbal and dietary supplements of uncertain quality can lead to an increase in iDILI. Antimicrobials, central nervous system agents, and herbal and dietary supplements are the most common causes of iDILI in developed countries. iDILI is still a diagnosis of exclusion, and thus careful history taking and thorough work‐ups for competing etiologies, such as acute viral hepatitis, autoimmune hepatitis, and others, are essential. The pathogenesis of iDILI is not clear and includes a mix of host reactions, drug metabolites, and environmental factors. Immediate cessation of the suspected offending drug is key to preventing or minimizing progressive damage. No definitive therapies for iDILI are available, and the treatments remain largely supportive. (Hepatology Communications 2017;1:494–500)

Hepatitis B virus vaccination in HIV-infected people: A review

HBV immunization is highly recommended in people infected with HIV. However, the classical schedule used in the general population has been shown to be insufficient in people living with HIV. This review summarizes the main studies dealing with HBV vaccination in people living with HIV, depending on their baseline status (in particular, never vaccinated, already vaccinated, or with an isolated anti-HBc serological profile). It shows that reinforced 40µg intramuscular HBV vaccination schedules are now frequently recommended, either initially in people never vaccinated, or in the lack of an anamnestic response in other situations. Adjuvants cannot be currently recommended. Anti-HBs titers have to be checked 1 to 2 months following the last vaccine dose, and annually thereafter a booster is necessary if antiHBs titers decrease below 10 mIU/mL. In patients with a CD4 cell count <200/µL, guidelines recommend starting the vaccination regimen as soon as possible after HAART has been started.

Human Immunodeficiency Virus Infection, Antiretroviral Therapy, and Liver Pathology

The improvement in antiretroviral therapy has significantly impacted the lives of people living with human immunodeficiency virus (HIV). In high-income countries, HIV deaths are predominated by liver disease consequent to viral hepatitis coinfection, alcohol, and nonalcoholic fatty liver disease. Published liver pathology findings have shifted from being predominated by opportunistic infections to the metabolic effects of HIV and antiretroviral therapy as well as drug-induced liver injuries. Differences remain between high-income and low-income countries, where opportunistic infections and immune reconstitution syndromes, dominate findings.

Multicenter study of skin rashes and hepatotoxicity in antiretroviral-naïve HIV-positive patients receiving non-nucleoside reverse-transcriptase inhibitor plus nucleoside reverse-transcriptase inhibitors in Taiwan

OBJECTIVES

Two nucleos(t)ide reverse-transcriptase inhibitors (NRTIs) plus 1 non-NRTI (nNRTI) remain the preferred or alternative combination antiretroviral therapy (cART) for antiretroviral-naive HIV-positive patients in Taiwan. The three most commonly used nNRTIs are nevirapine (NVP), efavirenz (EFV) and rilpivirine (RPV). This study aimed to determine the incidences of hepatotoxicity and skin rashes within 4 weeks of initiation of cART containing 1 nNRTI plus 2 NRTIs.

METHODS

Between June, 2012 and November, 2015, all antiretroviral-naive HIV-positive adult patients initiating nNRTI-containing cART at 8 designated hospitals for HIV care were included in this retrospective observational study. According to the national HIV treatment guidelines, patients were assessed at baseline, 2 and 4 weeks of cART initiation, and subsequently every 8 to 12 weeks. Plasma HIV RNA load, CD4 cell count and aminotransferases were determined. The toxicity grading scale of the Division of AIDS (DAIDS) 2014 was used for reporting clinical and laboratory adverse events.

RESULTS

During the 3.5-year study period, 2,341 patients initiated nNRTI-containing cART: NVP in 629 patients, EFV 1,363 patients, and RPV 349 patients. Rash of any grade occurred in 14.1% (n = 331) of the patients. In multiple logistic regression analysis, baseline CD4 cell counts (per 100-cell/μl increase, adjusted odds ratio [AOR], 1.125; 95% confidence interval [95% CI], 1.031-1.228) and use of NVP (AOR, 2.443; 95% CI, 1.816-3.286) (compared with efavirenz) were independently associated with the development of skin rashes. Among the 1,455 patients (62.2%) with aminotransferase data both at baseline and week 4, 72 (4.9%) developed grade 2 or greater hepatotoxicity. In multiple logistic regression analysis, presence of antibody for hepatitis C virus (HCV) (AOR, 2.865; 95% CI, 1.439-5.704) or hepatitis B surface antigen (AOR, 2.397; 95% CI, 1.150-4.997), and development of skin rashes (AOR, 2.811; 95% CI, 1.051-7.521) were independently associated with the development of hepatotoxicity.

CONCLUSIONS

The baseline CD4 cell counts and use of NVP were associated with increased risk of skin rashes, while hepatotoxicity was independently associated with HCV or hepatitis B virus coinfection, and development of skin rashes in antiretroviral-naïve HIV-positive Taiwanese patients within 4 weeks of initiation of nNRTI-containing regimens.

Epidemiology and Genetic Risk Factors of Drug Hepatotoxicity

Idiosyncratic drug-induced liver injury (DILI) from prescription medications and herbal and dietary supplements has an annual incidence rate of approximately 20 cases per 100,000 per year. However, the risk of DILI varies greatly according to the drug. In the United States and Europe, antimicrobials are the commonest implicated agents, with amoxicillin/clavulanate the most common, whereas in Asian countries, herbal and dietary supplements predominate. Genetic analysis of DILI is currently limited, but multiple polymorphisms of human leukocyte antigen genes and genes involved in drug metabolism and transport have been identified as risk factors for DILI.

Risk of Acute Liver Injury With Antiretroviral Therapy by Viral Hepatitis Status

Background

The risk of hepatotoxicity with antiretroviral therapy (ART) remains unknown. We determined the comparative risk of acute liver injury (ALI) for antiretroviral drugs, classes, and regimens, by viral hepatitis status.

Methods

We followed a cohort of 10 083 human immunodeficiency virus (HIV)-infected persons in Kaiser Permanente Northern California (n = 2099) from 2004 to 2010 and the Veterans Aging Cohort Study (n = 7984) from 2004 to 2012. Within the first year of ART, we determined occurrence of (1) liver aminotransferases >200 U/L and (2) severe ALI (coagulopathy with hyperbilirubinemia). We used Cox regression to determine hazard ratios (HRs) with 95% confidence intervals (CIs) of endpoints among initiators of nucleos(t)ide analogue combinations, antiretroviral classes, and ART regimens, all stratified by viral hepatitis status.

Results

Liver aminotransferases >200 U/L developed in 206 (2%) persons and occurred more frequently among HIV/viral hepatitis-coinfected than HIV-monoinfected persons (116.1 vs 20.7 events/1000 person-years; P < .001). No evidence of differential risk was found between initiators of abacavir/lamivudine versus tenofovir/emtricitabine among coinfected (HR, 0.68; 95% CI, .29–1.57) or HIV-monoinfected (HR, 1.19; 95% CI, .47–2.97) groups. Coinfected patients had a higher risk of aminotransferases >200 U/L after initiation with a protease inhibitor than nonnucleoside reverse-transcriptase inhibitor (HR, 2.01; 95% CI, 1.36–2.96). Severe ALI (30 events; 0.3%) occurred more frequently in coinfected persons (15.9 vs 3.1 events/1000 person-years; P < .001) but was too uncommon to evaluate in adjusted analyses.

Conclusions

Within the year after ART initiation, aminotransferase elevations were infrequently observed and rarely led to severe ALI. Protease inhibitor use was associated with a higher risk of aminotransferase elevations among viral hepatitis-coinfected patients.

Prevalence and Factors Associated With Hepatitis B and C Co-Infection Among HIV-1-Infected Patients in Kenya

Background:

Hepatitis B virus (HBV) and hepatitis C virus (HCV) are among the most chronic viral infections worldwide. Co-infections with HBV and HCV have become increasingly common among people living with HIV, resulting in a growing public health concern. The primary aim of our study was to determine the prevalence of HBV and HCV and their associated factors among HIV-1-infected patients attending the Ngong Sub-County Hospital comprehensive care clinic.

Methods:

After providing consent, a 5 mL blood sample was collected from each study participant visiting the comprehensive care clinic. The blood was screened for hepatitis B surface antigen and HCV antibodies using chemiluminescence immunoassay test according to the manufacturer's instructions. The CD4 T-cell counts were determined using FACSCalibre machine, while HIV-1 viral load was determined using the Abbott m2000rt System according to the manufacturer's instructions. A questionnaire was used to collect sociodemographic information and data on factors associated with HBV and HCV co-infections.

Results:

One hundred and ninety HIV-1-infected patients participated in this study: 150 (78.9%) women and 40 (21.1%) men. In the overall study population, the prevalence of HBV co-infection was 5.8% (95% CI, 2.6%–8.9%) and of HCV co-infection was 4.2% (95% CI, 1.6%–7.4%). However, no individual was co-infected with all 3 viruses. HCV was associated with antiretroviral treatment (OR 0.2; 95% CI, 0.0–0.8; P=.036), while HBV showed a significant association with condom usage (OR 0.3; 95% CI, 0.1–0.9; P=.039) and median viral load.

Conclusion:

A high prevalence of HIV/HBV and HIV/HCV co-infection was reported in this study, suggesting that HIV-infected patients should be routinely screened for HBV and HCV infections, and preventive and control measures should be put in place that include public education on HBV and HCV infections.

Efavirenz: Enhancing the gold standard

Efavirenz, the potent, once-daily non-nucleoside reverse transcriptase inhibitor, has been successfully used since 1996 and is still a cornerstone of antiretroviral therapy for use in treatment-naïve, treatment-experienced and difficult-to-treat patients. The efficacy of efavirenz in these patient groups has been established in many clinical and cohort studies. Furthermore, efavirenz is now available as a single 600 mg tablet, providing a simplified therapy and decreased pill burden, which may lead to improved adherence and treatment outcomes. Efavirenz has a well-characterized tolerability profile, the more notable side effects being mainly short-term and non-life-threatening, such as central nervous system disturbances and rash.

Impact of hepatitis B on mortality and specific causes of death in adults with and without HIV co-infection in NYC, 2000-2011

High rates of immigration from endemic countries contribute to the high chronic hepatitis B (HBV) prevalence in New York City (NYC) compared to the United States overall, i.e. about 1 million individuals. We describe the impact of HBV infection on mortality and specific causes of death in NYC. We matched surveillance and vital statistics mortality data collected from 2000 to 2011 by the New York City Department of Health and Mental Hygiene (DOHMH) and analysed demographics and premature deaths (i.e. whether death occurred at <65 years) in persons with and without chronic HBV or HIV infection (excluding those with hepatitis C). From 2000 to 2011, a total of 588 346 adults died in NYC. Of all decedents, 568 753 (97%) had no report of HIV or HBV, and 4346 (0·7%) had an HBV report. Of HBV-infected decedents, 1074 (25%) were HIV co-infected. Fifty-five percent of HBV mono-infected and 95% of HBV/HIV co-infected decedents died prematurely. HBV disproportionately impacts two subgroups: Chinese immigrants and HIV-infected individuals. These two subgroups are geographically clustered in different neighbourhoods of NYC. Tailoring prevention and treatment messages to each group is necessary to reduce the overall burden of HBV in NYC.