Increasing mortality due to end-stage liver disease in patients with human immunodeficiency virus infection

The clinical prognostic risk stratification system for HIV infected hepatocellular carcinoma

BACKGROUND

Patients with human immunodeficiency virus (HIV) are more susceptible to liver cancer because of their compromised immune system. There is no specific prognostic model for HIV-infected hepatocellular carcinoma (HCC) patients.

METHODS

Clinical data of 85 patients with HIV-infected HCC was divided into a 7:3 ratio for training and internal validation sets, while the data of 23 patients with HIV-infected HCC was served as the external validation set. Data of 275 HIV-negative HCC patients was considered as external HIV-negative validation set. Variables associated with overall survival (OS) in the training set were used to develop the HIV-infected HCC prognosis (HIHP) model. The model was tested in the internal and external validation sets. The predictive accuracy of the model was assessed with conventional HIV-negative HCC prognostic scoring systems.

RESULTS

In the training set, variables independently associated with OS in multivariable analysis were organ involvement and tumor number. The HIHP model demonstrated a significant association with OS in the training set, with a median OS of 13 months for low risk, 7 months for medium risk, and 3 months for high risk (p < 0.001). The HIHP model showed a significant association with OS, and exhibited greater discriminative abilities compared to conventional HIV-negative HCC prognostic models both in the internal and external validation sets. In the external HIV-negative validation set, the HIHP model did not show better discrimination than conventional HIV-negative HCC scores.

CONCLUSION

The new model presented in the work provided a more accurate prognostic prediction of OS in HIV-infected HCC patients. However, the model is not applicable to patients with HIV-negative HCC.

Nonviral Liver Disease Burden in People Living With HIV and Elevated Transaminases: A Cross-Sectional Study

INTRODUCTION

Because of improved life expectancy in people living with HIV (PLWH), liver disease is increasingly being recognized. We assessed nonviral chronic liver disease burden in PLWH.

METHODS

The HIV non-virAL liver disease study (2014-2021) prospectively recruited PLWH with elevated serum alanine aminotransferase levels and negative hepatitis serology. Clinically significant hepatic fibrosis (CSHF) was defined as liver stiffness measurement of >7.1 kPa and hazardous alcohol use as Alcohol Use Disorders Identification Test score ≥ 8. Primary outcome was prevalence/predictors of CSHF.

RESULTS

Total recruited were n = 274, 92% male, median age 52 (45-59) years, and 96% having undetectable HIV viral load. Overall, n = 97 (35%) had hazardous alcohol use, n = 72 (26%) had metabolic syndrome, and 17%-27% had exposure to hepatotoxic antiretrovirals. Prevalence of CSHF was 20% (n = 54), prevalence of cirrhosis (liver stiffness measurement > 12.5 kPa) being 7% (19/274). Risk factors for CSHF were hazardous alcohol use in 44% (n = 24), metabolic syndrome in 46% (n = 25), and hepatotoxic antiretrovirals in 56% (n = 30), most having more than one risk factor. Independent predictors of CSHF were serum high-density lipoprotein (odds ratio [OR] 0.220; 95% confidence interval [CI]: 0.061 to 0.790, P = 0.020) (inverse relationship); serum aspartate aminotransferase (OR 1.033, 95% CI: 1.001 to 1.067, P = 0.045), and didanosine use (OR 2.878, 95% CI: 1.228 to 6.774, P = 0.015). Moderate-severe hepatic steatosis was identified in 52% (n = 142). FIB-4 and aspartate aminotransferase-to-platelet ratio index performed poorly in predicting CSHF (positive predictive value 27.3% and 30.6%, respectively) and advanced fibrosis (≥F3) (positive predictive value 17.6% and 5.9%, respectively).

CONCLUSION

In this study, 20% of PLWH had CSHF associated with high prevalence of hazardous alcohol use/metabolic syndrome/potentially hepatotoxic antiretrovirals. These potentially modifiable risk factors need addressing.

The human microbiome and gut-liver axis in people living with HIV

PURPOSE OF REVIEW

Chronic liver disease is a major cause of morbidity and mortality amongst people living with HIV (PLWH). Emerging data suggests that gut microbial translocation may play a role in driving and modulating liver disease, a bi-directional relationship termed the gut-liver axis. While it is recognized that PLWH have a high degree of dysbiosis and gut microbial translocation, little is known about the gut-liver axis in PLWH.

RECENT FINDINGS

Recent studies have shown that microbial translocation can directly lead to hepatic inflammation, and have linked gut microbial signatures, dysbiosis, and translocation to liver disease in PLWH. Additionally, multiple trials have explored interventions targeting the microbiome in PLWH. Emerging research supports the interaction between the gut microbiome and liver disease in PLWH. This offers new opportunities to expand our understanding of the pathophysiology of liver disease in this population, as well as to explore possible clinical interventions.

Outcomes of ABO-incompatible liver transplantation in end-stage liver disease patients co-infected with hepatitis B and human immunodeficiency virus

BACKGROUND

Human immunodeficiency virus (HIV)-positive patients coinfected with hepatitis B virus (HBV) are eligible for liver transplantation (LT) in Africa and Southeast Asia, particularly China. However, the outcome of HIV-HBV coinfected patients referred for ABO-incompatible LT (ABOi-LT) is unknown.

AIM

To clarify the outcome of ABOi-LT for HIV-HBV coinfected patients with end-stage liver disease (ESLD).

METHODS

We report on two Chinese HIV-HBV coinfected patients with ESLD who underwent A to O brain-dead donor LT and reviewed the literature on HIV-HBV coinfected patients treated with ABO-compatible LT. The pretransplantation HIV viral load was undetectable, with no active opportunistic infections. Induction therapy consisted of two sessions of plasmapheresis and a single dose of rituximab in two split doses, followed by an intraoperative regimen of intravenous immunoglobulin, methylprednisolone, and basiliximab. Post-transplant maintenance immunosuppressive agents consisted of tacrolimus and mycophenolate mofetil, and prednisone.

RESULTS

At the intermediate-term follow-up, patients showed undetectable HIV viral load, CD4(+) T cell counts greater than 150 cells/μL, no HBV recurrence, and stable liver function. A liver allograft biopsy showed no evidence of acute cellular rejection. Both patients survived at 36-42 mo of follow-up.

CONCLUSION

This is the first report of ABOi-LT in HIV-HBV recipients with good intermediate-term outcomes, suggesting that ABOi-LT may be feasible and safe for HIV-HBV coinfected patients with ESLD.

Perceptions Towards HCV Treatment with Direct Acting Antivirals (DAAs): A Qualitative Analysis with Persons with HIV/HCV Co-infection Who Delay or Refuse Treatment

In the United States, approximately 25% of people with HIV (PWH) are co-infected with hepatitis C (HCV). Since 2014, highly effective and well-tolerated direct-acting antivirals (DAAs) have revolutionized HCV treatment. Uptake of DAAs by people with HIV/HCV co-infection has improved but remains suboptimal due to system, provider, and patient-level barriers. To explore patient-level issues by better understanding their attitudes towards DAA treatment, we conducted qualitative interviews with 21 persons with HIV/HCV co-infection who did not consent to DAA treatment or delayed treatment for at least 1 year after diagnosis. We found PWH perceived DAA treatment barriers and facilitators on multiple levels of the social-ecological environment: the individual (HCV disease and treatment literacy), interpersonal (peer influence), institutional (media and healthcare provider relationship), and structural levels (treatment cost and adherence support). Recommendations to improve DAA treatment uptake include HCV-treatment adherence support, HCV disease and treatment literacy training (particularly for substance use and DAA treatment interactions), and encouraging PWH who have successfully completed DAA treatment to speak with their peers.

Controlled attenuation parameter accurately detects liver steatosis in people with HIV

OBJECTIVES

Hepatic steatosis is a leading cause of cirrhosis and hepatocellular carcinoma and is highly prevalent in persons with HIV (PWH). However, most studies of hepatic steatosis diagnosis in PWH have focused on those at high risk. We determined the accuracy of vibration-controlled transient elastography (VCTE) with controlled attenuation parameter (CAP) in detecting mild or greater hepatic steatosis as compared with the noninvasive gold standard magnetic resonance spectroscopy (MRS) in PWH.

METHODS

Among 149 participants with and without HIV, we evaluated test characteristics of CAP and calculated serum indices Hepatic Steatosis Index (HSI) and STEATO-ELSA in identifying 3T MRS-measured hepatic steatosis (defined as a liver fat fraction ≥5%).

RESULTS

Most participants were women and over half were African American. Median BMI was 27 kg/m 2 . Hepatic steatosis prevalence by MRS and CAP (cutoff 248 dB/m) was 36% and 47%, respectively. CAP had an AUROC of 0.82, and the at least 248 dB/m cutoff yielded a sensitivity, specificity, positive-predictive value, and negative-predictive value of 83%, 72%, 61%, and 88%, respectively. These test characteristics were not statistically different from the optimal cutoff of at least 252 dB/m. Higher waist circumference, greater visceral adipose tissue, heavy alcohol use, and VCTE scans flagged as having the probe positioned too low were associated with CAP and MRS discordance. Serum indices of hepatic steatosis had slightly worse performance characteristics than CAP.

CONCLUSION

CAP may be an effective alternative to MRS for noninvasive hepatic steatosis assessment in PWH. The commonly used CAP cutoff of at least 248 dB/m to diagnose hepatic steatosis can be used in PWH.

Crack cocaine use frequency is associated with HIV disease severity independent of antiretroviral therapy exposure: a prospective cohort study

We sought to evaluate the effect of crack cocaine use frequency on HIV disease severity among HIV-positive people who use unregulated drugs (PWUD). We analyzed data from the ACCESS study, an open prospective cohort of HIV-positive PWUD including comprehensive HIV clinical monitoring in a setting with no-cost healthcare. Multivariable generalized linear mixed-effects models were used to estimate the independent effect of time-updated crack cocaine use frequency on HIV disease severity, adjusting for ART exposure and relevant confounders. In multivariable adjusted models, daily or greater frequency of crack cocaine use was significantly associated with higher VACS Index scores (β = 0.8, 95% confidence interval: 0.1, 1.5) as compared to none. Our finding suggests that daily or greater frequency of crack cocaine use exacerbates HIV disease severity independent of ART exposure. The observed effect may reflect an underlying biological mechanism or other factors linked with crack cocaine use; further investigation is warranted.

Alcohol and HIV-Derived Hepatocyte Apoptotic Bodies Induce Hepatic Stellate Cell Activation

Recently, we found that both HIV and acetaldehyde, an alcohol metabolite, induce hepatocyte apoptosis, resulting in the release of large extracellular vesicles called apoptotic bodies (ABs). The engulfment of these hepatocyte ABs by hepatic stellate cells (HSC) leads to their profibrotic activation. This study aims to establish the mechanisms of HSC activation after engulfment of ABs from acetaldehyde and HIV-exposed hepatocytes (ABAGS+HIV). In vitro experiments were performed on Huh7.5-CYP (RLW) cells to generate hepatocyte ABs and LX2 cells were used as HSC. To generate ABs, RLW cells were pretreated for 24 h with acetaldehyde, then exposed overnight to HIV1ADA and to acetaldehyde for 96 h. Thereafter, ABs were isolated from cell suspension by a differential centrifugation method and incubated with LX2 cells (3:1 ratio) for profibrotic genes and protein analyses. We found that HSC internalized ABs via the tyrosine kinase receptor, Axl. While the HIV gag RNA/HIV proteins accumulated in ABs elicited no productive infection in LX2 and immune cells, they triggered ROS and IL6 generation, which, in turn, activated profibrotic genes via the JNK-ERK1/2 and JAK-STAT3 pathways. Similarly, ongoing profibrotic activation was observed in immunodeficient NSG mice fed ethanol and injected with HIV-derived RLW ABs. We conclude that HSC activation by hepatocyte ABAGS+HIV engulfment is mediated by ROS-dependent JNK-ERK1/2 and IL6 triggering of JAK-STAT3 pathways. This can partially explain the mechanisms of liver fibrosis development frequently observed among alcohol abusing PLWH.

Prevalence of HIV and Its Co-Infection with Hepatitis B/C Virus Among Chronic Liver Disease Patients in Ethiopia

Background

The efficient use of antiretroviral drugs has significantly reduced AIDS-related morbidities and mortalities; however, mortality due to non-AIDS-related end-stage liver diseases is escalating in those living with HIV.

Objective

The study was designed to determine the prevalence of HIV and its co-infection with HBV and HCV among chronic liver disease (CLD) patients in Ethiopia.

Methods

Three hundred and forty-five CLD patients were included in this study in two groups: Hepatocellular carcinoma (HCC) (n=128) and non-HCC (n=217) patients. The non-HCC group comprised patients with advanced liver disease (n=98) and chronic hepatitis (n=119). Enzyme immunoassays were used to determine HBV and HCV infection markers. In addition, a serial rapid HIV testing algorithm was employed to screen HIV infection.

Results

Regardless of the stage of liver disease, the overall frequency of HIV was 4.3% (15/345), with a 2% (7/345) and 0.3% (1/345) of HIV/HBV and HIV/HCV co-infection rate. Of all HIV-infected patients (n=15), 46.7% (7/15) and 6.7% (1/15) were co-infected with HBV (HBsAg⁺HBcAb⁺) and HCV (anti-HCV⁺ HCV-RNA⁺), respectively, and 86.7% (13/15) exhibited a marker of HBV exposure (total HBcAb⁺). Overall, the frequency of HIV and its co-infection with HBV was more noticeable among HCC than non-HCC patients [8.6% (11/128) vs 1.8 (4/217), p=0.005 and 3.9% (5/128) vs 0.9% (2/217), p=0.1]. The rate of HIV mono-infection was 3.9% (5/128) vs 0.9% (2/217) among HCC and non-HCC patients.

Conclusion

The frequency of HIV and its co-infections with HBV/HCV exhibited an increasing pattern with the severity of the liver disease. Thus, screening all HIV-positive patients for HBV and HCV infection and all CLD patients for HIV infection and taking necessary preventive measures would be an essential strategy to prevent the progression of CLD and death related to liver disease in people living with HIV.

Diagnosis and Clinical Manifestations of Acute Hepatitis C Infection in People Living with HIV

HIV/hepatitis C virus (HCV) coinfection is a global health problem with overlapping modes of transmission. We performed a single-center retrospective case series of acute HCV infections at the Atlanta Veterans Affairs Health Care System between January 2001 and June 2020 to better characterize the presentation and clinical course of acute HCV among veterans with HIV. Cases were discovered through routine clinical care. We identified 29 cases of acute HCV: all men. Risk for HCV acquisition included men who have sex with men (MSM; 93%) and injection drug use (17%). Thirteen (45%) had a concurrent sexually transmitted infection (STI). Symptoms were seen in 76% of acute HCV cases and resulted in hospitalization in 59% of symptomatic cases. Seven (24%) presented as HCV antibody seronegative. Three never seroconverted, all with CD4 T cell counts <200. Spontaneous HCV clearance occurred in 21% (n = 6) and was more common in those who developed jaundice (p = 0.01). Time to treatment was significantly reduced in the direct-acting antivirals (DAAs) era versus the interferon era (300 vs. 1631 days, p < 0.01). Of those who did not spontaneously clear, 87% were treated (n = 20/23) and 95% (n = 19/20) achieved sustained virological response. Three patients died before HCV treatment, all in the pre-DAA period (one death was liver related). In this case series of acute HCV infection in persons with HIV, many were symptomatic MSM who had a concurrent STI, suggesting sexual HCV transmission. Some presented as HCV antibody negative, highlighting the role of enhanced HCV screening and treatment in MSM with HIV to prevent HCV transmission in sexual networks.

Prevalence of HIV infection among non-elderly individuals with hepatitis C in Japan: a population-based cohort study using a health insurance claim data

Background

Hepatitis C virus (HCV) has been mainly transmitted through injection drug use, but recently, sexual transmission among men who have sex with men (MSM), which is also a major route of HIV transmission, is increasing. However, the prevalence of HIV and the incidence of other sexually transmitted infections (STIs) among HCV patients have been rarely reported.

Methods

Using a healthcare insurance claim data of employees and their dependents covering seven-million people in Japan, we evaluated HIV prevalence among HCV patients aged 20–59 years. Hemophilia patients were excluded. HIV and HCV were defined by registered diagnoses and receiving viral RNA testing. The time course of HCV and HIV infections was analyzed. Incidences of syphilis, amebiasis, chlamydia, gonorrhea, hepatitis A, and hepatitis B were assessed.

Results

From April 2012 to August 2018, 6,422 HCV patients were identified. HIV prevalence was 0.48% (31/6422, 95% CI [confidence interval]: 0.33–0.68%). HIV was diagnosed after HCV in 3.2% (1/31), before HCV in 58.1% (18/31), and concurrently in 38.7% (12/31). Compared with HCV patients without HIV infection, HCV/HIV co-infected patients were younger (median age, 37 vs 51 years, p < 0.001), more likely to be male (30/31 [96.8%] vs 3059/6391 [47.9%], p < 0.001), more likely to have other STIs (38.7% [12/31] vs 0.9% [56/6391], p < 0.001), and live in Tokyo, the most populous capital city in Japan (67.7% [21/31] vs 11.6% [742/6391], p < 0.001). In Tokyo, the HIV prevalence among 20–30 s male with HCV was 18.6% (13/70; 95% CI, 10.3–29.7%).

Conclusions

HIV prevalence among young male HCV patients was very high in Tokyo. HCV/HIV co-infected patients were more likely to acquire HIV before HCV, which is a known feature of MSM. They also had a higher incidence of STIs. These findings suggest that HCV might be prevalent as an STI among MSM particularly in Tokyo.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07152-5.

Non-alcoholic fatty liver disease: a multidisciplinary clinical practice approach—the institutional adaptation to existing Clinical Practice Guidelines

Abstract

Non-alcoholic fatty liver disease (NAFLD) is among the most frequently encountered chronic liver diseases in everyday clinical practice. It is considered the hepatic manifestation of metabolic syndrome. Today, liver biopsy is still the gold standard for NAFLD confirmation and assessing NAFLD's possible progression to non-alcoholic steatohepatitis, fibrosis, cirrhosis, and hepatocellular carcinoma. Because of the high prevalence of NAFLD and potential associated risks of invasive diagnostic procedures, it is of great interest to recruit the patients for liver biopsy. However, as the presence of liver fibrosis determines the further clinical course, liver biopsy is expectedly reserved for those with increased fibrosis risk. The quality of liver biopsy recruitment and patient monitoring could be significantly improved by using non-invasive tools to assess liver fibrosis presence and interactive collaboration between general practitioners, gastroenterologists, and endocrinologists. As a result, the quality of liver biopsy recruitment and patients monitoring could be significantly improved. Here, we proposed clinical practice guidelines that could be implemented for everyday clinical practice in NAFLD patients.

Novel pyridinium-type fullerene derivatives as multitargeting inhibitors of HIV-1 reverse transcriptase, HIV-1 protease, and HCV NS5B polymerase

In the present study, we newly synthesized four types of novel fullerene derivatives: pyridinium/ethyl ester-type derivatives 3b-3l, pyridinium/carboxylic acid-type derivatives 4a, 4e, 4f, pyridinium/amide-type derivative 5a, and pyridinium/2-morpholinone-type derivative 6a. Among the assessed compounds, cis-3c, cis-3d, trans-3e, trans-3h, cis-3l, cis-4e, cis-4f, trans-4f, and cis-5a were found to inhibit HIV-1 reverse transcriptase (HIV-RT), HIV-1 protease (HIV-PR), and HCV NS5B polymerase (HCV NS5B), with IC₅₀ values observed in the micromolar range. Cellular uptake of pyridinium/ethyl ester-type derivatives was higher than that of corresponding pyridinium/carboxylic acid-type derivatives and pyridinium/amide-type derivatives. This result might indicate that pyridinium/ethyl ester-type derivatives are expected to be lead compounds for multitargeting drugs to treat HIV/HCV coinfection.

In silico analysis of mutations associated with occult hepatitis B virus (HBV) infection in South Africa

Occult hepatitis B virus (OBI) infection is defined by the presence of viral DNA in the liver and/or serum in absence of hepatitis B surface antigen (HBsAg). While multiple studies have identified mutations that are associated with OBI, only a small portion of these mutations have been functionally characterized in vitro. Using complementary in silico approaches, the effects of OBI-associated amino acid mutations on HBV protein function in HBV/HIV-positive ART-naïve South Africans were evaluated. Two OBI-associated mutations in the PreS1 region, one in the PreS2 region, and seven in the surface region of subgenotype A1 sequences were identified as deleterious. In subgenotype A2 sequences, 11 OBI-associated mutations in the PreS1 region, seven in the PreS2 region, and 31 in the surface region were identified as deleterious. In the polymerase region, 14 OBI-associated mutations in subgenotype A1 and 71 OBI-associated mutations in subgenotype A2 were identified as deleterious. This study utilized in silico approaches to characterize the likely impact of OBI-associated mutations on viral function, thereby identifying and prioritizing candidates and reducing the significant cost associated with functional studies that are essential for mechanistic studies of the OBI phenotype.

Nonviral liver disease is the leading indication for liver transplant in the United States in persons living with human immunodeficiency virus

We evaluated whether indications for liver transplantation (LT) have changed among people with/without human immunodeficiency virus (HIV) infection and compared LT outcomes and trends by HIV serostatus. LT recipients (2008-2018) from the United Network for Organ Sharing and Organ Procurement and Transplantation Network (UNOS/OPTN) were identifed. Among 62 195 LT recipients, 352 (0.6%) were HIV-infected. The proportion of HIV-infected patients increased over time (P trend = .001), as did the number of transplant centers performing LT for HIV-infected recipients; average annual percentage change of 9.2% (p < .001). Nonviral causes became the leading indication in 2015 for HIV-uninfected and in 2018 for HIV-infected (P trend < .001). Three-year cumulative patient survival rates were 77.5%, for HIV-infected and 84.6%, for HIV-uninfected (p = .15). Over time, graft and patient survival rates improved for both HIV-infected and uninfected (p < .001). Among HCV-infected LT recipients, 3-year patient survival rates were 72.5% for HIV-infected and 81.8% for HIV-uninfected (p = .02). However, in a subanalysis restricted to 2014-2018, differences in graft and patient survival by HIV serostatus were no longer observed (3-year patient survival rates were 81.2% for HIV-infected and 86.4% for HIV-uninfected, p = .34). In conclusion, in the United States, nonviral liver disease is now the leading indication for LT in HIV-infected patients, and posttransplant outcomes have improved over time.

Validity of Self-Reported Hepatitis C Virus Status Among Criminal Justice-Involved Persons Living With HIV

The prevalence of HIV/hepatitis C virus (HCV) coinfection among justice-involved persons is high. The validity of self-reported HCV status in this population has important public health implications, yet has not been studied. Justice-involved persons with HIV from Washington, DC, were enrolled in a study that investigated a mobile health intervention to support HIV treatment. Self-reported and laboratory-confirmed HCV status was compared. Among 103 participants, chronic HCV prevalence was 13%. Positive predictive value of self-reported positive chronic HCV status was low at 55%, and negative predictive value was 98%. Cohen's kappa statistic was 0.60 for agreement. Two women who reported negative HCV status were found to have HCV.

Single-pill sofosbuvir and daclatasvir for treating hepatis C in patients co-infected with human immunodeficiency virus

BACKGROUND

The current recommendation for treating hepatitis C virus (HCV) in HIV patients includes the combination of sofosbuvir (SOF) and daclatasvir (DCV). DCV should be used at different doses to compensate for interactions with antiretroviral therapy (ART). Up to three pills a day might be required which will significantly add to the pill burden of these patients. In this study, we have used a single-tablet approach to treating HCV-HIV coinfection.

METHODS

Patients coinfected with HIV and HCV were prospectively enrolled from 10 centers throughout the country. Patients received a single once-daily fixed dose combination (FDC) pill containing 400 mg SOF and 30, 60 or 90 mg DCV depending on the type of ART they were receiving for 12 or 24 weeks. (ClinicalTrials.gov ID: NCT03369327).

RESULTS

Two hundred thirty-three patients were enrolled from 10 centers. Twenty-three patients were lost to follow-up and two patients died from causes unrelated to treatment. Two hundred eight patients completed the treatment course of which 201 achieved SVR (96.6%).

CONCLUSION

Single-tablet combination of DCV and SOF is an effective and safe treatment for patients coinfected with HIV and HCV. The combination works well in patients on ART in which dose adjustment is required. Patients with cirrhosis, previous treatment failure and various genotypes respond identically. The expenses of genotyping can be saved.

Hepatocellular cancer therapy in patients with HIV infection: Disparities in cancer care, trials enrolment, and cancer-related research

In the highly active antiretroviral therapy (HAART) era, hepatocellular carcinoma (HCC) is arising as a common late complication of human immunodeficiency virus (HIV) infection, with a great impact on morbidity and mortality. Though HIV infection alone may not be sufficient to promote hepatocarcinogenesis, the complex interaction of HIV with hepatitis is a main aspect influencing HCC morbidity and mortality.

Data about sorafenib effectiveness and safety in HIV-infected patients are limited, particularly for patients who are on HAART. However, in properly selected subgroups, outcomes may be comparable to those of HIV-uninfected patients. Scarce data are available for those other systemic treatments, either tyrosine kinase inhibitors, as well as immune checkpoint inhibitors (ICIs), which have been added to our therapeutic armamentarium. This review examines the influence of HIV infection on HCC development and natural history, summarizes main data on systemic therapies, offers some insight into possible mechanisms of T cell exhaustion and reversal of HIV latency with ICIs and issues about clinical trials enrollment. Nowadays, routine exclusion of HIV-infected patients from clinical trial participation is totally inappropriate, since it leaves a number of patients deprived of life-prolonging therapies.

A Randomized Trial Comparing Brief Advice and Motivational Interviewing for Persons with HIV-HCV Co-infection Who Drink Alcohol

Alcohol use contributes to the progression of liver disease in HIV-HCV co-infected persons, but alcohol interventions have never addressed low levels of alcohol use in this population. We enrolled 110 persons consuming at least 4 alcoholic drinks weekly in a clinical trial comparing two active 18-month long interventions, delivered every 3 months by phone, brief advice about drinking versus a motivational intervention. Final assessment was at 24 months. MI had larger reductions in alcohol use days than the BA arm at all follow-up assessments. The treatment by time effect was not significant for days of drinking (p = 0.470), mean drinks per day (p = 0.155), or for the continuous FIB-4 index (p = 0.175). Drinking declined in both conditions from baseline, but given the small sample, we do not have sufficient data to make any conclusion that one treatment is superior to the other.Trial Registry Trial registered at clinicaltrials.gov; Clinical Trial NCT02316184.

Incidence of Hepatotoxicity in Iranian Patients With HIV on Antiretroviral Therapies and Its Correlation with Virologic Response to HIV Treatment

OBJECTIVE

To investigate hepatotoxicity in Iranian patients with HIV to assess the association between virologic response to HIV treatment and serum alanine aminotransferase (ALT).

METHODS

This study was conducted with 200 control patients, 75 patients with HIV naïve to antiretroviral therapy (ART), and 443 patients who received ARTs with virologic response (≤1000 copies/mL) or virologic treatment failure (>1000 copies/mL). Serum ALT level and HIV viral load were determined in all patients.

RESULTS

Patient ALT levels were significantly higher than those of control patients (45.1 ± 44.4 IU/L vs 23.8 ± 5.4 IU/L). Compared to patients who were ART-naïve, patients with ART experience had significantly higher ALT levels (38.2 ± 26.2 IU/L vs 46.3 ± 46.7 IU/L), and severe hepatotoxicity was only detected in those with ART experience (8 patients, 1.8%). Mean ALT had no significant difference between virologic response/failure groups. The ALT activity and HIV load had a negative correlation coefficient, but it was not significant.

CONCLUSION

Periodic monitoring for the possibility of hepatotoxicity is highly recommended in all patients with HIV, especially in those receiving ART treatment.

Efficacy and Tolerability of Daclatasvir/Sofosbuvir (Datex) in Patients with HIV-HCV Co-infection

Background: Treatment of hepatitis C virus (HCV) infection with direct-acting antiviral agents in patients with HCV/human immunodeficiency virus (HIV) co-infection remains controversial due to drug interactions with antiretroviral therapy (ART). Objectives: In this study, we assessed the efficacy and tolerability of daclatasvir/sofosbuvir (DCV/SOF) in patients with HIV-HCV co-infection in the real-life setting in Iran. Methods: A total of 44 patients with HCV-HIV co-infection (genotypes 1, 3, and 4) were treated with DCV/SOF±RBV (ribavirin) (dose-adjusted DCV for concomitant ART). Assessment of risk factors, sustained virologic response at 12 weeks after the end of treatment (SVR12), safety, and serum CD4 count was performed. Results: Most patients were male (95.2%). Four patients were HCV treatment-experienced cases, and 15 had cirrhosis or advanced fibrosis. The most common genotype was 3 (53.5%), followed by 1 (44.2%) and 4 (2.3%). HIV-1 RNA < 50 copies/mL and CD4 count > 250 cells/mm3 were observed in 81.8% and 79.1% of patients, respectively. The highest risk factor was a history of IV drug use (81.8%), followed by using a common syringe (77.3%) and tattooing (70.5%). All patients with or without cirrhosis (100%) completed the HCV treatment course and achieved SVR12. Also. 92.6% of patients on ART had CD4 count > 250 cells/mm3 at the end of treatment. The HCV treatment regimen was well-tolerated. Moreover, 15.9% of patients experienced adverse events (AEs), including anorexia, nausea, diarrhea, palpitations, and anxiety. No serious AEs or discontinuation due to AEs were reported. Conclusions: Our study showed excellent tolerability and efficacy of DCV/SOF±RBV in HIV-HCV co-infected patients with or without cirrhosis.

Principles of Care for Patients with Liver Disease During the Coronavirus Disease 2019 (COVID-19) Pandemic: Position Statement of the Saudi Association for the Study of Liver Disease and Transplantation

In December 2019, a novel coronavirus was identified in patients in Wuhan, China. The virus, subsequently named severe acute respiratory syndrome coronavirus-2, spread worldwide and the disease (coronavirus disease 2019 or COVID-19) was declared a global pandemic by the World Health Organization in March 2020. Older adults and individuals with comorbidities have been reported as being more vulnerable to COVID-19. Patients with chronic liver disease (CLD) have compromised immune function due to cirrhosis and are more susceptible to infection. However, it is unclear if patients with CLD are more vulnerable to COVID-19 and its complications than other populations. The high number of severe cases of COVID-19 has placed an unusual burden on health systems, compromising their capacity to provide the regular care that patients with CLD require. Hence, it is incredibly crucial at this juncture to provide a set of interim recommendations on the management of patients with CLD during the current COVID-19 outbreak.

Hepatitis C Care Continuum in a Human Immunodeficiency Virus (HIV) Positive Cohort: Data From the HIV Atlanta Veterans Affairs Cohort Study

Background

Human immunodeficiency virus (HIV) and hepatitis C virus (HCV) coinfection is associated with accelerated progression to cirrhosis, end-stage liver disease, and liver-associated death. It is fortunate that curative direct-acting antivirals for the treatment of HCV are widely available in the VA healthcare system. We attempted to identify, evaluate, and treat all HIV/HCV-coinfected persons at the Atlanta VA Healthcare System.

Methods

Human immunodeficiency virus/HCV-coinfected persons at Atlanta VA between 2015 and 2018 were identified using the HIV Atlanta Veterans Affairs Cohort Study and Hepatitis C VA Clinical Case Registry. Retrospective reviews of each electronic medical record were conducted by the hepatitis C clinical team for validation. The primary end point was achieving sustained virologic response.

Results

One hundred thirty-eight veterans with HIV and hepatitis C viremia were identified. One hundred twenty-five (90%) were evaluated for treatment and 113 (91%) were initiated on direct-acting antiviral therapy. Median age at initiation of treatment was 60 years and the majority were black race (90%). Genotype 1a was most common (70%) and 41% had compensated cirrhosis. One hundred eight completed treatment and 96% achieved sustained virologic response. Six veterans had virologic relapse; 4 had treatment-emergent resistance mutations in the NS5a gene. Mean CD4 was 580 cells/mm³ with HIV viral suppression in 82% of the cohort. In those not treated, unstable housing (25%), active substance use (31%), and psychiatric conditions (42%) were identified barriers to care.

Conclusions

Through a concerted, systematic effort, over 80% of HIV/hepatitis C persons in the Atlanta VA have been initiated on treatment for hepatitis C, 96% of which have been cured.

Expanding the donor pool: Hepatitis C, hepatitis B and human immunodeficiency virus-positive donors in liver transplantation

Liver transplantation (LT) remains the best option for patients with end-stage liver disease but the demand for organs from deceased donors continues to outweigh the available supply. The advent of highly effective anti-viral treatments has reduced the number of patients undergoing LT for hepatitis C (HCV) and hepatitis B (HBV) related liver disease and yet the number of patients waiting for LT continues to increase, driven by an increase in the patients listed with a diagnosis of cirrhosis due to non-alcoholic steatohepatitis and alcohol-related liver disease. In addition, human immunodeficiency virus (HIV) infection, which was previously a contra-indication for LT, is no longer a fatal disease due to the effectiveness of HIV therapy and patients with HIV and liver disease are now developing indications for LT. The rising demand for LT is projected to increase further in the future, thus driving the need to investigate potential means of expanding the pool of potential donors. One mechanism for doing so is utilizing organs from donors that previously would have been discarded or used only in exceptional circumstances such as HCV-positive, HBV-positive, and HIV-positive donors. The advent of highly effective anti-viral therapy has meant that these organs can now be used with excellent outcomes in HCV, HBV or HIV infected recipients and in some cases uninfected recipients.

Full-Genome Analysis of Hepatitis C Virus in Japanese and Non-Japanese Patients Coinfected With HIV-1 in Tokyo

BACKGROUND

Acute hepatitis C virus (HCV) infection is increasing among HIV-1-infected individuals in Tokyo. Appropriate clinical management is needed.

SETTING

To delineate the epidemiological status of HCV transmission, we analyzed stocked plasma samples of HCV/HIV-1-coinfected patients seen at the largest referral center for HIV care in Tokyo.

METHODS

HCV full-genome sequences were amplified and determined using next-generation sequencing. HCV genotyping and phylogenetic and phylodynamic analyses of thus obtained sequences were performed and combined with the analysis of HIV-1 reverse transcriptase sequences.

RESULTS

HCV phylogenetic analysis identified 3 dense clusters containing cases of men who have sex with men (MSM) and injection drug users (IDUs). Most of the confirmed acute infection cases were included within these clusters, indicating that the clustered viruses are currently being actively transmitted among HIV-1-infected MSM and IDU. Phylodynamic analysis indicated population expansion of one of these clusters from 2006 to 2008, during which the largest number of HIV-1-infected MSM was diagnosed in Tokyo. HIV-1 reverse transcriptase sequences of HCV-coinfected patients included in the same clusters did not converge together and did not form clusters, but rather diverged in the area of subtype B in the phylogenetic tree, indicating that they acquired HCV infection from individuals different from those from whom they had acquired HIV-1 infection. It is considered that these MSM changed their sexual partners and that IDU changed their drug use groups.

CONCLUSIONS

The results warrant careful monitoring of high-risk groups including MSM and IDU and early introduction of HCV treatment to prevent HCV epidemic.

Correlates of same-sex behavior disclosure to health care providers among Black MSM in the United States: implications for HIV prevention

Disclosure of same-sex behavior to health care providers (HCPs) by men who have sex with men (MSM) has been argued to be an important aspect of HIV prevention. However, Black MSM are less likely to disclose compared to white MSM. This analysis of data collected in the United States from 2006-2009 identified individual and social network characteristics of Black MSM (n = 226) that are associated with disclosure that may be leveraged to increase disclosure. Over two-thirds (68.1%) of the sample had ever disclosed to HCPs. Part-time employment (AOR = 0.32, 95% CI = 0.11-0.95), bisexual identity (AOR = 0.29, 95% CI = 0.12-0.70), and meeting criteria for alcohol use disorders (AOR = 0.32, 95% CI = 0.14-0.75) were negatively associated with disclosure. Disclosers were more likely to self-report being HIV-positive (AOR = 4.47, 95% CI = 1.54-12.98), having more frequent network socialization (AOR = 2.15, 95% CI = 1.24-3.73), and having a social network where all members knew the participant had sex with men (AOR = 4.94, 95% CI = 2.06-11.86). These associations were not moderated by self-reported HIV status. Future interventions to help MSM identify social network members to safely disclose their same-sex behavior may also help disclosure of same-sex behavior to HCPs among Black MSM.

Prevalence of HIV, Hepatitis B and C Virus Co-infections among Iranian High-Risk Groups: A Systematic Review and Meta-Analysis

Co-infection with hepatitis B and C among HIV infected patients are prevalent among high-risk populations. This meta-analysis aimed to estimate the prevalence of HIV, HCV and HBV co-infections among high-risk populations in Iran.

We systematically searched the national and international electronic databases until 2016. The primary outcome was the prevalence of HIV, HBV, HCV and HIV co-infections in different high-risk populations in Iran. All English and Persian studies conducted on Iranian high-risk groups were included in the study. The review was reported based on PRISMA guidelines and data were analysed at 95% confidence level using random effect models.

Overall, 916 relevant papers were recognised and 14 articles were included in the meta-analysis. The pooled estimates of HBV/HCV, HCV/HIV, HBV/HIV and HBV/HCV/HIV were 1.3% (95%CI: 0.5–2.1), 16.3% (95%CI: 1.1–31.6), 0.5% (95%CI: 0–1.4) and 0.5% (95%CI: 0.2–0.8), respectively. Based on subgroup analysis, there was a higher proportion of all co-infections from the years 2010–2016 as compared to that of the years 2003–2009.

Our results highlighted that HCV/HIV co-infection in Iranian high-risk groups including injection drug users (IDUs) and prisoners is common. In addition, the increasing trend of coinfections should be considered alarming for policymakers.

High Human Immunodeficiency Virus (HIV) Viral Load and Coinfection with Viral Hepatitis Are Associated with Liver Enzyme Abnormalities among HIV Seropositive Patients on Antiretroviral Therapy in the Lake Victoria Zone, Tanzania

Background

Liver enzymes abnormalities have been found to be common among patients on antiretroviral treatment (ART). Apart from the effects of ART on these changes, other factors that can potentially contribute to the abnormal levels of these enzymes have been found to vary in different geographical locations. This study investigated factors associated with liver enzymes abnormalities among human immunodeficiency virus (HIV) infected individuals on ART from the Lake Victoria zone, Tanzania.

Methods

A cross-sectional study involving a total of 230 sera from HIV seropositive patients from different regions of the Lake Victoria zone was carried out in July 2017. All samples with required variables/parameters such as age, sex, ART regimen, and residence were serially included in the study. Hepatitis B virus (HBV) and Hepatitis C virus (HCV) detection and liver enzymes assays (alanine transaminase (ALAT) and aspartate transaminase (ASAT)) were assessed following the standard procedures. Data were analyzed by using STATA version 13.

Results

The median age of the study participants was 38 (interquartile range [IQR]:30-48) years. The overall prevalence of abnormal liver enzymes was 43.04% (99/230, 95% CI: 36.6-49.3). A total of 26.09% (60/230) had elevated ASAT while 23.9% (55/230) patients had elevated ALAT levels. ASAT levels were significantly high among patients with high HIV viral load (P= 0.002) while ALAT levels were significantly high among those coinfected with hepatitis C virus (P=0.017) and hepatitis B virus (P<0.001).

Conclusion

A significant proportion of HIV seropositive individuals on ART have abnormal levels of liver enzymes, which is significantly associated with high HIV viral load and viral hepatitis. This calls for the need to emphasize screening of viral hepatitis and provision of appropriate management among HIV seropositive individuals in this setting.

Immunological profiles of HIV-positive recipients of liver transplant

BACKGROUND

Scarce data are available about immune cell frequencies in HIV-positive recipients of liver transplant. Alterations in immune subsets can lead to persistent immune activation and disease progression or reduced HIV-specific responses. In liver transplantation, impaired immune tolerance can lead to organ rejection.

METHODS

HIV-positive subjects with undetectable HIVRNA and CD4 > 100/mm³ were included. Control groups were non-transplanted HIV-positive patients with similar immunovirological parameters and healthy subjects. B cells (memory, transitional, and mature subsets), T cells (effector TH1, nonclassic TH1, TH17, TH1/17; T regulatory naïve and effector subsets and CD8⁺ T regulatory cells), and NK cells (CD56^dim and CD56^bright subsets) were analyzed by flow cytometry.

RESULTS

A total of 56 patients, including 14 HIV-positive transplant recipients (HIV-LT), 14 HIV-positive controls, and 28 healthy controls were included. Median age of HIV-LT patients was 54.9 years with median time from transplant of 7.6 years. Eleven (79%) were HIV/HCV coinfected. Compared to nontransplanted patients, HIV-LT displayed significantly increased frequency of T CD8⁺ cells, lower percentage of T CD4+ cell, and lower number of nonclassic TH1, TH1/17 cells and naïve T CD4⁺ regulatory cells (Tregs). Healthy controls showed increased numbers of B cell subsets and decreased percentage of T effector subpopulations compared to HIV-LT. Compared to HIV-positive patients, healthy controls had higher B cells, NK cells, CD4⁺ T cells, naïve CD4+ Tregs but lower CD8⁺ T cells, effector Tregs, CD8⁺ Tregs, and all T effector cell subsets.

CONCLUSIONS

Immune cell subpopulations potentially associated with HIV progression and organ rejection were detected in HIV-positive transplant recipients. We confirmed altered frequencies of B, T, and NK cell populations in HIV-positive liver transplant recipients compared to healthy controls. The imbalance among immune cell subsets deserves further studies to identify markers of transplant outcome and potential therapeutic targets.

HCV Screening and Treatment Uptake Among Patients in HIV Care During 2014-2015

BACKGROUND

Despite the high prevalence of hepatitis C virus (HCV) among persons living with HIV (PWH), the prevalence of HCV screening, treatment, and sustained virologic response (SVR) is unknown. This study aims to characterize the continuum of HCV screening and treatment among PWH in HIV care.

SETTING

Adult patients enrolled at 12 sites of the HIV Research Network located in 3 regions of the United States were included.

METHODS

We examined the prevalence of HCV screening, HCV coinfection, direct-acting antiretroviral (DAA) treatment, and SVR-12 between 2014 and 2015. Multivariate logistic regression was performed to identify characteristics associated with outcomes, adjusted for site.

RESULTS

Among 29,071 PWH (age 18-87, 74.8% male, 44.4% black), 77.9% were screened for HCV antibodies; 94.6% of those screened had a confirmatory HCV RNA viral load test. Among those tested, 61.1% were determined to have chronic HCV. We estimate that only 23.4% of those eligible for DAA were prescribed DAA, and only 17.8% of those eligible evidenced initiating DAA treatment. Those who initiated treatment achieved SVR-12 at a rate of 95.2%. Blacks and people who inject drugs (PWID) were more likely to be screened for HCV than whites or those with heterosexual risk. Persons older than 40 years, whites, Hispanics, and PWID [adjusted odds ratio (AOR) 8.70 (7.74 to 9.78)] were more likely to be coinfected than their counterparts. When examining treatment with DAA, persons older than 50 years, on antiretroviral therapy [AOR 2.27 (1.11 to 4.64)], with HIV-1 RNA <400 [AOR 2.67 (1.71 to 4.18)], and those with higher Fib-4 scores were more likely to be treated with DAA.

CONCLUSIONS

Although rates of screening for HCV among PWH are high, screening remains far from comprehensive. Rates of SVR were high, consistent with previously published literature. Additional programs to improve screening and make treatment more widely available will help reduce the impact of HCV morbidity among PWH.

Comparison of the prevalence, severity, and risk factors for hepatic steatosis in HIV-infected and uninfected people

Background

Hepatic steatosis is prevalent in Western countries, but few studies have evaluated whether the frequency and severity of steatosis are greater in the setting of HIV infection. We compared the prevalence and severity of hepatic steatosis between HIV-infected (HIV+) and uninfected persons and identified factors associated with greater steatosis severity within both groups.

Methods

We performed a cross-sectional study among participants without cardiovascular disease who participated in a substudy of the Veterans Aging Cohort Study. Hepatic steatosis was defined by noncontrast computed tomography (CT) liver-to-spleen (L/S) attenuation ratio < 1.0. Multivariable linear regression was used to: 1) evaluate the association between HIV infection and severity of hepatic steatosis, as measured by absolute liver attenuation, and 2) identify factors associated with greater severity of steatosis, by HIV status.

Results

Among 268 participants (median age, 55 years; 99% male; 79% black; 23% obese; 64% HIV+ [91% on antiretroviral therapy]), the overall prevalence of steatosis was 7.8% and was similar between HIV+ and uninfected individuals (13 [7.6%] versus 8 [8.2%], respectively; p = 0.85). Participants with HIV, the majority of whom received antiretroviral therapy, had a higher mean absolute liver attenuation (mean difference, 5.68 Hounsfield units; p < 0.001), correlating with lesser hepatic steatosis severity, compared to uninfected participants. After adjusting for covariates, only advanced hepatic fibrosis was associated with greater severity of steatosis in HIV+ persons (p = 0.03) and uninfected individuals (p < 0.001).

Conclusions

In this sample of participants without cardiovascular disease, the prevalence of hepatic steatosis by noncontrast abdominal CT was not different by HIV status. Increasing severity of steatosis was independently associated with advanced hepatic fibrosis in both groups.

Electronic supplementary material

The online version of this article (10.1186/s12876-019-0969-1) contains supplementary material, which is available to authorized users.

Liver decompensation in HIV/Hepatitis B coinfection in the combination antiretroviral therapy era does not seem increased compared to hepatitis B mono-infection

BACKGROUND & AIMS

HIV/hepatitis B virus (HBV) coinfected subjects are thought to have faster progression to end-stage liver disease (ESLD) than HBV mono-infected subjects. We assessed whether this remains in the current cART-era.

METHODS

Data from subjects with follow-up completion post-2003 were compared between HIV/HBV coinfected subjects in the Dutch HIV Monitoring database and HBV mono-infected subjects from two centres. The primary outcomes of composite ESLD included portal hypertension, decompensated cirrhosis, hepatocellular carcinoma, liver transplantation and liver-related mortality. Outcomes were analysed using time-dependent cause-specific Cox regression models adjusted for follow-up time and relevant covariates. Subset-analyses were done in subjects with follow-up pre-2003.

RESULTS

In the 1336 co- vs 742 mono-infected subjects, coinfected subjects had no increased probability for ESLD compared to mono-infected subjects (cHR 0.7 (95% CI 0.4-1.1), but had increased probabilities for all-cause (cHR 7.4 [4.9-11.1]) and liver-related mortality (cHR 3.4 [1.6-7.5]). In the current combined cohort, treatment with tenofovir or entecavir was inversely associated with ESLD, all-cause and liver-related mortality (cHR 0.4 [95% CI 0.3-0.7], cHR 0.003 [0.001-0.01]), cHR 0.007 [0.001-0.05]). Other predictors for ESLD were older age, being of Sub-Sahara African descent, increased alanine aminotransferase levels and hepatitis C virus coinfection. While the probability for all-cause mortality was increased in coinfected subjects, this rate decreased compared to pre-2003 (HR 40.2 (95% CI: 8.7-186.2).

CONCLUSIONS

HIV/HBV coinfected patients no longer seem to be at increased risk for progression to ESLD compared to HBV mono-infected patients, likely due to widespread use of highly effective cART with dual HBV and HIV activity.

HIV-1 exposure and immune activation enhance sexual transmission of Hepatitis C virus by primary Langerhans cells

INTRODUCTION

The significant rise in incidence of Hepatitis C virus (HCV) infection among men-who-have-sex-with-men (MSM) living with HIV-1 suggests that HCV under specific circumstances is transmitted via sexual contact. During sexual transmission HCV has to cross the epithelial barrier to either directly enter the blood stream or indirectly via mucosal immune cells. However, the mechanisms of sexual transmission of HCV remain unclear. We investigated the role of Langerhans cells (LCs) in HCV susceptibility during sexual contact as LCs are among the first cells in mucosal tissues to encounter invading viruses.

METHODS

We investigated the phenotype of primary LCs in anal biopsies from MSM living with HIV-1. To investigate the role of primary LCs in HCV infection and transmission, we have used both isolated primary skin LCs and the ex vivo tissue transmission model.

RESULTS

Our data identified an important role for mucosal LCs in facilitating HCV transmission after HIV-1 exposure or immune activation. LCs were detected within mucosal anal tissues obtained from HIV-1 positive MSM biopsies. In order to perform functional studies, we used primary LCs from skin, which have a similar phenotype as mucosal LCs. Immature LCs were neither infected nor transmitted HCV to hepatocytes. Notably, exposure to HIV-1 significantly increased HCV transmission by LCs in the ex vivo transmission model. HIV-1 replication was crucial for the increased HCV transmission as HIV-1 inhibitors significantly reduced HIV-1-induced HCV transmission. Moreover, tissue immune activation of LCs also increased HCV transmission to target cells.

CONCLUSIONS

Thus, our data strongly indicate that HIV-1 or immune activation in MSM leads to capture of HCV by mucosal LCs, which might facilitate transmission to other cells or allow entry of HCV into the blood. This novel transmission mechanism by LCs also implicates that the activation state of LCs is an important cellular determinant for HCV susceptibility after sexual contact.

Outcomes in human immunodeficiency virus-infected recipients of heart transplants

BACKGROUND

With the advent of combined antiretroviral therapy (cART), growing evidence has shown human immunodeficiency virus (HIV) may no longer be an absolute contraindication for solid organ transplantation. This study compares outcomes of heart transplantations between HIV-positive and HIV-negative recipients using SRTR transplant registry data.

METHODS

Patient survival, overall graft survival and death-censored graft survival were compared between HIV-positive and HIV-negative recipients. Multivariate Cox regression and Cox regression with a disease risk score (DRS) methodology were used to estimate the adjusted hazard ratios among heart transplant recipients (HTRs).

RESULTS

In total, 35 HTRs with HIV+ status were identified. No significant differences were found in patient survival (88% vs 77%; P = 0.1493), overall graft survival (85% vs 76%; P = 0.2758), and death-censored graft survival (91% vs 91%; P = 0.9871) between HIV-positive and HIV-negative HTRs in 5-year follow-up. No significant differences were found after adjusting for confounders.

CONCLUSIONS

This study supports the use of heart transplant procedures in selected HIV-positive patients. This study suggests that HIV-positive status is not a contraindication for life-saving heart transplant as there were no differences in graft, patient survival.

Risk factors for liver Cancer in HIV endemic areas of Western Kenya

BACKGROUND

Hepatocellular carcinoma (HCC) is a malignant cancer of the liver and a leading cause of cancer-related mortality worldwide. Human immunodeficiency virus (HIV) has not been known to have a direct causal relationship with HCC despite independently causing inflammation of the liver. However, little is known on risk factors for HCC patients in an HIV endemic area. The objective of this study was to ascertain the risk factors of HCC and its association with HIV infection.

METHODS

This was an un-matched case-control study conducted between June 2015 and June 2016 in Kisumu County Referral Hospital, Kenya. The study enrolled 257 patients with HCC cases and 257 controls. A multivariable logistic regression analysis was used to assess the risk factors for HIV and controlling for exploratory variables. Independent t-test was used to compare means. Exposure variable with values < 0.05 were considered to be statistically significant.

RESULTS

HCC cases were more likely to be above 35 years old compared to controls (88.3% vs 23.0%), [aOR =51.6, 95% CI (27.8-95.6), P < 0.001)]. HBV infected patients have higher risk of HCC (47.1% vs 30.4%), [aOR = 3.3; 95% CI (1.7-5.0), P < 0.0001)]. HIV positive patients were more likely to have HCC than HIV negative patients (33.5% vs 10.9%), [aOR =4.3, 95% CI (2.2-8.4)), P < 0.001]. Females have lower risk of HCC than males (32.7 vs 23.7) [aOR = 0.2, 95% CI (0.1-0.4), P < 0.001]. The majority of HCC patients were at the time of diagnosis at stages C (35.1%) and D (48.6%) according to the Barcelona Clinic Liver Clinic (BCLC) criteria.

CONCLUSION

Liver cancer was more frequent among adults and subjects co-infected with HBV and HIV. Thus, HIV represents an additional risk factor for liver cancer in this Kenyan population. Regular health screening of HIV and HBV infected subjects may significantly improve the early diagnosis and effective therapy of liver cancer.

Liver as a target of human immunodeficiency virus infection

Liver injury is a characteristic feature of human immunodeficiency virus (HIV) infection, which is the second most common cause of mortality in HIV-infected patients. Now it is recognized that liver plays a key role in HIV infection pathogenesis. Antiretroviral therapy (ART), which suppresses HIV infection in permissive immune cells, is less effective in hepatocytes, thereby making these cells a silent reservoir of HIV infection. In addition to direct hepatotoxic effects of HIV, certain ART treatment modalities provide hepatotoxic effects. The exact mechanisms of HIV-triggered chronic hepatitis progression are not elucidated, but the liver is adversely affected by HIV-infection and liver cells are prominently involved in HIV-elicited injury. These effects are potentiated by second hits like alcohol. Here, we will focus on the incidence of HIV, clinical evidence of HIV-related liver damage, interactions between HIV and liver cells and the role of alcohol and co-infection with hepatotropic viruses in liver inflammation and fibrosis progression.

Diagnostic Value of Hepatic Vein Ultrasound in Early Detection of Liver Cirrhosis

Background

Cirrhosis is a common disease that destroys liver cells, and it has various etiologies. The early diagnosis of cirrhosis can be effective in improving prognosis. Considering the availability and affordability of ultrasound devices throughout the world, in this study we evaluated the diagnostic value of hepatic vein ultrasound examination in the early detection of liver cirrhosis.

Materials and Methods

In this study, 45 patients referred to the radiology department of Ghaem Hospital for liver biopsy were evaluated for changes in the hepatic veins under ultrasound with a transducer of 5-7MHz. One piece of the hepatic vein was selected for ultrasound, and the wall of hepatic veins was examined for straightness and uniformity of echogenicity. Subsequently, patients underwent biopsy by ultrasound guide. Of all the study subjects, eight patients presented mild chronic hepatitis without fibrosis, four patients were diagnosed with fatty liver, and 33 patients had severe cirrhosis or chronic hepatitis with fibrosis.

Results

Our results showed that hepatitis patients with or without fibrosis had irregular and wavy hepatic vein wall (impairment in straightness) with non-uniform echo (impairment in uniformity of echogenicity). While patients without hepatitis and cirrhosis, but diagnosed with fatty liver, had a smooth and regular hepatic vein wall with a uniform echo.

Conclusion

The present study showed that hepatic vein examination in terms of echogenicity and straightness could be used to diagnose hepatitis, its severity as well as its course towards fibrosis and cirrhosis.

Prevalence of anti-hepatitis C antibodies and its co-infection with HIV in rural Cameroon

Objective

To evaluate the prevalence of the co-infection between the human immunodeficiency virus (HIV) and hepatitis C virus (HCV), and the prevalence of factors associated with HCV transmission in a rural Cameroonian community.

Results

The mean age of the 174 participants included in the study was 30.3 (standard deviation = 13.26) years (age range 12–77 years). the prevalence of HCV/HIV co-infection was 1.7% [95% confidence interval (CI) 1.1–5.9]. The prevalence of HCV and HIV were 6.3% (95% CI 2.9–10.3) and 6.9 (95% CI 5.2–11.3), respectively. Histories of scarification (62.1%), multiple sex partners (31.0%) and sexually transmitted diseases (66.1%) were the most common risk factors of HCV transmission in this study.

Exposure to previous cART is associated with significant liver fibrosis and cirrhosis in human immunodeficiency virus-infected patients

Introduction

Combined antiretroviral therapy (cART) has improved survival in HIV-patients. While the first antiretrovirals, which became available in particular D-drugs (especially didanosine and stavudine) and unboosted protease inhibitors, may impair liver function, the modern cART seems to decrease liver fibrosis. This study assessed the influence of exposure to previous antiretrovirals on liver fibrosis in HIV-infected patients.

Methods

This observational cross-sectional single-center study recruited 333 HIV patients and assessed liver fibrosis using transient elastography (TE).

Results

83% were male with a median age of 45, while 131 were co-infected with viral hepatitis. Overall, 18% had significant fibrosis and 7.5% had cirrhosis. 11% of HIV mono-infected patients had significant fibrosis and 2% had cirrhosis. HCV infection (OR:5.3), history of exposure to didanosine (OR:2.7) and HIV load below 40copies/mL (OR:0.5) were independently associated with significant fibrosis, while HCV (OR:5.8), exposure to didanosine (OR:2.9) and azidothymidine (OR:2.8) were independently associated with cirrhosis. Interestingly, in HIV mono-infected patients, a HIV-load below 40copies/mL (OR:0.4) was independently associated with significant fibrosis, and didanosine (OR:20.8) with cirrhosis.

Conclusion

In conclusion, history of exposure to didanosine and azidothymidine continues to have an impact on the presence of liver cirrhosis in HIV patients. However, HCV co-infection and ongoing HIV-replication have the strongest effect on development of significant fibrosis in these patients.

Hepatitis C infection in patients with hereditary bleeding disorders: epidemiology, natural history, and management

Hereditary bleeding disorders include a group of diseases with abnormalities of coagulation. Prior to 1990, infection with hepatitis C virus (HCV) was mainly transmitted via pooled plasma products as a treatment for hereditary bleeding disorders. Anti-HCV positivity in these patients may be as high as >70% in some areas, while some of them have also been coinfected with human immunodeficiency virus. Since about 20% of HCV-infected patients clear the infection naturally, chronic HCV infection represents a significant health problem in this group of patients. Mortality due to chronic HCV infection is estimated to be >10 times higher in patients with hemophilia than in the general population, and is mainly due to liver cirrhosis and hepatocellular carcinoma. The antiviral treatment of HCV in patients with hereditary bleeding disorders is not different from that of any other infected patients. Nevertheless, many patients with hereditary bleeding disorders have declined (Peg)interferon-based treatment because of side effects. In recent years, multiple orally administrated direct-acting antivirals (DAAs) have been approved for HCV treatment. Unfortunately, there is not much experience from treating these patients with DAA regimens, as major studies and real-life data did not include adequate numbers of patients with inherited hemorrhagic disorders. However, the available data indicate that DAAs have an excellent safety profile with a sustained virological response rate of >90%.

Direct-Acting Antivirals Improve Access to Care and Cure for Patients With HIV and Chronic HCV Infection

Background

Direct-acting antivirals (DAA) as curative therapy for hepatitis C virus (HCV) infection offer >95% sustained virologic response (SVR), including in patients with human immunodeficiency virus (HIV) infection. Despite improved safety and efficacy of HCV treatment, challenges remain, including drug-drug interactions between DAA and antiretroviral therapy (ART) and restrictions on access by payers.

Methods

We performed a retrospective cohort study of all HIV/HCV co-infected and HCV mono-infected patients captured in care at our institution from 2011-2015, reflecting the DAA era, to determine treatment uptake and SVR, and to elucidate barriers to accessing DAA for co-infected patients.

Results

We identified 9290 patients with HCV mono-infection and 507 with HIV/HCV co-infection. Compared to mono-infected patients, co-infected patients were younger and more likely to be male and African-American. For both groups, treatment uptake improved from the DAA/pegylated interferon (PEGIFN)-ribavirin to IFN-free DAA era. One-third of co-infected patients in the IFN-free DAA era required ART switch and nearly all remained virologically suppressed after 6 months. We observed SVR >95% for most patient subgroups including those with co-infection, prior treatment-experience, and cirrhosis. Predictors of access to DAA for co-infected patients included Caucasian race, CD4 count ≥200 cells/mm³, HIV virologic suppression and cirrhosis. Time to approval of DAA was longest for patients insured by Medicaid, followed by private insurance and Medicare.

Conclusions

DAA therapy has significantly improved access to HCV treatment and high SVR is independent of HIV status. However, in order to realize cure for all, barriers and disparities in access need to be urgently addressed.

The effect of HIV infection and HCV viremia on inflammatory mediators and hepatic injury-The Women's Interagency HIV Study

Hepatitis C virus infection induces inflammation and while it is believed that HIV co-infection enhances this response, HIV control may reduce inflammation and liver fibrosis in resolved or viremic HCV infection. Measurement of systemic biomarkers in co-infection could help define the mechanism of inflammation on fibrosis and determine if HIV control reduces liver pathology. A nested case-control study was performed to explore the relationship of systemic biomarkers of inflammation with liver fibrosis in HCV viremic and/or seropositive women with and without HIV infection. Serum cytokines, chemokines, growth factors and cell adhesion molecules were measured in HIV uninfected (HIV-, n = 18), ART-treated HIV-controlled (ARTc, n = 20), uncontrolled on anti-retroviral therapy (ARTuc, n = 21) and elite HIV controllers (Elite, n = 20). All were HCV seroreactive and had either resolved (HCV RNA-; <50IU/mL) or had chronic HCV infection (HCV RNA+). In HCV and HIV groups, aspartate aminotransferase to platelet ratio (APRI) was measured and compared to serum cytokines, chemokines, growth factors and cell adhesion molecules. APRI correlated with sVCAM, sICAM, IL-10, and IP-10 levels and inversely correlated with EGF, IL-17, TGF-α and MMP-9 levels. Collectively, all HCV RNA+ subjects had higher sVCAM, sICAM and IP-10 compared to HCV RNA-. In the ART-treated HCV RNA+ groups, TNF-α, GRO, IP-10, MCP-1 and MDC were higher than HIV-, Elite or both. In ARTuc, FGF-2, MPO, soluble E-selectin, MMP-9, IL-17, GM-CSF and TGF-α are lower than HIV-, Elite or both. Differential expression of soluble markers may reveal mechanisms of pathogenesis or possibly reduction of fibrosis in HCV/HIV co-infection.

Clinical experience with dolutegravir/abacavir/lamivudine in HIV-HCV co-infected patients treated with a sofosbuvir-based regimen-safety and efficacy

BACKGROUND

There is no known reason to suspect an adverse drug interaction between dolutegravir-based antiretroviral therapy and sofosbuvir, simeprevir, or ledipasvir. There is a paucity of clinical data for this combination.

METHODS

Prospective, open-label study of patients with HIV well controlled on dolutegravir, abacavir, and lamivudine, who were co-infected with HCV genotype 1, and required therapy with simeprevir plus sofosbuvir or sofosbuvir/ledipasvir single-tablet regimen (STR) for 12 weeks. The two primary endpoints were percentage of patients achieving sustained virologic response (SVR) at 12 weeks post-treatment and percentage of patients with a HIV-1 viral load <50 copies/ml at end of the combination therapy.

RESULTS

Twenty-eight subjects were enrolled from August 2014 to September 2015. Thirteen patients were treated with simprevir plus sofosbuvir, and 15 subjects were treated with sofosbuvir/ledipasvir. 23 genotype 1a, and 5 genotype 1b were included. Nineteen were treatment naïve, and 2 patients had compensated cirrhosis. The mean age was 59 years (95% CI 58.21-59.78 years). The mean age was 59 years (95% CI: 58.21-59.78 years), and 25 patients were black. Out of the 28 patients who completed this study, SVR 12 was achieved in 27 of 28 patients (96%, 95% CI 89.6-100.0%), and all patients had an HIV virus load <50 copies/ml at week 12 of therapy, for an intent-to-treat rate of 100%. No patients ended therapy secondary to adverse events.

CONCLUSION

Our study suggests a good safety and efficacy for the combination of a dolutegravir, abacavir, and lamivudine with sofosbuvir-based DAA therapy.

Illness Perceptions, Medication Beliefs, and Adherence to Antiretrovirals and Medications for Comorbidities in Adults With HIV Infection and Hypertension or Chronic Kidney Disease

BACKGROUND

Mortality in patients with HIV infection is increasingly due to comorbid medical conditions. Research on how adherence to medications for comorbidities relates to antiretroviral (ARV) medication adherence and how interrelations between illness perceptions and medication beliefs about HIV and comorbidities affect medication adherence is needed to inform adherence interventions.

METHODS

HIV-infected adults with hypertension (HTN) (n = 151) or chronic kidney disease (CKD; n = 41) were recruited from ambulatory practices at an academic medical center. Illness perceptions and medication beliefs about HIV and HTN or CKD were assessed and adherence to one ARV medication and one medication for either HTN or CKD was electronically monitored for 10 weeks.

RESULTS

Rates of taking, dosing, and timing adherence to ARV medication did not differ from adherence to medication for HTN or CKD, with the exception that patients were more adherent to the timing of their ARV (78%) than to the timing of their antihypertensive (68%; P = 0.01). Patients viewed HIV as better understood, more chronic, having more negative consequences, and eliciting more emotions, compared with HTN. Patients viewed ARVs as more necessary than medication for HTN or CKD. Having a realistic view of the efficacy of ARVs (r = -0.20; P < 0.05) and a high level of perceived HIV understanding (r = 0.21; P < 0.05) correlated with better ARV adherence.

CONCLUSIONS

Patients with HIV showed similar rates of adherence to ARVs as to medications for comorbidities, despite perceiving HIV as more threatening and ARVs as more important. This can be used in adapting existing interventions for ARV adherence to encompass adherence to medications for comorbid conditions.

Management of hepatitis B in special populations

Special populations infected with chronic HBV include those with decompensated cirrhosis, coinfections (HIV, HCV, HDV), hemodialysis and renal failure, immunosuppressed including transplant patients, children and women in pregnancy. These populations differ in their natural history and risk for liver-related complications, the indications for anti-HBV therapy as well as the recommendations regarding the HBV drugs used, duration of therapy and anticipated endpoints. Reflecting the special populations with substantive changes in management in recent years, this review focuses on HBV-HIV coinfected patients, immunosuppressed patients at risk for reactivation, liver transplant recipients and pregnant women. Management of women in the context of pregnancy and post-partum requires consideration of risks to mother and fetus/infant, including the risk of mother-to-child transmission. HBV-HIV coinfected patients require initiation of treatment concurrent with their HIV therapy and the HBV drugs used must by selected to minimize HIV and HBV resistance long-term. Increasing recognition of the risk for HBV reactivation with immunosuppressive therapy has led to recommendations to use prophylactic HBV therapy in patients with moderate to high risk of reactivation. Liver transplant recipients with HBV require life-long therapy to prevent or treat HBV infection but with current therapies, graft and patient survival are excellent.

Efficacy Of Pegylated Interferon And Ribavirin Treatment In Coinfected HIV HCV Patients

The objectives of the study were to determine the efficacy of pegylated interferon alfa 2 b (PegINF) and ribavirin (RBV) treatment in co-infected HIV / HCV patients, to identify predictive factors associated with sustained viral response (SVR) in these patients. Out of the 956 HIV infected patients, 38 were HCVAb (4%) positive, 14 of which had undetectable HCV RNA, only 6 patients met the inclusion criteria. Screening failure was due to: liver cirrhosis Child Pugh B / C, hepatocellular carcinoma, pulmonary TB, thyroid dysfunction, CD4 <200 cells3, detectable HIV RNA and depressive syndrome. We initiated PegINF and RBV therapy for 48 weeks. SVR was achieved in 16.6% of cases (only one patient) and correlated with HCV RNA level, CD4 count, duration of HIV infection, CDC classification and liver fibrosis. In conclusion, our study group has a low prevalence of HIV / HCV co-infection (2.6%) with a large number of patients HCVAb positive but undetectable HCV RNA. Positive predictive factors for SVR were: low levels of HCV RNA, small duration of HIV infection, high levels of CD4, B1/B2 (CDC classification) and low degree of fibrosis.

Liver test abnormalities in patients with HIV mono-infection: assessment with simple noninvasive fibrosis markers

Background

Patients with HIV mono-infection may develop chronic liver disease due to a number of factors including hepatic steatosis. We estimated the prevalence and predictors of hepatic steatosis and fibrosis in a cohort of HIV-mono-infected patients with persistently deranged liver function tests.

Methods

Of 2398 consecutive patients at one UK clinical center, 156 (6.5%) had persistently abnormal transaminases in at least two measurements six months apart. We used APRI and FIB4 scores to determine the presence of significant and/or advanced fibrosis in this group as well as its potential associations.

Results

Mean age was 47.5±8.5 years and 91% (142/156) were males. Diabetes mellitus was present in 11% of patients; hypertension in 18%; and dyslipidemia in 52%. Almost all were on antiretroviral therapy (ART) (97%) and most were virologically suppressed (94%). Steatosis was detected by ultrasound in 71% of patients. The prevalence of FIB4≤1.45, 1.46-3.24 and >3.25 was 67%, 29% and 4%, respectively, and that of APRI≤0.5, 0.51-1.49 and >1.5 was 52%, 45% and 3% respectively. In multivariate analysis, only cumulative ART exposure was associated with FIB4>1.45 (odds ratio [OR] 1.008, 95% confidence interval [CI] 1.000-1.016), while APRI>0.5 was associated with higher alanine aminotransferase levels (OR 1.033, 95%CI 1.015-1.510). Twenty patients had a liver biopsy, of whom 13 had non-alcoholic fatty liver disease (NAFLD).

Conclusions

Elevated transaminases are often present in HIV-mono-infected patients and this may be associated with NAFLD and/or ART. Non-invasive screening for the presence of NAFLD and fibrosis in all HIV-mono-infected patients as part of their routine clinical management should be further explored.

Ledipasvir/sofosbuvir is effective and well tolerated in postkidney transplant patients with chronic hepatitis C virus

Patients with end-stage renal diseases on hemodialysis have a high prevalence of hepatitis C infection (HCV). In most patients, treatment for HCV is delayed until postrenal transplant. We assessed the effectiveness and tolerance of ledipasvir/sofosbuvir (LDV/SOF) in 32 postkidney transplant patients infected with HCV. The group was composed predominantly of treatment-naïve (75%) African American (68.75%) males (75%) infected with genotype 1a (62.5%). Most patients received a deceased donor kidney graft (78.1%). A 96% sustained viral response (SVR) was reported (27/28 patients). One patient relapsed. One patient with baseline graft dysfunction developed borderline rejection. No graft loss was reported. Six HIV-coinfected patients were included in our analysis. Five of these patients achieved SVR 12. There were four deaths, and one of the deaths was in the HIV group. None of the deaths were attributed to therapy. Coinfected patients tolerated therapy well with no serious adverse events. Serum creatinine remained stable at baseline, end of therapy, and last follow-up, (1.351±.50 mg/dL; 1.406±.63 mg/dL; 1.290±.39 mg/dL, respectively). In postkidney transplant patients with HCV infection with or without coinfection with HIV, a combination of LDV/SOF was well tolerated and effective.

Characterization of HCV NS3 Protease Variants in HCV/HIV-Coinfected Patients by Ultra-Deep Sequence Analysis: Relationship with Hepatic Fibrosis

BACKGROUND

Treatment of HCV/HIV coinfection is now largely based on utilization of direct acting agents. Pretreatment viral resistant-associated variants (RAVs) and host liver condition may affect the sustained virological response. In this study, we explored relative prevalence of protease resistance-associated mutations, the evolution of those RAVs after 12 weeks of pegylated interferon alfa exposure, and the role hepatic fibrosis might have on RAV display.

METHODS

Thirty nonresponder HCV/HIV-coinfected subjects were evaluated before and after 12 weeks of PegIFN treatment. Ultra-deep sequence analysis of NS3 RAVs was performed. Hepatic fibrosis was determined by sensitive computer-assisted histomorphometry determination.

RESULTS

At baseline, protease inhibitor RAVs were present in 73.3% of patients and expanded to 83.3% of patients after 12 weeks of PegIFN exposure. Q80K showed the highest prevalence before and after treatment at 46.7% and 56.7%, respectively. The presence of Q80K is positively correlated with percent collagen content of the liver tissue.

CONCLUSIONS

Key RAVs for HCV protease inhibitors are present in a major portion of the HCV/HIV-coinfected population before therapy. Some variants get selected after exposure. Correlation of Q80K with collagen content of the liver suggests that compartmentalization within the liver may contribute to persistence of mutations less fit than wildtype.