The Effects of Hepatitis C Infection and Treatment on All-cause Mortality Among People Living With Human Immunodeficiency Virus

Long-term trends in hepatitis C prevalence, treatment uptake and liver-related events in the Swiss HIV Cohort Study

BACKGROUND AND AIMS

Treatment for chronic hepatitis C virus (HCV) infections changed dramatically in the last decade. We assessed changes in the prevalence of replicating HCV infection, treatment uptake and liver-related morbidity and mortality in persons with HIV (PWH) and hepatitis C in the Swiss HIV cohort study.

METHODS

We included all cohort participants between 2002 and 2021. We assessed yearly prevalence of replicating HCV infection, overall and liver-related mortality, as well as the yearly incidence of liver-related events in persons with at least one documented positive HCV-RNA.

RESULTS

Of 14 652 participants under follow-up, 2294 had at least one positive HCV-RNA measurement. Of those, 1316 (57%) ever received an HCV treatment. Treatment uptake increased from 8.1% in 2002 to a maximum of 32.6% in 2016. Overall, prevalence of replicating HCV infection declined from 16.5% in 2004 to 1.3% in 2021. HCV prevalence declined from 63.2% to 7.1% in persons who inject drugs, and from 4.1% to 0.6% in men who have sex with men. Among the 2294 persons with replicating HCV infection, overall mortality declined from a maximum of 3.3 per 100 patient-years (PY) to 1.1 per 100 PY, and incidence of liver-related events decreased from 1.4/100 PY to 0.2/100 PY.

CONCLUSIONS

The introduction of DAA therapy was associated with a more than 10-fold reduction in prevalence of replicating HCV infection in PWH, approaching the estimates in the general population. Overall mortality and liver-related events declined substantially in persons living with HIV and hepatitis C.

Mitigating the HIV and Viral Hepatitis Workforce Crisis Through Development of an HIV/Hepatitis C Coinfection Mobile Application

A decline in the HIV workforce has led to a crisis of insufficient expertise to manage people with HIV (PWH), roughly a quarter of whom are coinfected with hepatitis C. Task shifting to nonspecialist providers can contribute to solving the HIV workforce shortage problem, but nonspecialist providers require sufficient training and support to acquire and retain the necessary knowledge and skills. Digital tools including mobile applications (apps) and telementoring which utilizes telecommunication technology for education and skill acquisition can be used for professional development. Described is the development and dissemination of a mobile app specifically for providers managing HIV/HCV coinfection in the United States. The app, through provider professional development, facilitates access to curative HCV treatment in PWH, encourages integration of HCV care into primary care and contributes to national goals to eliminate HIV and viral hepatitis by 2030.

Increased All-cause Mortality in People With HIV and Comorbidities: Hepatitis B and C Virus Seropositivity and Hyperglycemia in Myanmar, 2005-2017

Background

Hepatitis C virus (HCV) and hepatitis B virus (HBV) coinfection are associated with increased mortality in people with HIV (PWH), and hyperglycemia is a common comorbidity in PWH. In this study, we used routinely collected clinical data to assess the associations between HBV and HCV seropositivity with all-cause mortality and whether this relationship differs by hyperglycemia status.

Methods

Eligible participants included adult PWH (≥15 years) who initiated antiretroviral therapy between May 2005 and June 2016 in Myanmar. HBV and HCV serostatus and hyperglycemia were measured at enrollment to HIV care using HBV surface antigen, HCV antibody tests, and random blood glucose (≥140 mg/dL), respectively.

Results

Among 27 722 PWH, 2260 (8%) were HBV seropositive, 2265 (9%) were HCV seropositive, 178 (0.6%) were HBV-HCV seropositive, and 1425 (5%) had hyperglycemia. During the median follow-up (interquartile range) of 3.1 (1.5-5.1) years, 3655 (13%) PWH died, and the overall mortality rate was 3.8 (95% CI, 3.7-3.9) per 100-person-years (PY). The mortality rate (per 100 PY) among PWH who were HBV seropositive was 4.6, among PWH who were HCV seropositive it was 5.1, and among PWH who were HBV-HCV seropositive it was 7.1. When stratified by glycemic status, the mortality rate was higher among patients with hyperglycemia compared with those with euglycemia (5.4 vs 4.0 per 100 PY), and the difference in mortality rate between patients with hyperglycemia and euglycemia was highest among those with HCV seropositivity (9.8 vs 5.0 per 100 PY).

Conclusions

Increased mortality rates associated with HBV and HCV seropositivity in PWH differed by their glycemic status. PWH with HCV seropositivity and hyperglycemia had the highest mortality rates.

The Impact of Supportive Housing on Liver-Related Outcomes Among Persons With Hepatitis C Virus Infection

BACKGROUND

Hepatitis C virus (HCV) infection disproportionately impacts people experiencing homelessness. Hepatitis C virus can lead to negative health outcomes, including mortality. We evaluated the impact of a permanent supportive housing (PSH) program (ie, "treatment") on liver-related morbidity and mortality among persons with chronic homelessness and HCV infection.

METHODS

We matched records for persons eligible for a New York City PSH program (2007-2014) with Heath Department HCV and Vital Statistics registries and Medicaid claims. Among persons diagnosed with HCV before or 2 years posteligibility, we added stabilized inverse probability of treatment weights to negative binomial regression models to compare rates for liver disease-related emergency department visits and hospitalizations, and hazard ratios for mortality, by program placement 2 and 5 years posteligibility.

RESULTS

We identified 1158 of 8783 placed and 1952 of 19 019 unplaced persons with laboratory-confirmed HCV infection. Permanent supportive housing placement was associated with significantly reduced liver-related emergency department visits (adjusted rate ratio [aRR] = 0.76, 95% confidence interval [CI] = .61-.95), hospitalizations (aRR = 0.62, 95% CI = .54-.71), and all-cause (adjusted hazard ratio [aHR] = 0.65, 95% CI = .46-.92) and liver-related mortality (aHR = 0.72, 95% CI = .09-.83) within 2 years. The reduction remained significant for hospitalizations after 5 years.

CONCLUSIONS

Placement into PSH was associated with reduced liver-related morbidity and mortality among persons with HCV infection and chronic homelessness.

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.

Hepatitis C Coinfection and Mortality in People Living with HIV in Middle Tennessee

HIV and hepatitis C virus (HCV) coinfection is associated with poor health outcomes. This study was designed to assess risk factors for and mortality with coinfection before direct-acting antiviral treatment availability in a state with an evolving opioid epidemic. HCV infection was determined from review of the medical record at two clinics serving the majority of people living with HIV (PLWH) in care in Middle Tennessee from 2004 to 2013. Association of potential risk factors with HCV-positivity was assessed using logistic regression. Association of HCV-positivity with mortality was assessed with a Cox proportional hazards model, adjusting for selected covariates. A total of 3,501 patients were included: 24% female; 51% men who have sex with men; 47% white; 44% African American/black; median age of 38 at their first visit; median most recent CD4 count 502 cells/μL (301-716); and HIV viral load 47 copies/mL (39-605); followed for a median of 3.0 (1-5) years. Prevalence of HCV was 13%. Those with a history of injection drug use (IDU) demonstrated the highest odds of HCV-positivity [odds ratio 12.94; 95% confidence interval (CI) 9.39-17.83]. There were 305 deaths; median age at death was 47 years (40-53). HCV coinfection was associated with greater mortality (hazard ratio 1.61; 95% CI 1.20-2.17; p < .001). Among PLWH, HCV coinfection was associated with IDU and an independent predictor of mortality. These results affirm the importance of HCV coinfection and inform interventions targeting the continuum of HCV care, uptake of HCV treatment, and the impact of drug use in this population.

Metabolic Syndrome in HIV/HCV Co-infected Patients

Purpose of review

We review the scope and burden of metabolic syndrome in HIV/HCV co-infected patients, risk factors and potential mechanisms driving the increased cardio-metabolic risk in this population, and discuss relevant clinical considerations for management in the era of highly effective antiretroviral therapy (ART) and curative anti-HCV direct-acting antivirals.

Recent findings

HIV/HCV co-infected patients are at elevated risk of metabolic syndrome, attributed to (1) patient-specific factors, (2) viral-mediated effects, and (3) ART exposure. Risk factors for cardio-metabolic disorders are common in this population and include poor socioeconomic conditions, substance use, cardiovascular comorbidities, and liver/kidney disease. Chronic HIV/HCV infection induces an inflammatory and immune activated state in the host leading to alterations in glucose and lipid metabolism. Selection of life-saving ART must carefully consider the differential metabolic risk associated with each drug class and agent, such as dyslipidemia, hyperglycemia and insulin resistance, weight gain and hypertension. Emerging evidence supports metabolic derangements in chronic HCV may be improved by viral eradication with direct-acting antivirals, however, additional study in HIV/HCV co-infected patients is needed.

Summary

Future research programs should aim to better characterize metabolic syndrome in HIV/HCV co-infected patients with the goal of improved screening, treatment and prevention.