The impact of HIV therapy on co-infection with hepatitis B and hepatitis C viruses

Human immunodeficiency virus and hepatitis C virus/hepatitis B virus co-infection in Southern Brazil: clinical and epidemiological evaluation

Hepatitis B virus, hepatitis C virus and human immunodeficiency virus share a similar transmission pathway and are often diagnosed in the same patient. These patients tend to have a faster progression of hepatic fibrosis. This cross-sectional study describes the demographic features and clinical profile of human immunodeficiency virus/hepatitis co-infected patients in Paraná, Southern Brazil. A total of 93 human immunodeficiency virus-infected patients attending a tertiary care academic hospital in Southern Brazil were included. Clinical, demographic and epidemiological data were evaluated. Hepatitis B virus and/or hepatitis C virus positive serology was found in 6.6% of patients. The anti-hepatitis C virus serum test was positive in 85% (79/93) of patients, and the infection was confirmed in 72% of the cases. Eighteen patients (19%) were human immunodeficiency virus/hepatitis B virus positive (detectable HBsAg). Among co-infected patients, there was a high frequency of drug use, and investigations for the detection of co-infection were conducted late. A low number of patients were eligible for treatment and, although the response to antiretroviral therapy was good, there was a very poor response to hepatitis therapy. Our preliminary findings indicate the need for protocols aimed at systematic investigation of hepatitis B virus and hepatitis C virus in human immunodeficiency virus-infected patients, thus allowing for early detection and treatment of co-infected patients.

Seroprevalence of HBV and HIV co-infection in children and outcomes following highly active antiretroviral therapy (HAART) in Uyo, South-South Nigeria

BACKGROUND

Human Immunodeficiency Virus/Hepatitis B Virus (HIV/HBV) co-infection in Nigerian children has emerged as a major concern with the advent of HAART. Its impact on the immune system and liver has not been extensively studied in children.

OBJECTIVES

To determine the prevalence of HBV seropositivity among HIV positive children on HAART and its effect on immune response and liver enzymes.

METHODS

All consecutive HIV positive children aged two months to seventeen years on HAART constituted the study population. Age and gender; CD4+ count, ALT, creatinine and HBsAg were tested and documented at enrolment and 12months.

RESULTS

One hundred and seventy one patients were seen over this period. Seventy-two (43.4%) were males while 94 (56.6%) were females giving a male: female ratio of 1:1.3. The mean age of the patients was 63±43.4 months. Prevalence of HIV/HBV co-infection was 6.02% (95% CI 2.4-9.7). There was no significant effect of HBV status on elevation of ALT levels with 12 months of HAART. Co-infected patients had an odds ratio of achieving immune response of 0.14 (95% CI 0.02-0.79).

CONCLUSION

HIV/HBV co-infection rates in our children are comparable to other localities. ALT levels do not worsen with HAART and immune response of the co-infected children on HAART is lower.

Computational analysis to predict functional role of hsa-miR-3065-3p as an antiviral therapeutic agent for treatment of triple infections: HCV, HIV-1, and HBV

BACKGROUND

Triple infection (TI) with HIV-1, HCV, and HBV (TI) is highly prevalent in intravenous drug users (IDUs). These TI patients have a faster progression to AIDS, and even after antiretroviral therapy (ART) the prognosis of their disease is poor. The use of microRNA (miRNA) to silence genes holds potential applications for anti-HCV therapy.

METHODS

We analyzed the role of human miRNAs (hsa-miRs) in TI by computational analyses for HCV, HIV-1, and HBV showing identity to these three viral genomes.

RESULTS

We identified one unique miRNA, hsa-miR-3065-3p, that shares significant mutual identity to these three viral genomes (∼61-83%). In addition, hsa-miR-99, hsa-miR-548, and hsa-miR-122 also showed mutual identity with these three viral genomes, albeit at a lower degree (∼52-88%).

CONCLUSION

Here, we present evidence using essential components of bioinformatics tools, and hypothesize that utility of hsa-miR-3065-3p and perhaps miR-548 would be potential antiviral therapeutic agents in the treatment of TI patients because it shows near perfect alignment in the seed region for all three viruses. We also make an argument that current proposed therapy with hsa-miR-122 may not be the optimal choice for HCV patients since it lacks essential gene alignment and may be harmful for the patients.

Frequent hepatitis B virus rebound among HIV-hepatitis B virus-coinfected patients following antiretroviral therapy interruption

BACKGROUND

The impact of antiretroviral therapy (ART) interruption in HIV-hepatitis B virus (HBV)-coinfected patients was examined in the Strategic Management of AntiRetroviral Therapy (SMART) study.

METHODS

Plasma HBV DNA was measured in all hepatitis B surface antigen-positive (HBV-positive) participants at baseline, and at months 1, 2, 4, 6, 8, 10, and 12.

RESULTS

Among HBV-positive participants in the ART interruption (drug conservation) (n = 72) and ART continuation (virological suppression) (n = 62) arms, HBV DNA rebound of more than 1 log from baseline at months 1-4 was seen in 31-33% (P = 0.003) and 3-4% (P = 0.017), respectively. Thirteen HBV-positive participants had HBV DNA rebound of more than 3 log, including 12 in the drug conservation arm, of which eight were on tenofovir-containing regimens. Factors independently associated with a HBV DNA rebound were drug conservation arm (P = 0.0002), nondetectable HBV DNA at baseline (P = 0.007), and black race (P = 0.03). Time to ART reinitiation was shorter (7.5, 15.6, and 17.8 months; P < 0.0001) and proportion reinitiating greater (62.5, 46.5, and 39.7%; P = 0.0002) among HBV-positive participants as compared with hepatitis C virus-positive and non-HBV/hepatitis C virus participants in the drug conservation arm. No hepatic decompensation events occurred among HBV-positive participants in either arm.

CONCLUSION

HBV DNA rebound following ART interruption is common and may be associated with accelerated immune deficiency in HIV-HBV-coinfected patients.

The global burden of hepatitis C

Hepatitis C is of concern both to industrialized and developing countries. Preliminary unpublished estimates of the global burden of disease (GBD) attributable to HCV-related chronic liver disease seem to be substantial. Therefore, the reduction of global mortality and morbidity related to chronic hepatitis C should be a concern to public health authorities, and primary, secondary and tertiary prevention activities should be implemented and monitored in each country, with precise targets set to be reached. In order to decide on national health policies, there is a need to estimate the burden of disease, globally, regionally and nationally. To evaluate the GBD, three components have to be assessed: 1) The global, regional and national burden of morbidity and mortality associated with HCV infection, based on prevalence, incidence, transmission and economics; 2) The natural history of HCV infection, including 'healthy individuals'; and 3) The areas for which more research is needed. A working group was created to assist the World Health organization (WHO) in estimating the GBD associated with HCV infection.

Candidates for therapy: HBV

Hepatitis B may cause liver damage ranging from mild chronic hepatitis to severe active hepatitis, cirrhosis and hepatocellular carcinoma. HIV and HBV co-infection is more likely to lead to lower rates of HBeAg seroconversion, and higher HBV DNA concentrations. Immune restitution may lead to more severe hepatitis. The timing of acquisition of HBV versus HIV will have a bearing on considerations of treatment. Patients may have acquired HIV super-infection of chronic hepatitis B, HBV super-infection of HIV; alternatively, reactivation of hepatitis B may occur in a HIV positive patient, or the patient may be co-infected at diagnosis. The patient may be naïve or experienced or have resistant (HBV) at the time of superinfection. The risk of death is higher in patients with co-infection compared to those with HBV alone. The goals of therapy for hepatitis B are to prevent progression of the disease. If HBV replication can be suppressed, the accompanying reduction in histological activity lessens the risk of progression. Patients may request treatment to reduce infectivity, and this is relevant in co-infected patients. HBV has little effect on HIV or the effect of treatment on HIV; however, HIV, and HIV treatment profoundly affects the natural history of HBV. Therefore, it is usually important to target treatment of HBV to alter the outcome and take into account the impact of HBV treatment on HIV. Special concepts of treatment are applicable in HIV and HBV co-infected patients.

Current treatment and future directions in the management of chronic hepatitis B viral infection

The World Health Organization places hepatitis B virus (HBV) in the top 10 causes of death worldwide. It is estimated that there are over 400 million carriers of HBV as well. At least 20% to 30% of hepatitis B surface antigen (HBsAg) carriers will die of complications of chronic liver disease, including cirrhosis and liver cancer. The serious consequences of end-stage liver disease and liver cancer occur in 30% of chronic carriers and confront patients and physicians throughout the world. Vaccination is the major form of treatment (prevention) that may eventually eliminate HBV worldwide. This article discusses the currently available treatments as well as evolving treatments for chronic HBV infection.

Antiretroviral treatment change among HIV, hepatitis B virus and hepatitis C virus co-infected patients in the Australian HIV Observational Database

OBJECTIVES

To assess the impact of highly active antiretroviral therapy (HAART) on rates of change of antiretroviral treatment among patients co-infected with hepatitis B virus (HBV) and/or hepatitis C virus (HCV) in the Australian HIV Observational Database (AHOD).

METHODS

Analysis was based on 805 of the 2218 patients recruited to the AHOD by March 2003, who had commenced HAART after 1 January 1997, who had recorded test results for HBV surface antigen and anti-HCV antibody, and who had follow-up of more than 3 months. The effect of hepatitis co-infection on the rate of antiretroviral treatment change after commencing HAART was assessed using a random-effect Poisson regression model.

RESULTS

Among those included in the analyses, the prevalences of HBV and HCV were 4.8% and 12.8%, respectively. The overall rate of combination antiretroviral treatment change was 0.74 combinations per year. Factors independently associated with an increased rate of change of combination antiretroviral treatment were: prior AIDS-defining illness; prior exposure to double combination antiretroviral therapy; and antiretroviral treatment class. Co-infection with HBV and/or HCV was not found to be significantly associated with the rate of combination antiretroviral treatment change.

CONCLUSIONS

While both HBV and HCV co-infections are relatively common in the AHOD, they do not appear to be serious impediments to the treatment of HIV-infected patients.

Hepatitis B and C viral load changes following initiation of highly active antiretroviral therapy (HAART) in patients with advanced HIV infection

Chronic infection with either hepatitis B (HBV) or hepatitis C virus (HCV) is frequently present in patients seropositive for human immunodeficiency virus (HIV) because of shared routes of transmission. With the advent of highly active antiretroviral therapy (HAART) regimens capable of controlling HIV replication and dramatically prolonging the survival of HIV-infected patients, the impact of co-morbid infections such as HBV and HCV has come into focus. Several studies have monitored HBV or HCV viral loads following initiation of HAART, with disparate results. The effects of HAART on hepatitis B and C plasma viral loads (n = 9 and 32, respectively) and on liver enzyme levels were studied in a large cohort of prospectively studied subjects with advanced stage HIV disease. Comparing the mean pre- and post-HAART levels, there was an estimated increase of (a) 1.40 log(10) from 4.83 to 6.24 log(10) for HBV plasma viral load (P = 0.07), (b) 0.74 log(10) from 6.38 to 7.12 log(10) for HCV plasma viral load (P = 0.001), and (c) 19.4 U/L from 37.4 to 56.8 U/L for serum alanine aminotransferase (P < 0.001). While the number of subjects co-infected with HIV and HBV was limited, these data collected in a population of advanced stage HIV-infected patients raises questions regarding the interactions of these viruses with each other and the host immune system and has implications regarding the order in which antiviral therapies are initiated.

Grade 4 events are as important as AIDS events in the era of HAART

OBJECTIVE

To estimate incidence and predictors of serious or life-threatening events that are not AIDS defining, AIDS events, and death among patients treated with highly active antiretroviral therapy (HAART) in the setting of 5 large multicenter randomized treatment trials conducted in the United States.

METHODS

Data were analyzed from 2,947 patients enrolled from December 1996 through December 2001. All patients were to receive antiretrovirals throughout follow-up. Data collection was uniform for all main outcome measures: serious or life-threatening (grade 4) events, AIDS, and death.

RESULTS

During follow-up, 675 patients experienced a grade 4 event (11.4 per 100 person-years); 332 developed an AIDS event (5.6 per 100 person-years); and 272 died (4.6 per 100 person-years). The most common grade 4 events were liver related (148 patients, 2.6 per 100 person-years). Cardiovascular events were associated with the greatest risk of death (hazard ratio = 8.64; 95% CI: 5.1 to 14.5). The first grade 4 event and the first AIDS event were associated with similar risks of death, 5.68 and 6.95, respectively.

CONCLUSIONS

Grade 4 events are as important as AIDS events in the era of HAART. To adequately evaluate the impact of HAART on morbidity, comorbidities and other key factors must be carefully assessed.

Challenges facing health professionals caring for HIV-infected drug users

Although injection drug use accounts for only 5% to 10% of cumulative HIV infections globally, it is a more efficient way of spreading HIV than sexual intercourse. HIV epidemics among injection drug users (IDUs) have a potential for rapid spread of the virus within the IDU community and outward into the general population. Effective interventions addressing this mode of HIV transmission are needed because part of a comprehensive strategy to curb the spread of HIV infection. IDUs, often marginalized, pose serious health challenges that can no longer be overlooked. Health care providers need to familiarize themselves with these challenges in order to meet the needs of this disenfranchised population. Providers need to have a clear understanding of targeted behavior and their patients' environmental context. Efforts must be made to foster healthy behavior among IDUs to assist them in managing their infection effectively and become productive members of society. This paper reviews these challenges and outlines selected models that may assist health care providers in fostering behavior changes among HIV-positive injection drug users.