Survival of HIV-infected patients with compensated liver cirrhosis

Comparison of Error Incidence Between Single-Tablet Versus Multiple-Tablet INSTI-Based Regimens in the Inpatient Setting

BACKGROUND

Errors related to antiretroviral therapy (ART) occur in up to 86% of hospitalized patients living with human immunodeficiency virus (HIV) and may contribute to treatment failure, drug resistance, adverse effects, and toxicity. ART can be administered as a single-tablet regimen (STR) or multiple-tablet regimen (MTR), with limited data on whether the number of tablets affects inpatient error incidence.

OBJECTIVE

The purpose of this study was to determine the error rate of substituting dolutegravir-based STRs to an MTR while admitted.

METHODS

This multicenter, retrospective, observational study in adult inpatients receiving ART for HIV evaluated continuation of bictegravir-based STR versus dolutegravir-based STR given as an MTR. The primary outcome was the composite error incidence when ART was dispensed as an STR versus MTR. Secondary endpoints included number of errors per patient encounter, between-group error types, time to error correction and pharmacist involvement, and conversion back to STR at discharge.

RESULTS

Of 514 patient encounters (257 bictegravir-based STR; 257 dolutegravir-based MTR), there was a significantly lower composite incidence of errors in the STR group versus the MTR group (23% vs 31.5%; P = 0.029). A significantly higher incidence of dose-related errors in the MTR group occurred related to renal or hepatic dose adjustments, which was the only significantly different between-group error type identified. Approximately one error per encounter was identified in both groups, with median time to error correction slightly over 1 day. Multiple-tablet regimens were converted back to an STR at discharge in 89.9% of admissions.

CONCLUSION AND RELEVANCE

Providing INSTI-based ART as an STR while admitted may reduce ART-related medication errors and has potential to improve patient care; however, use of an STR may not address errors related to inappropriate dosing in organ dysfunction. Increased vigilance for medication errors is warranted when substituting with MTRs in inpatient settings.

Survival rate and its predictors in HIV patients: A 15-year follow-up of 3030 patients

BACKGROUND

The high prevalence of HIV infection and the deaths caused by it is one of the challenges for the healthcare systems throughout the world. In this study, we analyzed the survival of people living with HIV and co-infections, and related factors.

METHODS

This retrospective cohort study was performed on 3030 people living with HIV admitted to Imam Khomeini Behavioral Disease Counseling Center, Tehran, Iran, during 2004-2018. Required data were obtained from the individuals' files. Kaplan Meier diagrams and Log-rank tests were used to assess the relationship between different factors and survival. In addition, Cox regression analysis was performed to determine the effective factors in HIV mortality. Data were analyzed using STATA software, version 14.

RESULTS

The mean age of studied population was 43.2 ± 9.5 [years] and 77.3 % were male. Among the subjects, 3.2 % were infected with hepatitis B, 31.5 % with hepatitis C, and 13.9 % with Tuberculosis (TB). One, five, ten, and fifteen-year survival rates were 97.0 %, 93.0 %, 86.0 %, and 54.0 %, respectively. The mean survival time was 154.2 ± 0.9 months. Age more than 35, history of imprisonment, Unsafe sexual behavior, TB, and hepatitis C are independently associated with death in people living with HIV (p < 0.05).

CONCLUSION

The survival of people living with HIV in the present study was in the favorable range compared to previous studies. However, co-infection with hepatitis C was associated with reduced survival of the subjects in this study. Therefore, it is suggested to detect and then prevent and control HCV co-infection to increase the survival of subjects.

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.

The role of liver and spleen elastography in advanced chronic liver disease

Portal hypertension is the main driver of complications in patients with advanced chronic liver disease (ACLD). In the last decade, many non-invasive tests, such us liver and spleen elastography, have been proposed and validated for the identification of patients with clinically significant portal hypertension (CSPH) and its complications, mainly hepatic decompensation and liver-related morbidity and mortality. Moreover, elastography accurately stratifies for the risk of HCC development, HCC recurrence and decompensation after liver surgery. Recent studies suggest a role of SSM in monitoring response to treatments and interventions in ACLD, such as viral eradication, non-selective beta-blockers and transjugular intrahepatic portosystemic shunt placement. However, one of the most indications to perform elastography in ACLD still remains the screening for esophageal varices. In fact, according to the Baveno VI consensus, liver stiffness measurement (LSM) <20 kPa and platelet count >150,000/mm³ can safely identify patients at low risk of varices requiring treatment (VNT) and could therefore avoid invasive upper invasive endoscopy; LSM>20-25 kPa can accurately rule-in CSPH in patients with viral etiology. Spleen stiffness measurement (SSM) is a direct surrogate of portal hypertension and has been demonstrated more accurate in predicting portal hypertension severity and VNT. A combined model including Baveno VI Criteria and SSM (≤46 kPa) can significantly increase the number of spared endoscopies (>40-50%), maintaining a low (<5%) of missed VNT.

CD4/CD8 Ratio and CD4 Nadir Predict Mortality Following Noncommunicable Disease Diagnosis in Adults Living with HIV

Incidence of noncommunicable diseases (NCDs), including cardiovascular disease (CVD), cirrhosis, and non-AIDS-defining cancers (NADCs), have been associated with HIV viremia, CD4 cell counts, and CD4/CD8 ratio in persons living with HIV (PLWH). This study examined the importance of these markers to mortality risk following NCD diagnosis. We examined factors associated with mortality following incident CVD, cirrhosis, or NADCs in a clinical cohort of PLWH between 1998 and 2015. We calculated Kaplan-Meier estimates and used multivariable Cox proportional hazard models. We included 341 patients with NCDs (CVD = 169, cancer = 103, and cirrhosis = 67), of whom 129 died. Median age at NCD diagnosis was 49 years and median proportion of time before NCD with virologic suppression was 64%. Median survival after CVD was longer than for cancer or cirrhosis (11.6 years vs. 4.8 and 3.4 years, respectively; log rank test p < .001). In multivariable Cox proportional hazard models, higher CD4/CD8 ratio preceding NCD (adjusted hazard ratio [aHR] per 0.1 increase = 0.92 [95% confidence interval 0.85-0.99]) and higher CD4 nadir (aHR per 100 cells/μL = 0.84 [0.72-0.97]) were associated with decreased mortality risk. Neither CD4 cell count before NCD nor HIV viremia was statistically associated with mortality in adjusted models. When restricted to 116 patients with virologic suppression for ≥80% of time before NCD, only CD4 nadir was associated with mortality risk. Low CD4/CD8 ratio and CD4 nadir were associated with increased mortality risk after NCD, suggesting that prior immunosuppression or ongoing immune imbalance remain important for outcomes following serious NCDs.

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.

Long-Term Liver Diseases after Initiation of Antiretroviral Therapy in HIV-Infected Patients with and without HBV or HCV Coinfection

Coinfection of hepatitis B virus (HBV) or hepatitis C virus (HCV) with HIV is common and associated with increased mortality and increased risk of progression to chronic liver disease. We aimed to study long-term liver diseases after initiation of antiretroviral therapy (ART) in HIV-infected patients with and without HBV or HCV coinfection. A retrospective cohort of 92 patients (32 patients with HBV and/or HCV coinfection) was analyzed. Overall mean age was 38.3 years, and 54.3% were males. Immunological and virological responses were similar between the 2 groups ( P > .05). During a median follow-up period of 6.1 years, 12 (13.0%) patients had liver diseases. Kaplan-Meier analysis showed that the coinfection group had a significantly higher probability of developing liver diseases after ART (log-rank test, P < .001). Among the subgroup of 32 patients with coinfection, patients who were initiated ART at CD4 count <200 cells/mm³ had a higher rate of liver diseases compared to those who were initiated ART at CD4 count ≥200 cells/mm³ (42.3% versus 16.7%; P = .004).

Budget impact analysis of sofosbuvir-based regimens for the treatment of HIV/HCV-coinfected patients in northern Italy: a multicenter regional simulation

Objectives

Chronic hepatitis C virus (HCV) is a leading cause of hospitalization and death in populations coinfected with human immunodeficiency virus (HIV). Sofosbuvir (SOF) is a pan-genotypic drug that should be combined with other agents as an oral treatment for HCV. We performed a 5-year horizon budget impact analysis of SOF-based regimens for the management of HIV/HCV-coinfected patients.

Methods

A multicenter, prospective evaluation was conducted, involving four Italian Infectious Diseases Departments (Galliera, San Martino, Sanremo, and La Spezia). All 1,005 genotype-coinfected patients (30% cirrhotics) under observation were considered (patients in all disease-stages were considered: chronic hepatitis C, cirrhosis, transplant, hepatocellular carcinoma). Disease stage costs per patient were collected; the expected disease progression in the absence of treatment and sustained virological response (SVR) success rate for SOF-based regimens were calculated based on the literature and expert opinion. Drug prices were based on what the National Health Service paid for them. The comparison of “no treatment” disease progression costs versus the economic impact of SOF-based regimens was investigated.

Results

Over the following 5 years, the disease progression scenario resulted in direct costs of approximately €54 million. Assuming an SVR success rate of 90%, average SOF-based regimens cost up to €50,000 per person, resulting in a final cost of more than €56 million, so this option is not economically viable. At the average price of €12,000, SOF-based regimens, expense was €17 million, saving 68%. At this price level, the economic resources invested in treating mild to moderate fibrosis stage patients would be equal to the amount of direct costs of disease management in this stage, resulting in a valid return of investment in the short-term.

Conclusion

Given the high rates of SVR, in the Italian Healthcare System, SOF-based regimens, price is a determinant and a predictor of the overall cost for the Hepatitis C patient’s management. At the average price per therapy of €12,000 over the next 5 years, SOF-based regimens are becoming highly sustainable.

Role of liver transplantation in human immunodeficiency virus positive patients

End-stage liver disease (ESLD) is a leading cause of morbidity and mortality amongst human immunodeficiency virus (HIV)-positive individuals. Chronic hepatitis B and hepatitis C virus (HCV) infection, drug-induced hepatotoxicity related to combined anti-retro-viral therapy, alcohol related liver disease and non-alcohol related fatty liver disease appear to be the leading causes. It is therefore, anticipated that more HIV-positive patients with ESLD will present as potential transplant candidates. HIV infection is no longer a contraindication to liver transplantation. Key transplantation outcomes such as rejection and infection rates as well as medium term graft and patient survival match those seen in the non-HIV infected patients in the absence of co-existing HCV infection. HIV disease does not seem to be negatively impacted by transplantation. However, HIV-HCV co-infection transplant outcomes remain suboptimal due to recurrence. In this article, we review the key challenges faced by this patient cohort in the pre- and post-transplant period.

Use of first-generation HCV protease inhibitors in patients coinfected by HIV and HCV genotype 1

BACKGROUND

In HCV genotype 1-infected patients with HIV co-infection, tritherapy [HCV protease inhibitors (PIs) plus peg-interferon and ribavirin] has been shown to have an increased rate of sustained virological response. However, complex drug-to-drug interactions and tolerability issues remain a concern.

METHODS

Under the auspices of four French scientific societies of medicine, a committee was charged of establishing guidelines on the use of first-generation HCV PIs in these patients. This scientific committee based its work on preliminary results from tritherapy clinical trials in co-infected patients and, since data on these patients are still scarce, on the statements already made by the French Association for the Study of the Liver (AFEF) on the use of tritherapy in HCV mono-infected patients, written in May 2011 and updated in 2012. Each AFEF guideline concerning HCV monoinfection was examined to determine whether it could be used in the context of HIV/HCV coinfection.

RESULTS

These guidelines are addressed for the treatment of coinfected patients with various profiles, including treatment-naïve or patients with failure to previous bitherapy and mention those patients for whom tritherapy should start or those for whom it should be delayed. Preliminary results of triple therapy as well as factors associated to virological response are also discussed. Other issues include virological monitoring, clinical and virological criteria to stop therapy, practical treatment management, treatment adherence and the management of side effects and interactions with antiretroviral drugs. These guidelines were submitted for critical review to independent experts.

Reversible hepatic decompensation following cessation of antiretroviral therapy in a patient with HIV and hepatitis C co-infection

We report the case of 47-year-old man with HIV and hepatitis C virus-associated cirrhosis who, following discontinuation of his antiretroviral therapy (ART), rapidly developed hepatic decompensation. On restarting his ART there was a noticeable improvement in his liver function, which was attributed to regaining good HIV virus control. Further data on the effects of restarting ART after ART cessation-associated hepatic decompensation are needed.

Human immunodeficiency virus and liver disease forum 2012

In the United States, more than 1.1 million individuals are infected with the human immunodeficiency virus (HIV). These patients exhibit a high frequency of coinfections with other hepatotropic viruses and ongoing fibrosis, leading to cirrhosis and liver-related mortality. Etiologies of liver disease include viral hepatitis coinfections, drug-related hepatotoxicity, fatty liver disease, and direct and indirect effects from HIV infection, including increased bacterial translocation, immune activation, and presence of soluble proteins, that modulate the hepatic cytokine environment. New treatments for hepatitis C virus (HCV) using direct-acting agents appear viable, though issues related to intrinsic toxicities and drug-drug interactions remain. Recent research suggests that acute HCV infection, unrecognized hepatitis D infection, and hepatitis E may all represent emergent areas of concern. Antiretroviral agents, including those used in recent years, may represent risk factors for hepatic injury and portal hypertension. Key issues in the future include systematic implementation of liver disease management and new treatment in HIV-infected populations with concomitant injection drug use, alcohol use, and low socioeconomic status.

Liver stiffness is associated with risk of decompensation, liver cancer, and death in patients with chronic liver diseases: a systematic review and meta-analysis

BACKGROUND & AIMS

Liver stiffness measurement (LSM), using elastography, can independently predict outcomes of patients with chronic liver diseases (CLDs). However, there is much variation in reporting and consistency of findings. We performed a systematic review and meta-analysis to evaluate the association between LSM and outcomes of patients with CLDs.

METHODS

We performed a systematic review of the literature, through February 2013, for studies that followed up patients with CLDs prospectively for at least 6 months and reported the association between baseline LSM and subsequent development of decompensated cirrhosis or hepatocellular carcinoma (HCC), as well as mortality. Summary relative risk (RR) estimates per unit of LSM and 95% confidence intervals (CIs) were estimated using the random effects model.

RESULTS

Our final analysis included 17 studies, reporting on 7058 patients with CLDs. Baseline LSM was associated significantly with risk of hepatic decompensation (6 studies; RR, 1.07; 95% CI, 1.03-1.11), HCC (9 studies; RR, 1.11; 95% CI, 1.05-1.18), death (5 studies; RR, 1.22; 95% CI, 1.05-1.43), or a composite of these outcomes (7 studies; RR, 1.32; 95% CI, 1.16-1.51). We observed considerable heterogeneity among studies-primarily in the magnitude of effect, rather than the direction of effect. This heterogeneity could not be explained by variations in study locations, etiologies and stages of CLD, techniques to measure liver stiffness, adjustment for covariates, or method of imputing relationship in the meta-analysis.

CONCLUSIONS

Based on a meta-analysis of cohort studies, the degree of liver stiffness is associated with risk of decompensated cirrhosis, HCC, and death in patients with CLDs. LSM therefore might be used in risk stratification.

Liver stiffness predicts liver-related complications and mortality in HIV patients with chronic hepatitis C on antiretroviral therapy

BACKGROUND

Liver disease is currently one of the leading causes of death in HIV individuals. Hepatic fibrosis largely mediates this effect and infection with hepatitis C virus (HCV) is the most common cause. Few studies have examined so far the predictive value of liver fibrosis staging on mortality and liver decompensation in HIV/HCV-coinfected patients.

METHODS

A prospective programme of liver fibrosis assessment using transient elastometry has been ongoing at our institution since 2004. Data from all HIV/HCV-coinfected patients who underwent a transient elastometry examination and have at least 18 months of follow-up were selected for the current analysis.

RESULTS

A total of 545 HIV/HCV-coinfected patients were examined (mean age 41 years, 71% men, 81% IDUs, mean BMI 23.3 kg/m2, HBsAg+ 4.2%, alcohol abuse 8.4%, mean CD4 cell count 519 cells/μl). The mean follow-up was 70.9 ± 15.7 months. During follow-up, 12 patients (2.2%) died, four of them due to hepatic complications. Liver-related events (ascites, encephalopathy, oesophageal varices or hepatocellular carcinoma) appeared in 53 patients (10%). In the multivariate analysis, baseline liver stiffness was the strongest predictor of liver-related complications [odds ratio (OR) 1.12, 95% confidence interval (CI) 1.08-1.16, P < 0.0001] and of all-cause mortality (OR 1.09, 95% CI 1.01-1.19, P = 0.02). The achievement of sustained virological response following peginterferon/ribavirin therapy during the study period was protective against the development of liver-related events (OR 0.02, 95% CI 0-0.23, P = 0.01).

CONCLUSION

Liver fibrosis staging, as measured by transient elastometry, predicts liver-related complications and all-cause mortality in HIV/HCV-coinfected patients on antiretroviral therapy.

Hepatitis B Co-Infection is Associated with Poorer Survival of HIV-Infected Patients on Highly Active Antiretroviral Therapy in West Africa

BACKGROUND

Hepatitis B has been reported to be high in HIV-infected African populations. However, the impact of this co-infection on the survival of HIV-infected Africans on long-term highly active antiretroviral therapy (HAART) remains poorly characterised. We investigated the impact of HBV/HIV co-infection on survival of HIV infected patients undergoing antiretroviral therapy in a West African population.

METHODS

This was a clinic-based cohort study of HIV-infected adults enrolled in Nigeria, West Africa. Study subjects (9,758) were screened for hepatitis B and hepatitis C at HAART initiation. Kaplan-Meier survival and Cox proportional hazards models were used to estimate probability of survival and to identify predictors of mortality respectively, based on hepatitis B surface antigen status. All patients had signed an informed written consent before enrolment into the study; and we additionally obtained permission for secondary use of data from the Harvard institutional review board.

RESULTS

Patients were followed up for a median of 41 months (interquartile range: 30-62 months) during which, 181 (1.9%) patients died. Most of the deaths; 143 (79.0%) occurred prior to availability of Tenofovir. Among those that were on antiretroviral therapy, hepatitis B co-infected patients experienced a significantly lower survival than HIV mono-infected patients at 74 months of follow up (94% vs. 97%; p=0.0097). Generally, hepatitis B co-infection: HBsAg-positive/HIV-positive (Hazards Rate [HR]; 1.5: 95% CI 1.09-2.11), co-morbid tuberculosis (HR; 2.2: 95% CI 1.57-2.96) and male gender (HR; 1.5: 95% CI 1.08-2.00) were significantly predictive of mortality. Categorising the patients based on use of Tenofovir, HBV infection failed to become a predictor of mortality among those on Tenofovir-containing HAART.

CONCLUSIONS

HBsAg-positive status was associated with reduced survival and was an independent predictor of mortality in this African HIV cohort on HAART. However, Tenofovir annulled the impact of HBV on mortality of HIV patients in the present study cohort.

End-stage liver disease: prevalence, risk factors and clinical characteristics in a cohort of HIV-HCV coinfected Han Chinese

INTRODUCTION

Since the advent of combined antiretroviral therapy (cART), liver-related mortality has become the leading cause of non-AIDS-related deaths in human immunodeficiency virus (HIV) infected patients in Western countries.

OBJECTIVE

To investigate the incidence, mortality and risk factors of end-stage liver disease (ESLD) in HIV and hepatitis C virus (HCV) coinfected former plasma donors (FPDs) and blood recipients (BRs).

METHOD

A retrospective study was conducted.

RESULTS

Of 321 HIV-HCV coinfected patients, 42 (13.1%) developed ESLD and 40 (12.5%) died. Factors that were independently associated with ESLD included older age at baseline (Odds ratios [OR]: 2.444, P=0.035), alanine aminotransferase (ALT) greater or equal to 2 (the upper limit of normal [ULN]) at the end of follow-up (OR: 16.460, P=0.000), hepatitis B virus (HBV) (OR: 2.525, P=0.043), CDC stage C (OR: 5.806, P=0.001), duration of cART greater than 5 years (OR: 3.256, P=0.010), and CD4 count greater or equal to 200 cells/mm(3) at the end of follow-up (OR: 0.383, P=0.016). The probability of developing ESLD in HIV-HCV coinfected BRs was significantly higher than in FPDs (P=0.008). Mortality was also significantly higher in HIV-HCV coinfected patients with ESLD than in those without ESLD (P=0.000).

CONCLUSION

In the cART era, ESLD was common among HIV-HCV coinfected Han Chinese patients and was responsible for reducing patient survival time.

Management of hepatitis C in HIV and/or HBV co-infected patients

Co-infection with either HIV or HBV in chronic hepatitis C patients is common, since all these viruses share transmission routes and geographical distribution. Interaction between these viruses generally amplifies liver damage, increasing the risk of developing end-stage liver disease and hepatocellular carcinoma. HIV-HCV co-infection is associated with poorer response to antiviral therapy. New antivirals against HCV are eagerly awaited for this population. HBV-HCV dual infections are less common. The principles guiding indication of therapy in monoinfected patients should be followed considering which virus replicates in persons with serological markers of dual HBV-HCV infection. Although there is growing evidence supporting the use of direct acting antivirals (DAA) in dually infected patients with active HCV replication, prospective trials should be conducted to demonstrate their benefit, assessing carefully the rate and clinical consequences of HBV rebounds.

Liver stiffness predicts clinical outcome in human immunodeficiency virus/hepatitis C virus-coinfected patients with compensated liver cirrhosis

Our aim was to assess the predictive value of liver stiffness (LS), measured by transient elastography (TE), for clinical outcome in human immunodeficiency virus / hepatitis C virus (HIV/HCV)-coinfected patients with compensated liver cirrhosis. This was a prospective cohort study of 239 consecutive HIV/HCV-coinfected patients with a new diagnosis of cirrhosis, done by TE, and no previous decompensation of liver disease. The time from diagnosis to the first liver decompensation and death from liver disease, as well as the predictors of these outcomes, were evaluated. After a median (Q1-Q3) follow-up of 20 (9-34) months, 31 (13%, 95% confidence interval [CI]: 9%-17%) patients developed a decompensation. The incidence of decompensation was 6.7 cases per 100 person-years (95% CI, 4.7-9-6). Fourteen (8%) out of 181 patients with a baseline LS < 40 kPa developed a decompensation versus 17 (29%) out of 58 with LS ≥ 40 kPa (P = 0.001). Factors independently associated with decompensation were Child-Turcotte-Pugh (CTP) class B versus A (hazard ratio [HR] 7.7; 95% CI 3.3-18.5; P < 0.0001), log-plasma HCV RNA load (HR 2.1; 95% CI 1.2-3.6; P = 0.01), hepatitis B virus coinfection (HR, 10.3; 95% CI, 2.1-50.4; P = 0.004) and baseline LS (HR 1.03; 95% CI 1.01-1.05; P = 0.02). Fifteen (6%, 95% CI: 3.5%-9.9%) patients died, 10 of them due to liver disease, and one underwent liver transplantation. CTP class B (HR 16.5; 95% CI 3.4-68.2; P < 0.0001) and previous exposure to HCV therapy (HR 7.4; 95% CI 1.7-32.4, P = 0.007) were independently associated with liver-related death; baseline LS (HR 1.03; 95% CI 0.98-1.07; P = 0.08) was of borderline significance.

CONCLUSION

LS predicts the development of hepatic decompensations and liver-related mortality in HIV/HCV-coinfection with compensated cirrhosis and provides additional prognostic information to that provided by the CTP score.

Five-year review of HIV-hepatitis B virus (HBV) co-infected patients in a New York City AIDS center

A retrospective review of 4,721 human immunodeficiency virus (HIV)-infected patients, followed at St. Luke's Roosevelt Hospital Center, New York City, was conducted from January 1, 2005 to December 31, 2009. HIV-Hepatitis B virus (HBV) co-infection rate was 218/4,721, 4.6%. Among co-infected patients, 19 patients (19/218, 8.7%) died; 13 patients (13/19, 68.4%) died from non-acquired immune deficiency syndrome (AIDS) defining including 2 patients with liver failure. More non-survivors (5 patients, 5/19, 26.3%) had liver cirrhosis than those who survived (8 patients, 8/199, 4.0%; P = 0.002). There were more patients with positive HBV e antigen (HBeAg) among non-survivors, (12 patients, 12/19, 63.2%) than among survivors (74 patients, 74/199, 37.2%; P = 0.047). HIV-HBV co-infection is associated with increased overall mortality. Therefore, use of dual active antiretrovirals, particularly, tenofovir (TDF) based regimen for optimal suppression of HIV-HBV and immune restoration with prevention of high risk behaviors may contribute to improved outcomes.

Hepatitis delta in HIV/HBV co-infected patients in Brazil: is it important?

OBJECTIVES

This study was carried out to evaluate the prevalence of hepatitis delta virus (HDV) among human immunodeficiency virus (HIV)/hepatitis B virus (HBV) co-infected patients from São Paulo, in the Southeast Region of Brazil.

METHODS

A total of 3259 HIV patients with serological markers for HBV were initially enrolled in the study. Among these patients, 154 (4.7%) were hepatitis B surface antigen (HBsAg)-reactive. Serum samples were obtained from 86 HBsAg-positive patients and were submitted to anti-HDV serological assay.

RESULTS

One (1.2%) HIV/HBV patient was found to be anti-HDV-positive, and the HDV infection was confirmed by PCR. Phylogenetic analysis showed that this HDV sequence grouped with other HDV genotype 1 sequences from Mediterranean European countries, suggesting that this virus has a common ancestor with HDV from that region. This patient was probably infected by sexual transmission, as he reported unprotected sexual intercourse with multiple partners over the course of many years but denied intravenous drug use or any travel to the Brazilian Amazon, an area known to have a high HDV prevalence.

CONCLUSIONS

HDV infection is infrequent in the Southeast Region of Brazil, however there have been a few cases in this region. HIV/HBV patients are at potential risk for HDV infection, therefore investigations for the presence of HDV infection must be carried out in these patients.

Treatment of chronic hepatitis C in HIV-infected patients with compensated liver cirrhosis

The greatest benefit of hepatitis C virus (HCV) therapy is seen in cirrhotics attaining sustained virological response (SVR). However, concerns about toxicity and poorer responses often discourage treatment of cirrhotics. This may be particularly relevant in HIV-HCV-coinfected patients, in whom progression of liver fibrosis is faster and treatment responses lower. This is a retrospective analysis of HIV-HCV-coinfected patients who had received peginterferon-ribavirin therapy at our institution. Individuals naïve for interferon in whom liver fibrosis had been assessed using elastometry within the year before being treated were chosen. Response rates and toxicities were compared in cirrhotics (>14.5 KPa) and noncirrhotics. Patients with previous liver decompensation were excluded. Overall, 41 cirrhotics and 190 noncirrhotics entered the study. Groups were similar in age, gender, HCV genotypes and baseline serum HCV-RNA. SVR occurred at similar rates in cirrhotic and noncirrhotics, either considered by intention-to-treat (39%vs 45%; P = 0.4) or as treated (50%vs 52%, P = 0.8). In multivariate analysis (odds ratio, 95% CI, P), SVR was associated with HCV genotypes 2-3 (5, 2.9-11, <0.01) and lower serum HCV-RNA (2, 1.4-3.03 for every log decrease, <0.01) but not with cirrhosis (1.2, 0.4-3.6, 0.6). Treatment discontinuations because of adverse events tended to be more common in cirrhotics than in noncirrhotics (17%vs 12%; P = 0.2), but only severe thrombocytopenia was more frequent in cirrhotics than in non-cirrhotics (20%vs 3% at week 24; P < 0.01). Response to peginterferon-ribavirin therapy is similar in HIV-HCV coinfected patients with and without liver cirrhosis. Therefore, treatment must be encouraged in all compensated cirrhotic patients, although closer monitoring and management of side effects, mainly thrombocytopenia, may be warranted.

Liver transplantation in human immunodeficiency virus-positive patients

With the successful introduction of combined antiretroviral therapy (cART), human immunodeficiency virus (HIV) is now regarded as a chronic illness with excellent long-term outcomes. However, chronic exposure to viral etiologies (ie, chronic hepatitis B and hepatitis C) and drug-induced toxicity secondary to cART have resulted in increasing rates of mortality and morbidity due to end-stage liver disease. HIV disease is no longer considered an absolute contraindication to liver transplantation (LT) by most transplant centers worldwide. Because the burden of liver disease in this cohort is likely to increase, this review addresses the key etiologies and the management strategies available for HIV-positive patients undergoing LT.

The natural history of liver cirrhosis in HIV-hepatitis C virus-coinfected patients

OBJECTIVE

To provide detailed information about the natural history of HIV-hepatitis C virus (HCV)-coinfected patients with cirrhosis.

METHODS

Prospective cohort including 340 HIV-HCV-coinfected patients with compensated (n = 248) or decompensated (n = 92) cirrhosis. We evaluated predictors of survival and of first hepatic decompensation.

RESULTS

The mortality rate for patients with decompensated and compensated cirrhosis was 27.14 deaths per 100 person-years [95% confidence interval (CI) 18.93-35.35] and 3.98 deaths per 100 person-years (95% CI 2.42-5.54), respectively. Rate of first hepatic decompensation in patients with compensated cirrhosis was 4.62 per 100 persons-years (95% CI 2.91-6.33). In the complete cohort, permanent HAART interruption during follow-up, CD4 cell count nadir and baseline Child-Pugh score (CPS) B or C were significantly associated with shorter survival. In patients with compensated cirrhosis factors significantly associated with decreased survival were having the first hepatic decompensation during follow-up, permanent HAART discontinuation, and CPS B and C at baseline. For patients with compensated cirrhosis, time since diagnosis of HCV infection, CPS B and C and permanent HAART discontinuation were significantly associated with the risk of first hepatic decompensation. Sustained viral response to anti-HCV therapy was not independently associated with better survival in patients with compensated cirrhosis.

CONCLUSION

HIV-HCV-coinfected patients with cirrhosis have a relatively good 3-year survival (87%). In contrast, 2-year survival of patients with decompensated liver cirrhosis is only 50%. Three-year survival was mostly impacted by liver-related factors and HAART maintenance.

HIV in NSW in 2010: sustaining success in an evolving epidemic

NSW has been recognised internationally for achieving a sustained, stable rate of HIV infection since 2000. An early mobilisation by communities initially at risk of HIV--gay men, sex workers and injecting drug users--resulted in rapid behaviour change and provided the basis for a continuing cooperative partnership with government, health service providers and researchers. This special issue of the NSW Public Health Bulletin describes the current response to HIV in NSW. Experts from diverse disciplinary and professional fields offer perspectives on the epidemiology, morbidity and impacts of HIV, current prevention challenges including with Aboriginal communities and people from culturally and linguistically diverse backgrounds, models for the diagnosis, care and treatment of HIV, and the legislative protection of public health and those who are living with HIV. The NSW experience demonstrates that the sustained cooperation of those affected, together with the efforts of government, health service providers and researchers, can achieve HIV control.

Increasing burden of liver disease in patients with HIV infection

Introduction of effective combined antiretroviral therapy has made HIV infection a chronic illness. Substantial reductions in the number of AIDS-related deaths have been accompanied by an increase in liver-related morbidity and mortality due to co-infection with chronic hepatitis B and C viruses. Increases in non-alcoholic fatty liver disease and drug-induced hepatotoxicity, together with development of hepatocellular carcinoma, also potentiate the burden of liver disease in individuals with HIV infection. We provide an overview of the key causes, disease mechanisms of pathogenesis, and recommendations for treatment options including the evolving role of liver transplantation.