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Thomadakis C, Basoulis D, Tsachouridou O, Protopapas K, Paparizos V, Astriti M, Chini M, Chrysos G, Marangos M, Panagopoulos P, Kofteridis D, Sambatakou H, Mastrogianni E, Panatzis N, Pechlivanidou E, Psichοgiou M, Touloumi G. HCV Cascade of Care in HIV/HCV Co-Infected Individuals: Missed Opportunities for Micro-Elimination. Viruses 2024; 16:885. [PMID: 38932178 PMCID: PMC11209384 DOI: 10.3390/v16060885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/17/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024] Open
Abstract
People living with HIV-HCV co-infection comprise a target group for HCV-micro-elimination. We conducted an HCV cascade of care (CoC) for HIV-HCV co-infected individuals living in Greece and investigated factors associated with different HCV-CoC stages. We analyzed data from 1213 participants from the Athens Multicenter AIDS Cohort Study. A seven-stage CoC, overall and by subgroup (people who inject drugs (PWID), men having sex with men (MSM), men having sex with women (MSW), and migrants], was constructed, spanning from HCV diagnosis to sustained virologic response (SVR). Logistic/Cox regression models were employed to identify factors associated with passing through each CoC step. Among 1213 anti-HCV-positive individuals, 9.2% died before direct-acting antiviral (DAA) availability. PWID exhibited higher mortality rates than MSM. Of 1101 survivors, 72.2% remained in care and underwent HCV-RNA testing. Migrants and PWID showed the lowest retention rates. HCV-RNA was available for 79.2% of those in care, with 77.8% diagnosed with chronic HCV. Subsequently, 71% initiated DAAs, with individuals with very low CD4 counts (<100 cells/μL) exhibiting lower odds of DAA initiation. SVR testing was available for 203 individuals, with 85.7% achieving SVR. The SVR rates did not differ across risk groups. In 2023, significant gaps and between-group differences persisted in HCV-CoC among HIV-HCV co-infected individuals in Greece.
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Affiliation(s)
- Christos Thomadakis
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, 115 27 Athens, Greece; (C.T.); (N.P.); (E.P.)
| | - Dimitrios Basoulis
- 1st Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, 115 27 Athens, Greece; (D.B.); (E.M.); (M.P.)
| | - Olga Tsachouridou
- Infectious Diseases Unit, 1st Internal Medicine Department, AHEPA University Hospital, Aristotle University of Thessaloniki, 546 36 Thessaloniki, Greece;
| | - Konstantinos Protopapas
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, 124 62 Athens, Greece;
| | - Vasilios Paparizos
- AIDS Unit, Clinic of Venereologic & Dermatologic Diseases, Medical School, Syngros Hospital, National and Kapodistrian University of Athens, 161 21 Athens, Greece;
| | - Myrto Astriti
- 1st Department of Internal Medicine and Infectious Diseases Unit, General Hospital of Athens G. Gennimatas, 115 27 Athens, Greece;
| | - Maria Chini
- 3rd Department of Internal Medicine Infectious Diseases Unit, Red Cross General Hospital, 115 26 Athens, Greece;
| | - Georgios Chrysos
- Infectious Diseases Unit, Tzaneion General Hospital of Piraeus, 185 36 Athens, Greece;
| | - Markos Marangos
- Department of Internal Medicine & Infectious Diseases, Patras University General Hospital, 265 04 Patras, Greece;
| | - Periklis Panagopoulos
- Infectious Diseases Unit, 2nd University Department of Internal Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, 681 00 Alexandroupolis, Greece;
| | - Diamantis Kofteridis
- Department of Internal Medicine, University Hospital of Heraklion, 715 00 Heraklion, Greece;
| | - Helen Sambatakou
- HIV Unit, 2nd Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Hippokration University General Hospital, 115 27 Athens, Greece;
| | - Elpida Mastrogianni
- 1st Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, 115 27 Athens, Greece; (D.B.); (E.M.); (M.P.)
| | - Nikos Panatzis
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, 115 27 Athens, Greece; (C.T.); (N.P.); (E.P.)
| | - Evmorfia Pechlivanidou
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, 115 27 Athens, Greece; (C.T.); (N.P.); (E.P.)
| | - Mina Psichοgiou
- 1st Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, 115 27 Athens, Greece; (D.B.); (E.M.); (M.P.)
| | - Giota Touloumi
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, 115 27 Athens, Greece; (C.T.); (N.P.); (E.P.)
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Butt ZA, Wong S, Rossi C, Binka M, Wong J, Yu A, Darvishian M, Alvarez M, Chapinal N, Mckee G, Gilbert M, Tyndall MW, Krajden M, Janjua NZ. Concurrent Hepatitis C and B Virus and Human Immunodeficiency Virus Infections Are Associated With Higher Mortality Risk Illustrating the Impact of Syndemics on Health Outcomes. Open Forum Infect Dis 2020; 7:ofaa347. [PMID: 32964065 PMCID: PMC7489531 DOI: 10.1093/ofid/ofaa347] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/10/2020] [Indexed: 02/06/2023] Open
Abstract
Background Hepatitis C virus (HCV), hepatitis B virus (HBV), and human immunodeficiency virus (HIV) infections are associated with significant mortality globally and in North America. However, data on impact of concurrent multiple infections on mortality risk are limited. We evaluated the effect of HCV, HBV, and HIV infections and coinfections and associated factors on all-cause mortality in British Columbia (BC), Canada. Methods The BC Hepatitis Testers Cohort includes ~1.7 million individuals tested for HCV or HIV, or reported as a case of HCV, HIV, or HBV from 1990 to 2015, linked to administrative databases. We followed people with HCV, HBV, or HIV monoinfection, coinfections, and triple infections from their negative status to date of death or December 31, 2016. Extended Cox proportional hazards regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for factors associated with all-cause mortality. Results Of 658 704 individuals tested for HCV, HBV, and HIV, there were 33 804 (5.13%) deaths. In multivariable Cox regression analysis, individuals with HCV/HBV/HIV (HR, 8.9; 95% CI, 8.2–9.7) infections had the highest risk of mortality followed by HCV/HIV (HR, 4.8; 95% CI, 4.4–5.1), HBV/HIV (HR, 4.1; 95% CI, 3.5–4.8), HCV/HBV (HR, 3.9; 95% CI, 3.7–4.2), HCV (HR, 2.6; 95% CI, 2.6–2.7), HBV (HR, 2.2; 95% CI, 2.0–2.3), and HIV (HR, 1.6; 95% CI, 1.5–1.7). Additional factors associated with mortality included injection drug use, problematic alcohol use, material deprivation, diabetes, chronic kidney disease, heart failure, and hypertension. Conclusions Concurrent multiple infections are associated with high mortality risk. Substance use, comorbidities, and material disadvantage were significantly associated with mortality independent of coinfection. Preventive interventions, including harm reduction combined with coinfection treatments, can significantly reduce mortality.
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Affiliation(s)
- Zahid A Butt
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada.,British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stanley Wong
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Carmine Rossi
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Mawuena Binka
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Jason Wong
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Amanda Yu
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | | | - Maria Alvarez
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | | | - Geoff Mckee
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Mark Gilbert
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mark W Tyndall
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mel Krajden
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.,BCCDC Public Health Laboratory, Vancouver, British Columbia, Canada
| | - Naveed Z Janjua
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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Directly acting antivirals for hepatitis C virus arrive in HIV/hepatitis C virus co-infected patients: from 'mind the gap' to 'where's the gap?'. AIDS 2016; 30:975-89. [PMID: 26836785 DOI: 10.1097/qad.0000000000001042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In patients living with HIV infection with hepatitis C (HCV) is common. HIV/HCV co-infection results in more rapid liver fibrosis progression than HCV alone and end-stage liver disease is a major cause of morbidity and mortality in co-infected patients. Historically, treatment outcomes with interferon based therapy in this group have been poor but with the advent of directly acting antiviral (DAA) drugs for HCV, rates of cure have improved dramatically. This article reviews recent evidence on the treatment of HCV in co-infected patients including the efficacy of new regimens and information on drug-drug interactions between DAAs and antiretroviral therapy. We also discuss the relationship between the pathogenesis of HIV and HCV infections, the treatment of acute hepatitis C and the current debate regarding the cost-effectiveness and affordability of DAAs.
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Cho H, Kikuchi M, Li Y, Nakamoto N, Amorosa VK, Valiga ME, Chang KM. Induction of Multiple Immune Regulatory Pathways with Differential Impact in HCV/HIV Coinfection. Front Immunol 2014; 5:265. [PMID: 25071758 PMCID: PMC4086204 DOI: 10.3389/fimmu.2014.00265] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 05/23/2014] [Indexed: 12/13/2022] Open
Abstract
Persistent viral infections including HCV, HBV, and HIV are associated with increased immune regulatory pathways including the extrinsic FoxP3+CD4+ regulatory T cells (Tregs) and intrinsic inhibitory pathways such as programed death-1 (PD-1) and cytotoxic T lymphocyte antigen-4 (CTLA-4) with potentially reversible suppression of antiviral effector T cells (1–12). Immunological consequences of viral coinfections relative to these immune regulatory pathways and their interplay are not well-defined. In this study, we examined the frequency, phenotype, and effector function of circulating T cell subsets in patients with chronic HCV and/or HIV infection, hypothesizing that HCV/HIV coinfection will result in greater immune dysregulation with pathogenetic consequences (13, 14). We show that multiple T cell inhibitory pathways are induced in HCV/HIV coinfection including FoxP3+ Tregs, PD-1, and CTLA-4 in inverse association with overall CD4 T cell frequency but not with liver function or HCV RNA titers. The inverse association between CD4 T cell frequency and their FoxP3, PD-1, or CTLA-4 expression remained significant in all subjects combined regardless of HCV and/or HIV infection, suggesting a global homeostatic mechanism to maintain immune regulation relative to CD4 T cell frequency. PD-1 blockade rescued T cell responses to HIV but not HCV without significant impact by CTLA-4 blockade in vitro. Collectively, these findings highlight complex immune interactions in viral coinfections and differential regulatory pathways influencing virus-specific T cells that are relevant in immunotherapeutic development.
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Affiliation(s)
- Hyosun Cho
- Philadelphia VAMC , Philadelphia, PA , USA ; Department of Medicine, University of Pennsylvania School of Medicine , Philadelphia, PA , USA ; Duksung Women's University , Seoul , South Korea
| | - Masahiro Kikuchi
- Philadelphia VAMC , Philadelphia, PA , USA ; Department of Medicine, University of Pennsylvania School of Medicine , Philadelphia, PA , USA
| | - Yun Li
- Philadelphia VAMC , Philadelphia, PA , USA ; Department of Medicine, University of Pennsylvania School of Medicine , Philadelphia, PA , USA
| | - Nobuhiro Nakamoto
- Philadelphia VAMC , Philadelphia, PA , USA ; Department of Medicine, University of Pennsylvania School of Medicine , Philadelphia, PA , USA
| | - Valerianna K Amorosa
- Philadelphia VAMC , Philadelphia, PA , USA ; Department of Medicine, University of Pennsylvania School of Medicine , Philadelphia, PA , USA
| | - Mary E Valiga
- Philadelphia VAMC , Philadelphia, PA , USA ; Department of Medicine, University of Pennsylvania School of Medicine , Philadelphia, PA , USA
| | - Kyong-Mi Chang
- Philadelphia VAMC , Philadelphia, PA , USA ; Department of Medicine, University of Pennsylvania School of Medicine , Philadelphia, PA , USA
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5
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Sarkar M, Bacchetti P, French AL, Tien P, Glesby MJ, Nowicki M, Plankey M, Gange S, Sharp G, Minkoff H, Peters MG. Lower liver-related death in African-American women with human immunodeficiency virus/hepatitis C virus coinfection, compared to Caucasian and Hispanic women. Hepatology 2012; 56:1699-705. [PMID: 22618868 PMCID: PMC3440547 DOI: 10.1002/hep.25859] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Accepted: 05/15/2012] [Indexed: 12/15/2022]
Abstract
UNLABELLED Among individuals with and without concurrent human immunodeficiency virus (HIV), racial/ethnic differences in the natural history of hepatitis C virus (HCV) have been described. African Americans have lower spontaneous HCV clearance than Caucasians, yet slower rates of liver fibrosis once chronically infected. It is not clear how these differences in the natural history of hepatitis C affect mortality, in either HIV-positive or -negative individuals. We conducted a cohort study of HIV/HCV coinfected women followed in the multicenter Women's Interagency HIV Study to determine the association of self-reported race/ethnicity with all-cause and liver-related mortality. Survival analyses were performed using Cox's proportional hazards models. The eligible cohort (n = 794) included 140 Caucasians, 159 Hispanics, and 495 African Americans. There were 438 deaths and 49 liver-related deaths during a median follow-up of 8.9 years and maximum follow-up of 16 years. African-American coinfected women had significantly lower liver-related mortality, compared to Caucasian (hazard ratio [HR], 0.41; 95% confidence interval [CI]: 0.19-0.88; P = 0.022) and Hispanic coinfected women (HR, 0.38; 95% CI: 0.19-0.76; P = 0.006). All-cause mortality was similar between racial/ethnic groups (HRs for all comparisons: 0.82-1.03; log-rank test: P = 0.8). CONCLUSIONS African-American coinfected women were much less likely to die from liver disease, as compared to Caucasians and Hispanics, independent of other causes of death. Future studies are needed to investigate the reasons for this marked racial/ethnic discrepancy in liver-related mortality.
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Affiliation(s)
- Monika Sarkar
- Department of Medicine, University of California, San Francisco, CA, USA.
| | - Peter Bacchetti
- Epidemiology and Biostatistics, University of California San Francisco
| | - Audrey L. French
- Medicine, CORE Center/Stroger Hospital of Cook County, Chicago, IL
| | - Phyllis Tien
- Medicine, Division of Infectious Diseases, University of California San Francisco
| | - Marshall J. Glesby
- Medicine, Division of Infectious Diseases, Weill Cornell Medical College, New York, NY
| | - Marek Nowicki
- Medicine, University of Southern California, Los Angeles, CA
| | - Michael Plankey
- Medicine, Division of Infectious Diseases, Georgetown University, Washington, DC
| | - Stephen Gange
- Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Gerald Sharp
- Epidemiology Branch, NIH, NIAID, DAIDS, Bethesda, MD
| | - Howard Minkoff
- Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY
| | - Marion G. Peters
- Medicine, Division of Gastroenterology and Hepatology, University of California San Francisco
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Wise M, Finelli L, Sorvillo F. Prognostic factors associated with hepatitis C disease: a case-control study utilizing U.S. multiple-cause-of-death data. Public Health Rep 2010; 125:414-22. [PMID: 20433036 DOI: 10.1177/003335491012500310] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Hepatitis C, an important cause of premature mortality, is the most common chronic bloodborne infection in the United States. The severity of disease is strongly affected by a number of other medical conditions and health behaviors. We sought to estimate the association of several exposures with hepatitis C on death certificates. METHODS We enrolled 63,189 hepatitis C deaths as cases in a case-control study using multiple-cause-of-death data for the U.S. from 1999 to 2004. Three control groups were assembled from all remaining deaths with no mention of hepatitis C, including a random sample of all deaths, digestive disease deaths, and circulatory disease deaths. RESULTS Hepatitis B, human immunodeficiency virus (HIV), hemochromatosis, and alcohol use were all strongly associated with hepatitis C, even after controlling for confounding variables. The simultaneous presence of many of these exposures had a synergistic association with hepatitis C being listed as a cause of death. Hepatitis B, HIV, and alcohol use were recorded among 6.4%, 10.5%, and 18.2% of case deaths, respectively. CONCLUSIONS The strong association of alcohol use, HIV, and hepatitis B with hepatitis C, as well as the frequent occurrence of these conditions, indicates that targeted interventions for mitigating the potential effect of these exposures may present an efficient means of limiting progression of hepatitis C-related liver disease and reducing the population burden of hepatitis C mortality.
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Affiliation(s)
- Matthew Wise
- Department of Epidemiology, University of California, Los Angeles, School of Public Health, Los Angeles, CA, USA.
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Oramasionwu CU, Brown CM, Ryan L, Lawson KA, Hunter JM, Frei CR. HIV/AIDS disparities: the mounting epidemic plaguing US blacks. J Natl Med Assoc 2010; 101:1196-204. [PMID: 20070007 DOI: 10.1016/s0027-9684(15)31130-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The human immunodeficiency virus (HIV)/AIDS epidemic presents a formidable challenge for the black community. Blacks, although a small proportion of the US population, are overrepresented, not only in the number of people living with HIV, but also in the categories of new diagnoses and AIDS-related deaths. Fortunately, national initiatives are in place to slow and ultimately reverse these racial inequities. While these disparities may be widely recognized, their causes are not clearly understood. A variety of underlying issues exist for blacks in the United States that may also contribute to these growing disparities. These include transmission risk factors, socioeconomic factors, underrecognition, delayed presentation, and other comorbid conditions. We present a review of the literature regarding the potential causes of racial disparities and how they may contribute to health outcomes for blacks with HIV/AIDS in the United States. We also identify possible gaps in knowledge and offer future directions for research of HIV/AIDS racial disparities.
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Chen TY, Ding EL, Seage Iii GR, Kim AY. Meta-analysis: increased mortality associated with hepatitis C in HIV-infected persons is unrelated to HIV disease progression. Clin Infect Dis 2010; 49:1605-15. [PMID: 19842982 DOI: 10.1086/644771] [Citation(s) in RCA: 176] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND It is unclear whether coinfection with hepatitis C virus (HCV) increases mortality in patients with human immunodeficiency virus (HIV) infection during the era of highly active antiretroviral therapy (HAART). With use of a meta-analysis, we estimated the effect of HCV infection on HIV disease progression and overall mortality in the pre-HAART and HAART eras. METHOD The PubMed and EMBASE databases were searched for studies published through 30 April 2008. Additional studies were identified from cited references. Studies reporting disease progression or mortality among HCV-HIV coinfected patients were selected. Cross-sectional studies, studies without HCV-negative control subjects, and studies involving children and/or patients who had undergone liver transplantation were excluded. Two authors reviewed articles and extracted data on the demographic characteristics of study populations and risk estimates. Meta-regression was used to explore heterogeneity. RESULTS Ten studies from the pre-HAART era and 27 studies from the HAART era were selected. In the pre-HAART era, the risk ratio for overall mortality among patients with HCV-HIV coinfection, compared with that among patients with HIV infection alone, was 0.68 (95% confidence interval [CI], 0.53-0.87). In the HAART era, the risk ratio was 1.12 (95% CI, 0.82-1.51) for AIDS-defining events and 1.35 (95% CI, 1.11-1.63) for overall mortality among coinfected patients, compared with that among patients with HIV monoinfection. CONCLUSIONS HCV coinfection did not increase mortality among patients with HIV infection before the introduction of HAART. In contrast, in the HAART era, HCV coinfection, compared with HIV infection alone, increases the risk of mortality, but not the risk of AIDS-defining events. Future studies should determine whether successful treatment of HCV infection could reduce this excess risk of mortality in coinfected patients.
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Affiliation(s)
- Ting-Yi Chen
- Wayne State University, Detroit Medical Center, Detroit, MI 48201, USA.
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Silverberg MJ, Leyden W, Quesenberry CP, Horberg MA. Race/ethnicity and risk of AIDS and death among HIV-infected patients with access to care. J Gen Intern Med 2009; 24:1065-72. [PMID: 19609624 PMCID: PMC2726884 DOI: 10.1007/s11606-009-1049-y] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2008] [Revised: 05/05/2009] [Accepted: 06/04/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Prior studies evaluating racial/ethnic differences in responses to antiretroviral therapy (ART) among HIV-infected patients have not adequately accounted for many potential confounders, and few have included Hispanic patients. OBJECTIVE To identify racial/ethnic differences in ART adherence, and risk of AIDS and death after ART initiation for HIV patients with similar access to care. DESIGN Retrospective cohort study. PARTICIPANTS 4,686 HIV-infected patients (66% White, 20% Black, and 14% Hispanic) initiating ART and who were enrolled in an integrated healthcare system. MEASUREMENTS Main outcomes evaluated were ART adherence, new AIDS clinical events, and all-cause mortality. The potential confounding effects of demographics, socioeconomic status, ART parameters, HIV disease stage, and other clinical parameters were considered in multivariable models. RESULTS Adjusted mean adherence levels were higher among White (70.1%; ref) compared with Black (64.2%; P < 0.001) and Hispanic patients (65.2%; P < 0.001). Adjusted hazard ratios (HR) for the risk of new AIDS events (White patients as reference) were 1.3 (P = 0.09) for Black and 0.9 (P = 0.64) for Hispanic patients. The adjusted HR for AIDS comparing Hispanic to Black patients was 0.7 (P = 0.11). Hispanic patients had fewer deaths compared with other racial/ethnic groups, particularly cancer and cardiovascular-related. However, adjusted HRs for death were 1.2 (P = 0.37) and 0.9 (P = 0.62) for Black and Hispanic patients, respectively, compared with White patients and 0.9 (P = 0.63) for Hispanic compared with Black patients. Adjustment for adherence did not change inferences for AIDS or death. CONCLUSIONS In the setting of similar access to care, we did not observe a disparity for the risk of clinical events for racial/ethnic minorities, despite lower ART adherence.
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Affiliation(s)
- Michael J Silverberg
- Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612, USA.
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10
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Oramasionwu CU, Hunter JM, Skinner J, Ryan L, Lawson KA, Brown CM, Makos BR, Frei CR. Black race as a predictor of poor health outcomes among a national cohort of HIV/AIDS patients admitted to US hospitals: a cohort study. BMC Infect Dis 2009; 9:127. [PMID: 19671170 PMCID: PMC2736968 DOI: 10.1186/1471-2334-9-127] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2009] [Accepted: 08/11/2009] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND In general, the Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) population has begun to experience the benefits of highly active antiretroviral therapy (HAART); unfortunately, these benefits have not extended equally to Blacks in the United States, possibly due to differences in patient comorbidities and demographics. These differences include rates of hepatitis B and C infection, substance use, and socioeconomic status. To investigate the impact of these factors, we compared hospital mortality and length of stay (LOS) between Blacks and Whites with HIV/AIDS while adjusting for differences in these key characteristics. METHODS The 1996-2006 National Hospital Discharge Surveys were used to identify HIV/AIDS patients admitted to US hospitals. Survey weights were incorporated to provide national estimates. Patients < 18 years of age, those who left against medical advice, those with an unknown discharge disposition and those with a LOS < 1 day were excluded. Patients were stratified into subgroups by race (Black or White). Two multivariable logistic regression models were constructed with race as the independent variable and outcomes (mortality and LOS > 10 days) as the dependent variables. Factors that were significantly different between Blacks and Whites at baseline via bivariable statistical tests were included as covariates. RESULTS In the general US population, there are approximately 5 times fewer Blacks than Whites. In the present study, 1.5 million HIV/AIDS hospital discharges were identified and Blacks were 6 times more likely to be hospitalized than Whites. Notably, Blacks had higher rates of substance use (30% vs. 24%; P < 0.001), opportunistic infections (27% vs. 26%; P < 0.001) and cocaine use (13% vs. 5%; P < 0.001). Conversely, fewer Blacks were co-infected with hepatitis C virus (8% vs. 12%; P < 0.001). Hepatitis B virus was relatively infrequent (3% for both groups). Crude mortality rates were similar for both cohorts (5%); however, a greater proportion of Blacks had a LOS > 10 days (21% vs. 19%; P < 0.001). Black race, in the presence of comorbidities, was correlated with a higher odds of LOS > 10 days (OR, 95% CI = 1.20 [1.10-1.30]), but was not significantly correlated with a higher odds of mortality (OR, 95% CI = 1.07 [0.93-1.25]). CONCLUSION Black race is a predictor of LOS > 10 days, but not mortality, among HIV/AIDS patients admitted to US hospitals. It is possible that racial disparities in hospital outcomes may be closing with time.
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Affiliation(s)
- Christine U Oramasionwu
- College of Pharmacy, The University of Texas, Austin, TX, USA
- Department of Medicine, The University of Texas Health Science Center, San Antonio, TX, USA
| | - Jonathan M Hunter
- Department of Medicine, The University of Texas Health Science Center, San Antonio, TX, USA
| | - Jeff Skinner
- The National Institute of Allergy and Infectious Diseases, The National Institutes of Health, Bethesda, MD, USA
| | - Laurajo Ryan
- College of Pharmacy, The University of Texas, Austin, TX, USA
- Department of Medicine, The University of Texas Health Science Center, San Antonio, TX, USA
| | | | - Carolyn M Brown
- College of Pharmacy, The University of Texas, Austin, TX, USA
| | - Brittany R Makos
- College of Pharmacy, The University of Texas, Austin, TX, USA
- Department of Medicine, The University of Texas Health Science Center, San Antonio, TX, USA
| | - Christopher R Frei
- College of Pharmacy, The University of Texas, Austin, TX, USA
- Department of Medicine, The University of Texas Health Science Center, San Antonio, TX, USA
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Missiha SB, Ostrowski M, Heathcote EJ. Disease progression in chronic hepatitis C: modifiable and nonmodifiable factors. Gastroenterology 2008; 134:1699-714. [PMID: 18471548 DOI: 10.1053/j.gastro.2008.02.069] [Citation(s) in RCA: 159] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2007] [Revised: 02/15/2008] [Accepted: 02/21/2008] [Indexed: 12/13/2022]
Abstract
The hepatic complications of chronic hepatitis C (CHC) usually occur only after progression to cirrhosis has taken place. Progression to cirrhosis, however, is extremely variable and depends on a broad set of host and viral factors that modify the rate at which fibrosis develops in a given individual. Despite their inherent limitations, studies of the natural history of CHC have identified several nonmodifiable factors associated with disease progression. These include age at acquisition of infection, sex, and race. More recent reports suggest important roles for host genetic polymorphisms and viral factors. Of greater immediate relevance to patients and their clinicians are the potentially modifiable factors, which include excessive alcohol consumption; smoking (tobacco and marijuana); insulin resistance; and coinfection with hepatitis B virus, human immunodeficiency virus type 1, or schistosomiasis. Unfortunately, to date, there are no reliable predictive models that can accurately estimate the risk of CHC disease progression.
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Affiliation(s)
- Sharif B Missiha
- Division of Gastroenterology, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Ebinuma H, Nakamoto N, Li Y, Price DA, Gostick E, Levine BL, Tobias J, Kwok WW, Chang KM. Identification and in vitro expansion of functional antigen-specific CD25+ FoxP3+ regulatory T cells in hepatitis C virus infection. J Virol 2008; 82:5043-53. [PMID: 18337568 PMCID: PMC2346728 DOI: 10.1128/jvi.01548-07] [Citation(s) in RCA: 135] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2007] [Accepted: 03/04/2008] [Indexed: 01/14/2023] Open
Abstract
CD4(+)CD25(+) regulatory T cells (CD25(+) Tregs) play a key role in immune regulation. Since hepatitis C virus (HCV) persists with increased circulating CD4(+)CD25(+) T cells and virus-specific effector T-cell dysfunction, we asked if CD4(+)CD25(+) T cells in HCV-infected individuals are similar to natural Tregs in uninfected individuals and if they include HCV-specific Tregs using the specific Treg marker FoxP3 at the single-cell level. We report that HCV-infected patients display increased circulating FoxP3(+) Tregs that are phenotypically and functionally indistinguishable from FoxP3(+) Tregs in uninfected subjects. Furthermore, HCV-specific FoxP3(+) Tregs were detected in HCV-seropositive persons with antigen-specific expansion, major histocompatibility complex class II/peptide tetramer binding affinity, and preferential suppression of HCV-specific CD8 T cells. Transforming growth factor beta contributed to antigen-specific Treg expansion in vitro, suggesting that it may contribute to antigen-specific Treg expansion in vivo. Interestingly, FoxP3 expression was also detected in influenza virus-specific CD4 T cells. In conclusion, functionally active and virus-specific FoxP3(+) Tregs are induced in HCV infection, thus providing targeted immune regulation in vivo. Detection of FoxP3 expression in non-HCV-specific CD4 T cells suggests that immune regulation through antigen-specific Treg induction extends beyond HCV.
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Affiliation(s)
- Hirotoshi Ebinuma
- Philadelphia Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
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Abstract
Hepatitis C virus (HCV) is a highly mutable RNA virus with a high propensity for chronic infection, affecting over 3% of the world's population. Persistent infection is associated with chronic hepatitis that may progress to cirrhosis and hepatocellular carcinoma over many years of infection. While cellular immune response plays a key role in viral infection, HCV persistence is associated with antiviral effector T-cell dysfunction with increased CD4+ CD25+ Tregs and interleukin-10+ Tr1cells, raising the possibility that the balance between antiviral effector and regulatory T-cell subsets contributes to the outcome of HCV infection.
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Affiliation(s)
- Kyong-Mi Chang
- Department of Medicine, University of Pennsylvania & Philadelphia VA Medical Center, Philadelphia, USA
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Smith JO, Sterling RK. Hepatitis C and HIV. Curr Gastroenterol Rep 2007; 9:83-90. [PMID: 17335682 DOI: 10.1007/s11894-008-0025-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
HIV and hepatitis C virus (HCV) are global health concerns, and coinfection with these viruses is common due to shared routes of transmission. Mortality rates from AIDS and HIV-associated opportunistic infections have decreased since the institution of highly active antiretroviral therapy, but the incidence of liver-related mortality in coinfected patients has subsequently risen significantly. This increase in progression of liver disease and its subsequent increased mortality have spurred research into the optimization of evaluation and management of the HIV-HCV coinfected patient.
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Affiliation(s)
- Jenny O Smith
- Section of Hepatology, Virginia Commonwealth University Medical Center, 1200 East Broad Street, Room 1492, Box 908341, Richmond, VA 23298-0341, USA
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