Hepatic decompensation in antiretroviral-treated patients co-infected with HIV and hepatitis C virus compared with hepatitis C virus-monoinfected patients: a cohort study

Abstract

Background: The incidence and determinants of hepatic decompensation have been incompletely examined among patients co-infected with HIV and hepatitis C virus (HCV) in the antiretroviral therapy (ART) era, and few studies have compared outcome rates with those of patients with chronic HCV alone.

Objective: To compare the incidence of hepatic decompensation between antiretroviral-treated patients co-infected with HIV and HCV and HCV-monoinfected patients and to evaluate factors associated with decompensation among co-infected patients receiving ART.

Design: Retrospective cohort study.

Setting: Veterans Health Administration.

Patients: 4280 co-infected patients who initiated ART and 6079 HCV-monoinfected patients receiving care between 1997 and 2010. All patients had detectable HCV RNA and were HCV treatment-naive.

Measurements: Incident hepatic decompensation, determined by diagnoses of ascites, spontaneous bacterial peritonitis, or esophageal variceal hemorrhage.

Results: The incidence of hepatic decompensation was greater among co-infected than monoinfected patients (7.4% vs. 4.8% at 10 years; P < 0.001). Compared with HCV-monoinfected patients, co-infected patients had a higher rate of hepatic decompensation (hazard ratio [HR] accounting for competing risks, 1.56 [95% CI, 1.31 to 1.86]). Co-infected patients who maintained HIV RNA levels less than 1000 copies/mL still had higher rates of decompensation than HCV-monoinfected patients (HR, 1.44 [CI, 1.05 to 1.99]). Baseline advanced hepatic fibrosis (FIB-4 score >3.25) (HR, 5.45 [CI, 3.79 to 7.84]), baseline hemoglobin level less than 100 g/L (HR, 2.24 [CI, 1.20 to 4.20]), diabetes mellitus (HR, 1.88 [CI, 1.38 to 2.56]), and nonblack race (HR, 2.12 [CI, 1.65 to 2.72]) were each associated with higher rates of decompensation among co-infected patients.

Limitation: Observational study of predominantly male patients.

Conclusion: Despite receiving ART, patients co-infected with HIV and HCV had higher rates of hepatic decompensation than HCV-monoinfected patients. Rates of decompensation were higher for co-infected patients with advanced liver fibrosis, severe anemia, diabetes, and nonblack race.

Primary funding source: National Institutes of Health.

Conflict of interest statement

Potential conflicts of interest: None to report.

Figures

Figure 1

Selection of antiretroviral-treated HIV/hepatitis C virus-coinfected and hepatitis C virus-monoinfected patients for inclusion in the study. * HIV infection determined by International Classification of Diseases, Ninth Revision diagnosis codes.

Figure 1

Selection of antiretroviral-treated HIV/hepatitis C virus-coinfected and hepatitis C virus-monoinfected patients for inclusion in the study. * HIV infection determined by International Classification of Diseases, Ninth Revision diagnosis codes.

Figure 2

Standardized cumulative incidences of hepatic decompensation, based on competing risk regression analyses. Estimates of the cumulative incidence of hepatic decompensation are reported for each group. a. Standardized cumulative incidences of hepatic decompensation between antiretroviral-treated HIV/hepatitis C virus-coinfected (denoted by solid line) and hepatitis C virus-monoinfected patients (denoted by dotted line). b. Standardized cumulative incidences of hepatic decompensation between antiretroviral-treated HIV/hepatitis C virus-coinfected patients with HIV RNA levels ≥1,000 copies/mL on any HIV RNA test result during follow-up (denoted by dashed line), antiretroviral-treated HIV/hepatitis C virus-coinfected patients with HIV RNA <1,000 copies/mL on all HIV RNA test results throughout follow-up (denoted by solid line), and hepatitis C virus-monoinfected patients (denoted by dotted line). c. Standardized cumulative incidences of hepatic decompensation between antiretroviral-treated HIV/hepatitis C virus-coinfected patients with pre-antiretroviral therapy CD4 T lymphocyte counts <200 cells/mm3 (denoted by solid line), antiretroviral-treated HIV/hepatitis C virus-coinfected patients with pre-antiretroviral therapy CD4 T lymphocyte counts ≥200 cells/mm3 (denoted by dashed line), and hepatitis C virus-monoinfected patients (denoted by dotted line). Strata for CD4 cell counts ≥200 cells/mm3 were collapsed into a single plot because these HRs were indistinguishable (see Table 2).

Figure 2

Standardized cumulative incidences of hepatic decompensation, based on competing risk regression analyses. Estimates of the cumulative incidence of hepatic decompensation are reported for each group. a. Standardized cumulative incidences of hepatic decompensation between antiretroviral-treated HIV/hepatitis C virus-coinfected (denoted by solid line) and hepatitis C virus-monoinfected patients (denoted by dotted line). b. Standardized cumulative incidences of hepatic decompensation between antiretroviral-treated HIV/hepatitis C virus-coinfected patients with HIV RNA levels ≥1,000 copies/mL on any HIV RNA test result during follow-up (denoted by dashed line), antiretroviral-treated HIV/hepatitis C virus-coinfected patients with HIV RNA <1,000 copies/mL on all HIV RNA test results throughout follow-up (denoted by solid line), and hepatitis C virus-monoinfected patients (denoted by dotted line). c. Standardized cumulative incidences of hepatic decompensation between antiretroviral-treated HIV/hepatitis C virus-coinfected patients with pre-antiretroviral therapy CD4 T lymphocyte counts <200 cells/mm3 (denoted by solid line), antiretroviral-treated HIV/hepatitis C virus-coinfected patients with pre-antiretroviral therapy CD4 T lymphocyte counts ≥200 cells/mm3 (denoted by dashed line), and hepatitis C virus-monoinfected patients (denoted by dotted line). Strata for CD4 cell counts ≥200 cells/mm3 were collapsed into a single plot because these HRs were indistinguishable (see Table 2).

Figure 2

Standardized cumulative incidences of hepatic decompensation, based on competing risk regression analyses. Estimates of the cumulative incidence of hepatic decompensation are reported for each group. a. Standardized cumulative incidences of hepatic decompensation between antiretroviral-treated HIV/hepatitis C virus-coinfected (denoted by solid line) and hepatitis C virus-monoinfected patients (denoted by dotted line). b. Standardized cumulative incidences of hepatic decompensation between antiretroviral-treated HIV/hepatitis C virus-coinfected patients with HIV RNA levels ≥1,000 copies/mL on any HIV RNA test result during follow-up (denoted by dashed line), antiretroviral-treated HIV/hepatitis C virus-coinfected patients with HIV RNA <1,000 copies/mL on all HIV RNA test results throughout follow-up (denoted by solid line), and hepatitis C virus-monoinfected patients (denoted by dotted line). c. Standardized cumulative incidences of hepatic decompensation between antiretroviral-treated HIV/hepatitis C virus-coinfected patients with pre-antiretroviral therapy CD4 T lymphocyte counts <200 cells/mm3 (denoted by solid line), antiretroviral-treated HIV/hepatitis C virus-coinfected patients with pre-antiretroviral therapy CD4 T lymphocyte counts ≥200 cells/mm3 (denoted by dashed line), and hepatitis C virus-monoinfected patients (denoted by dotted line). Strata for CD4 cell counts ≥200 cells/mm3 were collapsed into a single plot because these HRs were indistinguishable (see Table 2).