Hepatitis C and HIV Outlook

posted: 18/11/2009

We can now say that having both hepatitis C and HIV doesn’t make it any more likely people will go on to develop an AIDS illness, but people do have a worsened chance of dying early.

One third higher risk of early death

A massive study of all the studies, a ‘meta-analysis’ of over 100,000 people has produced these findings. Since effective HIV treatment became available in the mid 1990s, co-infected people still have a 35% higher risk of death compared to people with just HIV.

The investigators believe that that “the major contributor to mortality among co-infected subjects during the HAART [highly active antiretroviral therapy] era is likely to be liver disease.”

HIV treatments mean that many people with HIV can look forward to a long and healthy life. However, the outlook for people with both HIV and hepatitis C is significantly shorter than for people who only have HIV.

Indeed, liver-related disease is now an important cause of death in HIV/hepatitis co-infected patients. Although there is a lot of evidence showing that HIV accelerates the course of hepatitis C disease, there is less agreement about the effect of hepatitis C on HIV disease progression.

A team of US investigators therefore conducted a meta-analysis of 37 studies published before April 2008 to see what impact hepatitis C had on HIV disease progression and overall mortality.

Before HIV treatments experience
Ten of the studies were before effective antiretroviral therapy became available. These studies showed that before HIV treatment became available, people with both HIV and hep C were slightly less likely to face worsening HIV than people who only had HIV – not a worsening in HIV health as you might have expected.
This part of the analysis had 4413 people with both hep C and HIV and 10,213 individuals who only had HIV.

After HIV treatments
They then looked at studies after 1996 when modern HIV treatments became available. This part of the analysis had 25,319 people with both hep C and HIV and 61,697 people with only HIV. These showed that people with both hep C and HIV were 35% more likely to die early compared with people who only have HIV.

Older, on treatment, how long with hep C
People with both hep C and HIV who were older, or taking antiretroviral therapy had an especially higher risk of death.

Moreover, the longer someone has both hep C and HIV, then the greater the risk of earlier death.

End outcome
The results from the meta-analysis depend on whether you stop the clock when people get AIDS, or follow people until they die. If you stopped the clock at an AIDS diagnosis, then the results show there is no difference between people who only have HIV and those with hep C as well. But in life, none of us have time machines that can prevent our dying. Therefore we should pay more attention to the 36% higher risk of dying early with hep C.

Seven studies in the meta analysis looked at how hep C and HIV affected disease progression, whether this was defined as either an AIDS diagnosis or death. Co-infected people were 49% more likely to get AIDS or die early than people who only have HIV..

Liver disease likely killer
“The majority contributor to mortality among co-infected subjects during the HAART (highly active antiretroviral therapy) era is likely to be liver disease”, comment the investigators. “The meta-analysis did not demonstrate increased risks of developing AIDS-defining events among co-infected patients”, conclude the investigators.
 

What next?
They recommend that “future studies that attempt to examine mortality among coinfected subjects should attempt to determine the relative contributions of hepatitis C viremia as a surrogate marker for liver disease risk, whether injecting drug use is current…, and whether broader application of hepatitis C treatment positively impacts mortality in co-infected individuals.”

Source

Chen T-Y et al. Meta-analysis: increased mortality associated with hepatitis C in HIV-infected persons is unrelated to HIV disease progression. Clin Infect Dis 49 (10): 1605-1615, 2009.

photo credit and hepatitis c gene quilt panel 

Hope with 3rd Drug to Treat Hepatits C

posted: 10/11/2009

Adding a new hepatitis C protease inhibitor to existing treatments for hepatitis C led to a 'cure' for 80% of people who just have hepatitis C, a new study C has shown.

Trials are now starting on whether adding this extra drug will also work for people who also have HIV. These trials were delayed because of concerns about interactions between this new hepatitis C protease inhibitor, telaprevir, and anti-HIV drugs.

The patients in the study had hepatitis C genotype 1 infection – one of the harder-to-treat strains of hepatitis C.
 

Many people with HIV are also infected with hepatitis C (co-infection), and liver disease caused by hepatitis C is now a significant cause of death for people with the two infections.
 

Treatment for hepatitis C is with both pegylated interferon and ribavirin. Treatment normally lasts for a year, and can cause unpleasant side-effects. The aim is a 'cure'. This type of 'cure' means having an undetectable hepatitis C viral load six months after treatment has been completed.
 

Best hope for hepatitis C treatment with HIV is to start as soon as possible

Patients who start treatment soon after they are infected with hepatitis C have the best chance of this outcome. If you have already had hepatits C for some time, the 'cure' rate with the current two-drug treatment for a year falls to about one third of people living with HIV.
 

But new anti-hepatitis C drugs are in development, such as a protease inhibitor called telaprevir. It’s been investigated in studies where it’s used in combination with existing treatment. The new study has shown that when these three drugs were used, over 80% of patients who were only infected with hepatitis C were cured of their infection.
 

Studies looking at the safety and effectiveness of newer treatments for hepatitis C are only just starting in people with HIV. These studies have been delayed because of concerns about interactions with anti-HIV drugs.
 

More about hepatitis C treatment with HIV

The July edition of HIV Treatment Update included a feature 'Combinations and conundrums: the challenges of hepatitis C treatment'. Download it
You can subscribe to HIV Treatment Update via NAM's online bookshop, or email NAM  or ring 020 7840 0050. Subscriptions are free for people living with HIV in the UK.
 

Source

Read more about hepatitis C treatment with HIV in the Combinations and Conundrums article in HIV Treatment Update July 2009 pages 8-11 
 

Hepatitis C and HIV Guide

posted: 30/04/2009

I-Base has updated its Guide to hepatitis C for people living with HIV.

Here are the contents

• First questions
• HCV transmission: how HCV is caught and passed on
• Natural history of HCV
• Issues affecting specific individuals
• New HCV infection: new HCV infections in HIV-positive gay men
• Long-term coinfection: from blood products or by injection drug use
• Testing and monitoring
• HCV treatment and management of HCV infection
• Side effects and management strategies
• Deciding whether to treat HCV
• Research into new HCV drugs
• Living with co-infection: reducing stress and other lifestyle factors
• Other viral hepatitis infections
• Controversial aspects of HCV
• HIV vs. HCV: similarities and differences
• Glossary
• Further information – web links and resources

You can download the Guide here.

i-Base

picture

HIV+ Gay Men and Hep C International

posted: 09/03/2009

After the shock last year that almost 1 in 5 gay men living with HIV in Amsterdam also has hepatitis C, which is spreading rapidly, several posters at the CROI Conference in Montreal, Canada, examined the rise in sexually transmitted hepatitis C in gay men with HIV.

Each study highlighted different aspects of this new epidemic. Risk behaviour was compared between New York and the UK; in France there is a parallel hepatitis C epidemic of a different genotype; New York investigators documented rapid progression of liver fibrosis in their patients, and also treatment success rates.

British gay men with HIV seem to be taking many more risks than men in New York.

Amsterdam
The Amsterdam study presented at CROI  looked for acute HCV infection. It found 46 gay men with acute HCV infection between 2003 and August 2008 among 1380 gay male HIV-positive patients treated at just one hospital.

It found that although acute cases were not as common as in the earlier Amsterdam study, they were increasing very rapidly. There were two in 2003, one in 2004, nine in 2005, twelve in 2006, six in 2007 and 14 in the first eight months of 2008 (equivalent to a 2008 incidence of 1.5% a year). Fifty-nine per cent of patients, based on previous negative HCV tests, had had HCV infection for less than a year. Three-quarters of patients had genotype 1. None of the patients had classic risk factors such as injecting drug use or medical exposure to infected blood.

France
The French researchers did a national screen for acute hep C infection. They looked through the records of HIV-positive gay men in 115 clinics. They found 94 cases of acute hepatitis C infection.

The men investigated were aged 40 on average and had had HIV for ten years. Twenty two (62.5%) had undetectable HIV viral loads and over half had a CD4 count over 500.

2 out of 3 men had an STI diagnosed at the same time as HCV, and more than half of these were of syphilis. Having another STI was one of the largest risk factors for HCV. Other significant risks included unprotected anal sex and either surgery or endoscopy. Only five patients cited fisting, often suspected of spreading HCV, as a risk factor.

The researchers found that about half the French men with hep C have the relatively uncommon type of hep C - genotype 4d. The virological evidence is of large connected networks of gay men with hepatitis C.

New York

Sexually transmitted hepatitis C among HIV-positive gay men in America has lagged a few years behind the outbreaks in Europe, but has now established itself in New York. Two studies looked at the New York outbreak.

This team, led by Daniel Fierer, has previously documented alarmingly rapid liver fibrosis (scarring) in HIV-positive men who become infected with HCV, and a further study has confirmed this. Among 24 HIV-positive gay men who agreed to a liver biopsy, one had stage 3 fibrosis (one step short of cirrhosis), 18 had stage 2 fibrosis, three had stage 1, and two had none.

The profile of the men was very similar to the French men; they were 40 years old on average and their median CD4 count was 525. Three-quarters were on antiretrovirals of whom 94%, 64% of the total, had an undetectable viral load. The average time since HIV diagnosis was seven years.

Four patients (13%) spontaneously cleared hep C infection. All the others were offered pegylated interferon and ribavirin treatment. Of these 41, half chose to delay or refused treatment. Of the other 21, six are still awaiting treatment; of the 15 treated, eight achieved a sustained viral response, equivalent to a cure. Two failed treatment. The others are still being treated or evaluated.

Twenty-one men were matched with similar HCV-negative men to look at risk factors. The only factors that reached significance were unprotected receptive anal sex, with or without ejaculation, unprotected oral sex with ejaculation, use of sex toys, and ‘sex while high’. Again, fisting was not a significant risk factor but there was an interesting difference between receptive fisting, which was not a risk factor at all, and insertive fisting (the ‘top’), which was of borderline significance (p=0.07).

Hepatitis C and HIV+ gay men in the UK
Another New York study compared the New York and UK outbreaks and looked at differences in the risk behaviours between 21 HCV/HIV-positive gay men (not the same cases as in the first study) and 60 UK cases previously reported by the HIV and Acute HCV Group.

UK gay men living with HIV take many more risks than those in New York.

UK patients were somewhat younger (average 36 versus 40) and had had HIV for less time (3.7 versus eight years), though their CD4 counts were the same, and a higher proportion of UK patients had undetectable HIV viral loads (59% versus 48%).

New York patients were more likely to have ever injected drugs (24% versus 3%), and were more likely to have shared injecting equipment (15% versus 1.7%) or shared crack pipes.

Brits Push the Risk Limits

Apart from those factors, the UK patients had the lion’s share of risky behaviours. Just to take a few:

• 73% of UK patients had been fisting ‘tops’ and 57% ‘bottoms’ compared with 33% and 24% of New York men;
• 67% of UK men had practised fisting in a group compared with 12% of the New Yorkers;
• 94% had had unprotected receptive anal sex in a group situation compared with 77% of the New York men
• UK men had also used far more non-injectable recreational drugs: 80% versus 24% had used ketamine, 77% versus 38% cocaine, and 80% versus 38% had used ecstasy.
• A third had used LSD compared with none of the Americans. The greater use of drugs in the UK was called a “notable finding” by the researchers although, perhaps surprisingly, they did not look at the high levels of methamphetamine use in the USA
• The UK men also had higher rates of STIs, with 85% having had a lifetime history of STIs compared with 38% of the Americans. All these differences were highly statistically significant.

Lastly, another US study found that only a minority of HIV-positive gay men are being screened for viral hepatitis of any kind in US HIV clinics. The study of eight clinics found only 43% of men were tested for hepatitis A, 33% for hepatitis B, and 48% for hepatitis C. Practice varied but was “suboptimal” at all clinics, the researchers comment.

HIV & Hepatitis leaflet from NAM

Hep C information from i_Base

Source and References