Coinfection with hepatitis viruses and outcome of initial antiretroviral regimens in previously naive HIV-infected subjects

Determinants of HIV progression and assessment of the optimal time to initiate highly active antiretroviral therapy: PISCIS Cohort (Spain)

OBJECTIVE

We analyze the factors related to progression to AIDS or death in HIV-infected patients from the Proyecto para la Informatización del Seguimiento Clínico epidemiológico de los pacientes con Infección por VIH/SIDA (PISCIS) Cohort and we assess the optimal time to initiate highly active antiretroviral therapy (HAART) taking lead time into account.

METHODS

We selected naive patients who were AIDS-free and initiated HAART after January 1998. Statistical analyses were performed using Cox proportional hazards models. Lead time was defined as the time it took the deferred group with an early disease stage to reach the later stage. The analysis accounting for lead time was performed using multiple imputation methods based on estimates from the pre-HAART period as described elsewhere.

RESULTS

Multivariate analysis on 2035 patients (median follow-up = 34.3 months) showed significantly higher hazard ratios (HRs) for a CD4 count <200 cells/microL (HR = 3.79, 95% confidence interval [CI]: 2.18 to 6.57), HIV-1 RNA level >100,000 copies/mL (HR = 1.84, 95% CI: 1.26 to 2.69), and hepatitis C virus (HCV) coinfection (HR = 2.40, 95% CI: 1.65 to 3.49), whereas a lower risk was found for those who started HAART between January 2001 and June 2004 (HR = 0.55, 95% CI: 0.30 to 0.90). When lead time and unseen events were included, we found a higher risk of progression to AIDS among patients who deferred treatment when the CD4 count reached <200 cells/microL (HR = 2.97, 95% CI: 1.91 to 4.63) and 200 to 350 cells/microL (HR = 1.85, 95% CI: 1.03 to 3.33) compared with those who started treatment with CD4 counts from 200 to 350 cells/microL and >350 cells/microL, respectively.

CONCLUSIONS

Advanced HIV disease, HCV coinfection, and early HAART period were determinants of AIDS progression or death. Lead-time analysis in asymptomatic HIV-infected patients suggests that the best time to start HAART is before the CD4 count falls to lower than 350 cells/microL.

Highly active antiretroviral therapy in HIV and hepatitis C coinfected individuals: friend or foe?

PURPOSE OF REVIEW

Highly active antiretroviral therapy dramatically reduces HIV-related morbidity and mortality. Liver disease has subsequently emerged as a major cause of death in HIV/hepatitis C virus-coinfected individuals. Whether HIV therapy also has a favourable impact on the course of liver disease needs to be explored and counterbalanced with toxicity issues related to the extended duration of antiretroviral therapy.

RECENT FINDINGS

Recent cohort studies have shown that highly active antiretroviral therapy is associated with a reduced rate of progression of hepatitis C virus liver disease, with some also showing a reduction in liver-related mortality. Increased mortality from liver disease has been linked with the extended duration of antiretroviral therapy. Highly antiretroviral therapy-associated liver steatosis has been described as an emerging cause of liver cirrhosis. New possibly HIV therapy-related adverse events such as hepatoportal sclerosis have been reported.

SUMMARY

Studies evaluating the impact of the early initiation of highly active antiretroviral therapy on liver disease in coinfected patients are urgently needed. The safety profile of currently available antiretroviral agents with regard to liver toxicity needs to be further elucidated in order to be able to recommend earlier HIV treatment in this particular patient population.

The simultaneous presence and expression of human hepatitis C virus (HCV), human herpesvirus-6 (HHV-6), and human immunodeficiency virus-1 (HIV-1) in a single human T-cell

We have developed a system that isolates and replicates HCV in vitro. These isolates are called CIMM-HCV. This system has made it possible to analyze the biology, nature, and extent of HCV variability, among other things. Individuals that are infected with HIV-1 are often also infected with HCV and HHV-6. In addition to HCV, our lab has systems for replicating HIV-1 and HHV-6. We asked whether all these viruses could infect the same cells. We report here the successful infection of a T-cell (CEM) by CIMM-HCV, HHV-6, and HIV-1. PCR analyses demonstrated that the CEM cells were productively infected by HHV-6A. RT-PCR showed that the same cell culture was positive for HCV and HIV-1. Co-infection of a T-cell by all three viruses was confirmed by transmission electron microscopy (TEM). All these viruses are highly cytolytic; therefore, triply-infected cells were short lived. However, HIV-1 and HCV co-infected cells unexpectedly lasted for several weeks. Viral replication was unhindered and the phenomenon of 'dominance' was not observed in our experiments. In addition, CIMM-HCV was present in the perinuclear space, suggesting their possible synthesis in the nucleus. This report is based entirely on viruses produced in vitro in our laboratories. As part of the determinations of host ranges of these viruses, studies were designed to demonstrate the infection of a single cell by these viruses and to study the consequences of this phenomenon. All measurements were made on cultured cells and cell culture supernatants.

Safety and tolerability of sequential pegylated IFN-alpha2a and tenofovir for hepatitis B infection in HIV(+) individuals

Chronic hepatitis B virus infections are a major cause of morbidity and mortality in HIV co-infected patients. The standard of care for treating HCV co-infection has been guided by major clinical trials, but the treatment of HBV co-infection has not been as thoroughly studied and the standard of care remains largely untested. The single pill formulation of tenofovir with emtricitabine has become a standard treatment approach in HBV co-infected patients. WU114 was a phase 1 clinical trial that examined the safety and tolerability of sequential treatment of HBV with pegylated interferon-alpha2a plus delayed-initiation tenofovir in HIV co-infected individuals. We postulated that initial HBV viral load reduction with pegylated interferon prior to initiation of nucleoside/nucleotide therapy would increase seroconversion events and durability of HBV virologic suppression. No severe pegylated IFN-alpha2a drug toxicities were seen in either the monotherapy or delayed tenofovir arms. Sequential pegylated interferon and tenofovir-based therapy was tolerable and should be compared with dual nucleoside/nucleotide suppression to determine relative frequencies of seroconversion and durability of HBV suppression in co-infected patients.

Evolution of hepatitis B serological markers in HIV-infected patients receiving highly active antiretroviral therapy

BACKGROUND

Evolution of serological markers of hepatitis B virus (HBV) carriage or infection has rarely been investigated among human immunodeficiency virus (HIV)-infected patients receiving highly active antiretroviral therapy (HAART).

METHODS

During the period 1997-2002, a total of 633 HIV-infected patients were tested for HBV serological markers at baseline, including hepatitis B surface antigen (HBsAg), antibody to HBsAg (anti-HBs ), antibody to hepatitis B core antigen (anti-HBc), hepatitis C virus (HCV) antibody (anti-HCV) antibody, HCV RNA level, and HBV DNA level, all of which were retested at least 1 year apart. Medical records were reviewed to identify clinical characteristics associated with evolution of these serological markers.

RESULTS

After a median duration of follow-up for 4.96 years, 161 patients (25.4%) had changes in HBV serological markers. Of 119 patients (18.8%) who tested positive for HBsAg at baseline, 6 (5.0%) developed anti-HBs, and 9 (7.6%) developed isolated anti-HBc. Of 270 patients (42.7%) who tested positive for anti-HBs, 18 (6.7%) lost anti-HBs. Of 179 patients (28.3%) in whom isolated anti-HBc had been detected, 73 (40.8%) developed anti-HBs, 18 (10.1%) lost all HBV markers, and 7 (3.9%) developed HBsAg. Of 65 patients (10.2%) who tested negative for all HBV markers, 13 (20%) developed anti-HBs, 13 (20%) developed isolated anti-HBc, and 4 (6.2%) developed HBsAg, indicating a high risk of HBV exposure. Patients in whom anti-HBc was detected at baseline were more likely to have acquired immunodeficiency syndrome (P=.008). Multivariate analysis revealed that an increase in the CD4 cell count after the commencement of HAART was significantly associated with persistence or subsequent development of anti-HBs in patients with anti-HBs or anti-HBc at baseline, respectively.

CONCLUSIONS

Periodic measurements of HBV serological markers in HIV-infected patients are recommended, because new HBV infections and changes of HBV serological markers are not uncommon in patients with improved immunity after commencement of HAART.

Hepatitis B and C virus coinfection in The TREAT Asia HIV Observational Database

BACKGROUND AND AIM

Most studies of hepatitis B virus (HBV) and hepatitis C virus (HCV) coinfection with HIV have been conducted among Western patient populations. This study aims to assess rates of HBV and HCV coinfection, and their impact on response to antiretroviral therapy and mortality, using data from The TREAT Asia HIV Observational Database (TAHOD), a multi-center cohort of patients with HIV in the Asia-Pacific region.

METHODS

Patients who had been tested either HBV surface antigen (HBsAg) or HCV antibody were included. Patients who ever tested positive for HBV or HCV were regarded as coinfected for the duration of the study.

RESULTS

Results of hepatitis tests were available for 55% (HBV) and 49% (HCV) of 2979 TAHOD patients, with prevalence of HBV and HCV coinfection both at approximately 10%. Mean CD4 change at 180 days after antiretroviral treatment initiation was 118.8 cells/muL and patients with either HBV or HCV had a lower but non-significant CD4 increase compared with patients with HIV only. Median time to reach undetectable viral load (<400 copies/mL) was 148 days and was not independently associated with HBV or HCV. In univariate analysis, patients with HCV had increased mortality (unadjusted hazard ratio, HR 2.80, P = 0.007). However, neither HBV (adjusted HR 0.80, 95% confidence interval CI 0.24-2.64, P = 0.710) nor HCV (adjusted HR 1.06, 95% CI 0.40-2.79, P = 0.905) was associated with increased mortality after adjustment for other covariates. Both HBV and HCV remained independently associated with elevated alanine aminotransferase (ALT) in the multivariate model (HBV, adjusted HR 1.94, 95% CI 1.04-3.62, P = 0.037; HCV, adjusted HR 2.74, 95% CI 1.47-5.12, P = 0.002).

CONCLUSION

The impact of hepatitis coinfection on immunological and virological responses to antiretroviral therapy and HIV disease progression among this Asian cohort are similar to that seen in Western countries. The longer-term impact of hepatitis coinfection on both HIV disease and liver disease morbidity and mortality needs to be monitored.

Hepatitis C virus quasispecies in HIV-infected women: role of injecting drug use and highly active antiretroviral therapy (HAART)

Despite the high frequency of HCV and HIV coinfection, little is known about HCV quasispecies in HIV-positive patients. The current analysis included 236 HIV+/anti-HCV+ women enrolled in the Women's Interagency HIV Study (WIHS). Hypervariable region 1 of the second envelope gene was analyzed by single-strand conformation polymorphism (SSCP). The relationship between the HCV quasispecies and clinical and demographic features were analyzed in multivariate models. Age over 40 years and high HCV RNA load were the only factors significantly associated with quasispecies complexity, assessed as the number of SSCP bands. High HIV and HCV plasma loads were associated with quasispecies stability over time, as reflected by stable SSCP band patterns. However, women who were actively injecting drugs were 3 times more likely to experience quasispecies changes than their noninjecting counterparts. No affect on HCV quasispecies dynamics was noted in relation to CD4 count or highly active antiretroviral therapy (HAART).

CONCLUSION

among HIV/HCV coinfected patients, HCV quasispecies complexity and dynamics correlate more closely with HIV and HCV plasma loads than with CD4+ cell counts. Active drug use is associated with quasispecies changes probably due to repeated superinfections with new HCV strains. This needs to be considered when planning treatment and prevention strategies for HCV in coinfected individuals.

The treatment of chronic hepatitis C in HIV-infected patients: a meta-analysis

OBJECTIVE

Hepatitis C virus (HCV) disease progression appears to be accelerated in patients coinfected with HIV. The impact of HCV on coinfected patients is being realized as patients are now living longer. The objective of our study was to further elucidate incremental improvement and safety concerns with combinations of pegylated interferon (peginterferon), interferon and ribavirin based on data obtained from prospective randomized controlled trials.

METHODS

A search of MEDLINE and the Cochrane database for material published between 1966 and 29 August 2005 and a hand search of abstracts from national meetings held between 2001 and August 2005 were performed. Trials comparing the use of peginterferon plus ribavirin vs peginterferon or interferon plus ribavirin were assessed.

RESULTS

In six randomized controlled trials, 1756 patients were randomized. Sustained virological response was greater for patients treated with peginterferon plus ribavirin compared with patients treated with interferon plus ribavirin [odds ratio (OR) 3.00; 95% confidence interval (CI) 2.27-3.96]. This increased sustained virological response with peginterferon and ribavirin was found for patients with HCV genotype 1 or 4 (OR 4.40; 95% CI 2.75-7.03) and genotype 2 or 3 (OR 2.56; 95% CI 1.71-3.85). Sustained virological responses were also higher with peginterferon and ribavirin as compared with peginterferon monotherapy (OR 2.60; 95% CI 1.84-3.67). Severe adverse effects (OR 1.09; 95% CI 0.74-1.4) and withdrawal rates (OR 0.97; 95% CI 0.75-1.25) were similar between patients treated with peginterferon plus ribavirin and patients treated with interferon plus ribavirin.

CONCLUSIONS

Patients with chronic HCV/HIV coinfection have a greater likelihood of achieving a sustained virological response with peginterferon plus ribavirin. The likelihoods of serious adverse effects and study withdrawal were similar.

Clinical implications of HIV and hepatitis B co-infection in Asia and Africa

Hepatitis B virus (HBV) is the leading cause of chronic liver disease and liver-related death worldwide, with the majority of these cases occurring in areas of Africa and Asia where HBV prevalence is high. Many of the countries that are affected by hepatitis B are also affected by a high HIV burden, leading to frequent HIV/HBV co-infection. The consequences of co-infection, including increased liver-related morbidity and mortality, increased hepatitis B viral replication, immune reconstitution to HBV in the setting of antiretroviral therapy, and hepatotoxicity from antiretroviral drugs, are especially important in regions with expanding antiretroviral programmes. Little data, however, are available on HIV/HBV co-infection from regions with high chronic hepatitis B prevalence. This Review discusses the epidemiology, natural history, pathogenesis, and management of HIV/HBV co-infection from these areas. Topics for future research relevant to HIV/HBV co-infection in Africa and Asia are also highlighted.

Early initiation of antiretroviral therapy: the current best way to reduce liver-related deaths in HIV/hepatitis C virus-coinfected patients

Approximately 25% to 35% of HIV-infected persons in developed countries are coinfected with hepatitis C virus (HCV). HCV liver disease is accelerated by HIV coinfection, especially at low CD4 cell counts. Highly active antiretroviral therapy (HAART) dramatically reduces HIV-related mortality, and liver disease has emerged as a major cause of death in HIV/HCV-coinfected persons. Anti-HCV therapy with pegylated interferon plus ribavirin can cure HCV infection in up to 40% of coinfected patients; however, only approximately 10% of coinfected patients are considered candidates. Hence, HCV therapy cures approximately 4% of coinfected patients. Eleven cohort studies have shown that HAART is associated with a reduced rate of progression of HCV liver disease, and 4 of these studies have demonstrated a reduction in liver-related mortality. Although offering HCV therapy to the few eligible HIV/HCV-coinfected patients is important, early initiation of HAART in coinfected patients has a greater public health impact in reducing liver-related mortality than in curing HCV infection in approximately 4% of these patients.

Treatment initiation with zidovudine-containing potent antiretroviral therapy impairs CD4 cell count recovery but not clinical efficacy

OBJECTIVE

Zidovudine-containing antiretroviral therapy has been associated with a lower rise in absolute CD4 cell counts in several randomized trials. We examined the predictive factors for this phenomenon and assessed its impact on clinical progression during treatment in a large patient cohort.

DESIGN

An analysis of data from the Swiss HIV Cohort Study.

METHODS

All 2177 treatment-naive adults who began potent antiretroviral therapy (ART) between September 1995 and September 2004 were included. Exclusion criteria were previous ART and treatment duration of less than 3 months. Follow-up was censored in the case of a treatment switch or stop.

RESULTS

A total of 1312 patients initiated zidovudine-containing ART and 865 started ART without zidovudine. Except for slightly higher absolute CD4 cell counts in the zidovudine group, prognostic characteristics at baseline and viral suppression during treatment did not differ. During an observation time of 2343 and 1486 patient-years, the CD4 cell count increased by a median of 221 versus 286 cells/microl at 2 years and 290 versus 379 cells/microl at 4 years in the zidovudine versus no zidovudine group; however, the rise in the percentage of CD4 cells was similar in both groups. The zidovudine group had a significantly slower rise in total lymphocytes and haemoglobin. In multivariable Cox models, the hazard for new HIV-associated clinical events was not affected by zidovudine-containing ART.

CONCLUSION

Over 4 years, zidovudine led to a smaller increase in absolute, but not percentage, CD4 cell counts. The effect can be explained as a slower rise in total lymphocytes and has no impact on clinical efficacy.

Impact of hepatitis C on HIV progression in adults with alcohol problems

BACKGROUND

Coinfection of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) is a substantial medical and public health concern due to its increasing prevalence and complex patient management. Alcohol use may worsen HCV-related liver disease and interfere with adherence to antiretroviral therapy (ART) and medical care. We therefore studied the association between HCV infection and markers of HIV disease progression in adults with alcohol problems.

METHODS

This is a longitudinal study of 396 HIV-infected persons with alcohol problems, 199 (50%) of whom were coinfected with HCV (positive HCV RNA test). CD4 cell counts and HIV RNA levels were assessed at baseline and then every 6 months for up to 42 months. Hepatitis C virus RNA status was determined at study enrollment. We examined the relationship between HCV infection and laboratory markers of HIV progression (CD4 cell count and log10 HIV RNA) by fitting multivariable longitudinal regression models for each outcome.

RESULTS

Among subjects who were adherent to ART, the presence of HCV infection was associated with a lower CD4 cell count (adjusted mean difference -46.0 cells/microL, p=0.03). There was no association observed between HCV infection and CD4 cell count among those not adherent to ART or those not taking ART. No significant association was observed between HCV infection and HIV RNA regardless of ART status.

CONCLUSIONS

Hepatitis C virus infection has an adverse effect on CD4 cell count in patients with alcohol problems who are adherent to ART. Addressing HCV coinfection among these patients may confer additional immunologic benefit for this patient population.

Altered expression of the tetraspanin CD81 on B and T lymphocytes during HIV-1 infection

CD81 is a member of the tetraspan superfamily and plays a role in immune responses and in hepatitis C virus (HCV) pathogenesis. We analysed CD81 cell surface and mRNA expression in different lymphocytic subpopulations in human immunodeficiency virus (HIV)-1, HCV and dually infected subjects. CD81 cell surface expression was evaluated with fluorescence activated cell sorter (FACS) analysis; mRNA quantification was performed with semiquantitative polymerase chain reaction (PCR). CD81 cell surface expression on CD4(+) T lymphocytes was significantly different by analysis of variance (anova) test (P < 0.001), with reduced expression in HIV-1(+) patients. In B lymphocytes, higher cell surface expression was present in HIV-1, in HCV and in dually infected subjects compared to healthy controls. CD81 expression on B lymphocytes showed a positive correlation with plasma HIV-RNA. CD81 mRNA levels in B lymphocytes were significantly higher in HIV-1(+) patients compared to healthy controls. The potential consequence of the down-regulation of CD81 in CD4(+) cells during HIV-1 infection in conjunction with diverted CD28, CD4 and CD3 expression is the disruption of T cell function. Increased CD81 expression on B lymphocytes might explain the higher prevalence of lymphoproliferative disorders in HIV-1 and HCV infection. Up-regulation of CD81 mRNA on CD4(+) T cells indicates that down-regulation of CD81 occurs at the post-transcriptional/translational level.

Impact of hepatitis D virus infection on the long-term outcomes of patients with hepatitis B virus and HIV coinfection in the era of highly active antiretroviral therapy: a matched cohort study

BACKGROUND

Triple infection with human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis D virus (HDV) is rare. The influence of HDV infection on the responses to highly active antiretroviral therapy and hepatic complications in patients with HBV-HIV coinfection remains uncertain.

METHODS

Twenty-six HDV-infected case patients and 78 HDV-uninfected matched control subjects were identified between 1 January 1995 and 30 June 2003. Clinical and immunologic outcomes were noted, and HBV and HIV loads and genotypic resistance of HBV to lamivudine were determined.

RESULTS

Case patients had a higher rate of injection drug use (7.7% vs. 1.3%; P=.05) and lower serum levels of HBV DNA (median level, 4.04 vs. 5.75 log10 copies/mL; P=.07) than control subjects. During a median observation period of 54.7 months, HDV infection did not have an adverse impact on clinical, virological, or immunologic responses to highly active antiretroviral therapy. However, case patients had higher rates of hepatitis flares (57.7% vs. 23.1%; P=.002), hyperbilirubinemia (34.6% vs. 14.1%; P=.04), liver cirrhosis (26.9% vs. 5.1%; P=.009), hepatic decompensation (23.1% vs. 5.1%; P=.007), and death (adjusted hazard ratio, 5.41; 95% confidence interval, 1.39-23.85; P=.02), although these patients had a lower risk of genotypic resistance to lamivudine (0% vs. 57.1%; P=.003).

CONCLUSIONS

HDV infection did not affect clinical, virological, or immunologic responses to highly active antiretroviral therapy in patients with HBV-HIV coinfection. HDV infection increased risk of hepatitis flares, liver cirrhosis, hepatic decompensation, and death in patients with HBV-HIV coinfection.

The prevalence of HIV, HBV and HCV among Filipino blood donors and overseas work visa applicants

OBJECTIVE

Our aim was to estimate the prevalence of HIV, HBV and HCV among the general population of the Philippines using data sources outside of the limited existing active surveillance network.

METHODS

We analysed aggregate HIV, HBV and HCV test results for hospital-based blood donors (BDs) and overseas Filipino worker candidates (OFWCs) that had been reported from licensed laboratories to the National STD/AIDS Cooperative Central Laboratory in Manila between 2002 and 2004.

FINDINGS

From over 144 000 blood-screening results, the HIV prevalence was 0.006% in BDs and 0.001% in OFWCs; that of HBV was 4.2% in both groups; and that of HCV was 0.3% in BDs and 0.9% in OFWCs. Males were at increased risk of both HBV and HCV; among OFWCs, younger women were at increased risk. Laboratories that tested sequentially but stopped testing after the first positive result were far less likely to detect HCV, indicating that sequential testing protocols may underestimate HCV and HIV prevalence. OFWCs were at low risk of HIV, and the risk of testing positive for these viruses was not increased among OFWCs applying for a repeated work visa, compared with first time-applicants.

CONCLUSION

Based on these data, we conclude that HIV is rare in the Philippines. In contrast with prior reports, we found no evidence that OFWCs constitute a high-risk group for HIV. Further research is needed to understand why younger women are at increased risk of acquiring HBV.

Predictors of antiretroviral treatment failure in an urban HIV clinic

BACKGROUND

Predictors of antiretroviral treatment (ART) failure are not well characterized for heterogeneous clinic populations.

METHODS

A retrospective analysis was conducted of HIV-infected patients followed in an urban HIV clinic with an HIV RNA measurement < or =400 copies/mL on ART between January 1, 2003, and December 31, 2004. The primary endpoint was treatment failure, defined as virologic failure (> or =1 HIV RNA measurement >400 copies/mL), unsanctioned stopping of ART, or loss to follow-up. Prior ART adherence and other baseline patient characteristics, determined at the time of the first suppressed HIV RNA load on or after January 1, 2003, were extracted from the electronic health record (EHR). Predictors of failure were assessed using proportional hazards modeling.

RESULTS

Of 829 patients in the clinic, 614 had at least 1 HIV RNA measurement < or =400 copies/mL during the study period. Of these, 167 (27.2%) experienced treatment failure. Baseline characteristics associated with treatment failure in the multivariate model were: poor adherence (hazard ratio [HR] = 3.44; 95% confidence interval [CI]: 2.34 to 5.05), absolute neutrophil count <1000/mm (HR = 2.90, 95% CI: 1.26 to 6.69), not suppressed on January 1, 2003 (HR = 2.69, 95% CI: 1.78 to 4.07) or <12 months of suppression (HR = 1.64, 95% CI: 1.10 to 2.45), CD4 count <200 cells/mm (HR = 1.90, 95% CI: 1.31 to 2.76), nucleoside-only regimen (HR = 1.75, 95% CI: 1.08 to 2.82), prior virologic failure (HR = 1.70, 95% CI: 1.22 to 2.39) and > or =1 missed visit in the prior year (HR = 1.56, 95% CI: 1.13 to 2.16).

CONCLUSIONS

More than one quarter of patients in a heterogeneous clinic population had treatment failure over a 2-year period. Prior ART adherence and other EHR data readily identify patient characteristics that could trigger specific interventions to improve ART outcomes.

Coinfection with hepatitis C virus increases lymphocyte apoptosis in HIV-infected patients

To test the role of hepatitis C virus (HCV) in CD4 cell depletion in human immunodeficiency virus (HIV)-coinfected patients, T cell apoptosis was measured by annexin V labeling in 31 HIV-infected and 30 HIV-HCV-coinfected patients who were not receiving antiretroviral therapy. Apoptosis in naive CD4(+) T cells and in naive and memory CD8(+) T cells was significantly higher in HIV-HCV-coinfected than in monoinfected patients.

Factors associated with exposure to hepatitis B virus in injection drug users

This study was undertaken to describe factors associated with exposure to the hepatitis B virus (HBV) in treated injection drug users to better aim prevention and care in high risk subgroups. The naturalistic study was conducted in Munich, Germany, and 1,018 patients who ever shared needles admitted for opioid detoxification were included. Sociodemographic, drug and drug treatment related variables and the virological status (HCV, HIV) were included in the bivariate and multiple logistic regression analysis. Sera were tested positive for antibodies against HBc in 40.2%, against HCV in 60.9%, and against HIV in 4.7% of patients. Older age, living without partner, longer duration of IDU, positive drug treatment history, imprisonment, emergency treatment, daily alcohol consumption, type of opioid dependency, and being positive for anti-HCV or anti-HIV were significant individual factors associated with positive anti-HBc-serology. Using multiple logistic regression history of imprisonment and being positive for anti-HCV remained independently associated with positive anti-HBc-serology. HBV-infection in IDUs should alert for simultaneous HCV-infection. Contacts to the criminal justice system are to be used for HBV prevention programs, including vaccination when indicated. Prevention programs should be implemented early in or even before the begin of a drug career.

Thymic volume predicts CD4 T-cell decline in HIV-infected adults under prolonged treatment interruption

OBJECTIVE

To analyze the predictive capacity of thymic volume in CD4 T-cell loss after treatment interruption in HIV-infected patients with high nadir CD4 count.

METHODS

Thirty-nine HIV-infected patients with CD4 counts greater than or equal to 500 cells/microL, nadir CD4 counts greater than or equal to 250 cells/microL, and plasma viral loads less than 50 copies/mL for at least the past 12 months began a treatment interruption program. The event of interest for this study was the decrease of CD4 count below 350 cells/microL. Kaplan-Meier curves were used for all time-to-event analyses, and log-rank tests were used for comparison between groups in the univariate analysis. All variables with statistical association with CD4 T-cell loss were analyzed using multivariate Cox proportional hazards regression models.

RESULTS

Twenty-three percent of the patients had a decrease in CD4 count to less than 350 cells/microL. In the univariate analysis, only thymic volume was statistically significant with this event (P = 0.02). Nadir CD4 count nearly reached statistical significance. However, age, sex, HCV coinfection, CD4 count, T-cell receptor excision circle-bearing cells, and early viral load rebound did not show statistical differences. Thymic volume and CD4 T-cell loss were independently associated using Cox proportional hazards regression model (P = 0.04; relative risk, 0.76; 95% confidence interval, 0.59-0.99).

CONCLUSIONS

In this study, we demonstrate for the first time that thymic volume predicts CD4 T-cell loss in patients with nadir CD4 count greater than or equal to 250 cells/muL under treatment interruption.

Co-infection with HIV and hepatitis C virus in former plasma/blood donors: challenge for patient care in rural China

BACKGROUND

Illegal commercial plasma donation in the late 1980s and early 1990s caused blood-borne infections in China.

OBJECTIVES

To estimate the prevalence of HIV and hepatitis C virus (HCV) infections and to identify associated risk factors in central China with a history of illegal plasma collection activities.

DESIGN AND METHODS

A cross-sectional study was carried out in 2004, in which all adult residents in four villages in rural Shanxi Province were invited for a questionnaire interview and testing of HIV and HCV antibodies.

RESULTS

Of 3062 participating villagers, 29.5% reported a history of selling whole blood or plasma. HIV seropositivity was confirmed in 1.3% of subjects and 12.7% were HCV positive. Their co-infection rates were 1.1% among all study subjects, 85% among HIV-positive subjects, and 8.7% among HCV-positive subjects. Selling plasma [odds ratio (OR), 22.5; 95% confidence interval (CI), 16.1-31.7; P < 0.001] or blood (OR, 3.1; 95% CI, 2.3-4.2; P < 0.001) were independently associated with HIV and/or HCV infections. Although a spouse's history of selling plasma/blood was not associated with either infection, the HIV or HCV seropositivity of a spouse was significantly associated with HIV and/or HCV infections (both OR, 3.2; 95% CI, 2.0-5.2 in men, 2.0-4.9 in women; P < 0.001). For men, residence in the village with a prior illegal plasma collection center (OR, 2.5; 95% CI, 1.7-3.7; P < 0.001) and for women, older age (OR, 3.4; 95% CI, 1.2-14.0; P = 0.04) were associated with HIV and/or HCV infections.

CONCLUSIONS

HIV and HCV infections are now prevalent in these Chinese communities. HIV projects should consider screening and care for HCV co-infection.

HIV-related liver disease: infections versus drugs

HIV-infected individuals have myriad causes of hepatotoxicity that range from mild hepatitis to significant liver failure with its associated morbidity and mortality, especially in the setting of chronic viral hepatitis (HCV and HBV). Immune restoration by HAART therapy can contribute liver-related toxicity in HIV-coinfected patients. Clinicians need to be aware of this problem and individualize management in this challenging clinical scenario. Avoidance of potentially hepatotoxic agents or close monitoring during treatment of HIV may prevent liver failure in patients who have HIV. Furthermore, vaccination against hepatitis A virus and HBV in nonimmune HIV individuals may prevent acquisition of hepatitis A virus and HBV infections in patients who have HIV. Finally, treatment of HIV, and, if appropriate, treatment of those who are coinfected with HCV and HBV with close monitoring, may improve the outcome of patients who have HIV and are at risk fo r significant hepatotoxicity during treatment from immune restoration or hypersensitivity reactions.

Impact of Hepatitis C Virus Coinfection on Response to Highly Active Antiretroviral Therapy and Outcome in HIV-Infected Individuals: A Nationwide Cohort Study

BACKGROUND

Coinfection with hepatitis C virus (HCV) in human immunodeficiency virus (HIV) type 1-infected patients may decrease the effectiveness of highly active antiretroviral therapy. We determined the impact of HCV infection on response to highly active antiretroviral therapy and outcome among Danish patients with HIV-1 infection.

METHODS

This prospective cohort study included all adult Danish HIV-1-infected patients who started highly active antiretroviral therapy from 1 January 1995 to 1 January 2004. Patients were classified as HCV positive (positive HCV serological test and/or HCV PCR results [443 patients [16%]]), HCV negative (consistent negative HCV serological test results [2183 patients [80%]]) and HCV-U (never tested for HCV [108 patients [4%]]). The study end points were viral load, CD4+ cell count, and mortality.

RESULTS

Compared with the HCV-negative group, overall mortality was significantly higher in the HCV-positive group (mortality rate ratio, 2.4; 95% confidence interval [CI], 1.9-3.0), as was liver disease-related mortality (mortality rate ratio, 16; 95% CI, 7.2-33). Furthermore, patients in the HCV-positive group had a higher risk of dying with a prothrombin time <0.3, from acquired immunodeficiency syndrome-related disease, and if they had a history of alcohol abuse. Although we observed no difference in viral load between the HCV-positive and HCV-negative groups, the HCV-positive group had a marginally lower absolute CD4+ cell count.

CONCLUSIONS

HIV-HCV-coinfected patients are compromised in their response to highly active antiretroviral therapy. Overall mortality, as well as mortality from liver-related and acquired immunodeficiency syndrome-related causes, is significantly increased in this patient group.

Effect of hepatitis C infection on progression of HIV disease and early response to initial antiretroviral therapy

OBJECTIVES

To describe the effect of hepatitis C virus (HCV) on the progression of HIV disease and on early changes in the CD4 cell count and HIV viral load after HAART initiation.

DESIGN AND METHODS

Data were from a longitudinal medical records review project conducted in over 100 US medical clinics from 1998 to 2004. We analysed data from HIV-infected patients who received antiretroviral therapy (ART), calculated adjusted hazard ratios describing the hazard of death or progression to an AIDS-defining opportunistic illness (AIDS-OI) associated with prevalent HCV infection, and estimated the change in CD4 cell count and HIV viral load after HAART initiation, stratified by HCV status.

RESULTS

A total of 10 481 HIV-infected individuals were followed for a median of 1.9 years; 19% had HCV. HCV infection was not associated with progression to AIDS-OI or death after controlling for important confounding conditions. Factors significantly confounding the risk of both death and diagnosis of an AIDS-OI were alcoholism, drug-induced hepatitis, and the type of ART prescribed. Acute and chronic hepatitis B infection confounded the risk of AIDS-OI diagnosis. During the 12 months after starting HAART, proportional increases in CD4 cell counts did not differ between HCV-infected and HCV-uninfected individuals. Likewise, the short-term change in viral load did not differ.

CONCLUSION

In our cohort, HCV did not increase the risk of death or AIDS-OI, and did not affect the early immunological or virological response to initial HAART. Clinicians should evaluate patients with HCV for other, manageable problems, including alcoholism and other viral hepatitis.

Multiple viral infections

Individuals at risk of HIV are concomitantly at risk of acquiring parenterally or sexually transmitted viruses. Multiple hepatitis co-infection (HBV+HCV; HBV+HDV; HBV+HDV+HCV) has not been systematically sought after in the large cohorts of HIV-infected patients, but has been reported in 0.4% to more than 50% of patients. HIV-infected patients with multiple hepatitis have a higher rate of liver-related morbidity and mortality than patients with HIV infection alone or with a single hepatitis co-infection. The degree of immunodepression is an important factor in liver disease progression. Since GBV-C virus is transmitted parenterally or by sexual contact, a high prevalence was found in chronic hepatitis C and in HIV-infected patients. Patients with multiple hepatitis have been excluded from randomised therapeutic trials of viral hepatitis in HIV-infected and HIV-negative patients. Thus, the therapeutic approach is based on the results of a small series and empirically oriented toward the prevailing infection. HIV-infected patients should be tested for hepatitis B, C and D systematically and hepatitis B vaccination should be considered for those with HCV co-infection and absence of HBV markers. Studies are needed to assess treatment strategies.

Evaluating the impact of hepatitis C virus (HCV) on highly active antiretroviral therapy-mediated immune responses in HCV/HIV-coinfected women: role of HCV on expression of primed/memory T cells

OBJECTIVE

To evaluate the impact of hepatitis C virus (HCV) on the immune system before receipt of highly active antiretroviral therapy (HAART) and on immune recovery after receipt of HAART among human immunodeficiency virus (HIV)/HCV-coinfected women enrolled in the Women's Interagency HIV Study.

METHODS

The study included 294 HIV-infected women who initiated HAART and attended 2 follow-up visits. The women were grouped on the basis of positive HCV antibody and HCV RNA tests. There were 148 women who were HCV antibody negative, 34 who were HCV antibody positive but RNA negative, and 112 who were HCV antibody and RNA positive. Immune recovery was measured by flow-cytometric assessment for markers of activation and maturation on CD4+ and CD8+ T cells. Data analysis used repeated measures of variance.Results. HIV/HCV coinfection is associated with an increased number of CD4+ and CD8+ primed/memory T cells. HIV/HCV coinfection, however, did not affect any further decreases in CD4+ or CD4+ and CD8+ naive/memory T cell counts or enhanced T cell activation. HIV/HCV coinfection also did not affect HAART responses in the CD4+ and CD8+ T cell compartment.

CONCLUSIONS

HCV does not affect immune responses to HAART in HIV/HCV-coinfected individuals but is associated with an expansion of CD4+ and CD8+ memory T cell subsets. Functional impairment in the CD4+ and CD8+ T cell compartments still needs to be assessed in coinfected patients.

Influence of hepatitis C and hepatitis G virus co-infection on viral and cellular dynamics in patients infected with human immunodeficiency virus following interruption of highly active anti-retroviral therapy

This study describes the influence of hepatitis C virus (HCV) and hepatitis G virus (HGV) co-infection on CD4 cell count decline and plasma human immunodeficiency virus (HIV) viral load in HIV-infected patients during a 1-year period following interruption of highly active anti-retroviral therapy (HAART) guided by CD4 count. CD4 cell count decline and plasma HIV viral load did not differ between HIV mono-infected patients and those patients co-infected with HCV and HGV. HCV genotype 1 had no apparent influence on the cellular and viral dynamics in HIV-infected patients compared with other HCV genotypes, although the unbalanced groups make larger studies desirable.

Effect of hepatitis C coinfection on discontinuation and modification of initial HAART in primary HIV care

OBJECTIVES

To estimate the effect of hepatitis C (HCV) coinfection on time to first occurrence of either discontinuation or modification of initial HAART among previously antiretroviral therapy-naive HIV-infected patients.

METHODS

The analysis included antiretroviral therapy-naive patients who initiated HAART prior to November 2003 and were participating in the University of North Carolina Center for AIDS Research, HIV/AIDS observational clinical cohort. The effect of HCV status on time to first occurrence of either HAART discontinuation or modification was assessed using Kaplan-Meier survival estimates and multivariable proportional hazards regression was used to estimate hazard ratios.

RESULTS

Of 296 patients initiating HAART, 22% were coinfected with HCV. During a median follow-up of 473 days [interquartile range (IQR), 167-940] from HAART initiation, 104 (35%) patients discontinued and 91 (31%) modified their first regimen. Reasons for discontinuation and modification were comparable by HCV serostatus and included treatment failure (12%), toxicity (41%), and barriers to adherence (47%). The median time to first occurrence of either discontinuation or modification among HCV-infected patients was 401 days (IQR, 128-821), and among HCV-uninfected patients was 493 days (IQR, 204-952) (P = 0.22). After adjustment for baseline demographic and clinical characteristics, the hazard ratio contrasting HCV-infected with HCV-uninfected patients was 1.39 (95% confidence interval, 0.95-2.03; P = 0.09).

CONCLUSION

HCV coinfection was only marginally associated with a shorter duration of an initial HAART regimen, suggesting optimization of a first HAART regimen may not appreciably depend on HCV serostatus.

Treatment of hepatitis C in HIV-coinfected patients

OBJECTIVE

To review the current management of hepatitis C virus (HCV) in persons coinfected with HIV.

DATA SOURCES

A MEDLINE search (1966-February 2006) was conducted, using key words such as HIV, human immunodeficiency virus, hepatitis C, interferon, pegylated interferon, and therapy. Article bibliographies and conference abstracts were also reviewed to identify relevant studies.

STUDY SELECTION AND DATA EXTRACTION

Studies that examined HCV treatment in individuals coinfected with HIV and articles that focused on HCV/HIV coinfection were considered for this review.

DATA SYNTHESIS

Coinfection with HIV leads to a more rapid and severe course of HCV-related liver disease. Treatment of HCV with pegylated interferon (PEG-IFN) and ribavirin therapy is relatively well tolerated in individuals coinfected with HIV, with overall sustained virologic response (SVR) rates of 27-40%. High relapse rates and poor response in HCV-genotype 1 contribute to the lower SVR in coinfected individuals compared with HCV monoinfection. Treatment of HCV is more complicated in HIV-infected persons due to increased risk of myelosuppression, drug interactions, hepatotoxicity of antiretroviral therapy, and the relative contraindication to interferon therapy in advanced HIV disease. Current guidelines recommend that all HIV-positive patients with chronic HCV infection be considered as treatment candidates for anti-HCV therapy due to the higher risk of liver disease progression. Further studies are needed, however, to define the appropriate dose and duration of therapy in HCV/HIV-coinfected individuals.

CONCLUSIONS

Response to treatment with PEG-IFN and ribavirin is poorer in patients coinfected with HCV/HIV than in those infected with HCV alone. The benefits of anti-HCV therapy, including viral eradication, need to be weighed against the risks of adverse effects and drug-drug interactions between anti-HCV and antiretroviral medications.

Evolution of HVR-1 Quasispecies after 1-Year Treatment in HIV/HCV-Coinfected Patients According to the Pattern of Response to Highly Active Antiretroviral Therapy

Hepatitis C virus (HCV) variability is mainly attributed to the ability of the virus to respond to host immune pressure, acting as a driving force for the evolution of quasispecies. This study was aimed at studying the changes in HVR-1 heterogeneity and the evolution of HCV quasispecies in HIV/HCV-coinfected patients according to the pattern of response to highly active antiretroviral therapy (HAART).

Sixteen HIV/HCV-coinfected patients harbouring HCV genotype 1 and who had been on HAART for at least 1 year, 8 showing increasing CD4+T-cell counts (immunological responders) and 8 showing a stable or decreasing CD4+ T-cell counts (immunological non-responders), were selected from a prospective cohort study.

After 1 year of HAART, 11 patients showed HIV viral load <2.6 log10 cp/ml (virological responders), and 5 showed HIV viral load above this value (virological non-responders). Plasma samples, collected before starting therapy and after 1 year of HAART, underwent clonal sequence analysis for HVR-1 region of HCV. Non-synonymous/synonymous substitutions ratio (Ka/Ks), aminoacidic complexity (normalized Shannon entropy) and diversity (p-distance), were considered as parameters of quasispecies heterogeneity. After 1 year of HAART, heterogeneity of HVR-1 quasispecies significantly decreased in virological non-responders, whereas the heterogeneity tended to increase in virological responders. The differences in the evolution were less stringent, when considering immunological response. On the other hand, profound qualitative modifications of HVR-1 quasispecies were observed only in patients with both immunological and virological HAART response.

On the whole, these findings suggest that, in patients undergoing HAART, the extent of HCV variability and the evolution of HVR-1 quasispecies is influenced by the pattern of response to antiretroviral therapy.

Risks of Non-Accidental Mortality by Baseline CD4+ T-Cell Strata in Hepatitis-C-Positive and -Negative Individuals Initiating Highly Active Antiretroviral Therapy

Background

Patients coinfected with hepatitis C virus (HCV) and HIV experience higher mortality rates than patients infected with HIV alone. We designed a study to determine whether risks for later mortality are similar for HCV-positive and HCV-negative individuals when subjects are stratified on the basis of baseline CD4+ T-cell counts.

Methods

Antiretroviral-naive individuals, who initiated highly active antiretroviral therapy (HAART) between 1996 and 2002 were included in the study. HCV-positive and HCV-negative individuals were stratified separately by baseline CD4+ T-cell counts of 50 cell/μl increments. Cox-proportional hazards regression was used to model the effect of these strata with other variables on survival.

Results

CD4+ T-cell strata below 200 cells/μl, but not above, imparted an increased relative hazard (RH) of mortality for both HCV-positive and HCV-negative individuals. Among HCV-positive individuals, after adjustment for baseline age, HIV RNA levels, history of injection drug use and adherence to therapy, only CD4+ T-cell strata of <50 cells/μl (RH=4.60; 95% confidence interval [CI] 2.72–7.76) and 50–199 cells/μl (RH=2.49; 95% CI 1.63–3.81) were significantly associated with increased mortality when compared with those initiating therapy at cell counts >500 cells/μl. The same baseline CD4+ T-cell strata were found for HCV-negative individuals.

Conclusion

In a within-groups analysis, the baseline CD4+ T-cell strata that are associated with increased RHs for mortality are the same for HCV-positive and HCV-negative individuals initiating HAART. However, a between-groups analysis reveals a higher absolute mortality risk for HCV-positive individuals.

Influence of viral hepatitis on HIV infection

The natural history of HBV is known to be complicated by HIV-co-infection. In contrast, the effect of HBV on the outcome of patients infected with HIV-1 is controversial. Some cohort studies from the pre-HAART era described a more rapid progression to AIDS in patients carrying antibodies to the core-antigen or having chronic HBV infection, but post-HAART studies did not detect any impact of HBV co-infection on HIV-disease progression. Similarly, studies assessing the impact of HCV on progression of HIV-disease delivered conflicting results. In the Swiss cohort study, the presence of HCV was independently associated with an increased risk of progression to AIDS and death. Subsequent studies, however, did not find any difference in survival. Most interestingly, the EuroSIDA cohort analysis found no difference between HCV-positive and HCV-negative HIV-patients starting HAART in the time needed to decrease viral loads to less than 400 copies as well as in the time needed to increase CD4-counts by 50%. In summary, there are no major differences in HIV-related mortality between hepatitis B or C co-infected individuals and patients infected with HIV alone, particularly if antiretroviral treatment is given. There is, however, an increased risk of liver disease related morbidity and mortality as well as more hepatoxicity under antiretroviral treatment regimens.

Factors associated with sustained virologic suppression in patients receiving antiretroviral therapy in an urban HIV care clinic

Clinical trials commonly measure rates of virologic suppression at a specific time point, whereas sustained virologic suppression is the goal of highly active antiretroviral therapy (HAART). We explored factors associated with sustained virologic suppression in an urban clinic population. The study population was drawn from patients who enrolled in Montefiore Medical Center's Infectious Diseases Clinic from 1999 to 2000. A computerized query of the hospital information system generated a list of potential case patients having every HIV- 1 viral load (VL) less than 50 copies per milliliter throughout 2002 (at least three VL measurements were required), and a list of potential controls who failed to demonstrate sustained virologic suppression during 2002. Demographic and clinical information were collected by chart review, and case and control patient characteristics were compared by both univariate and multivariate analyses. Sixty-four case patients were compared to 64 controls. There were no significant differences in age, gender, ethnicity, type of antiretroviral therapy, or frequency of clinic visits. During the year of the study, cases experienced a significantly greater rise in CD4(+) lymphocyte counts than controls (108 cells per microliter versus 27 cells per microliter). On univariate analysis, factors associated with sustained virologic suppression included risk behavior other than heterosexual contact or injection drug use, being a non-smoker, and hepatitis C seropositivity. On logistic regression analysis, factors independently associated with sustained virologic suppression were risk behavior other than heterosexual contact or injection drug use (IDU), and hepatitis C seropositivity. In this study sample, being a nonsmoker, having a risk behavior for HIV acquisition other than heterosexual contact or IDU, and being seropositive for hepatitis C were associated with sustained virologic suppression. Computerized query of the hospital information system proved to be a powerful tool for the identification of study patients in a real-world clinic environment.

Emerging evidence of hepatitis C virus neuroinvasion

It has been reported that hepatitis C virus (HCV) infection is associated with cognitive dysfunction, fatigue and depression, which do not correlate with the severity of liver disease and cannot be accounted for by hepatic encephalopathy or drug abuse. There is also emerging evidence that HCV infection can have negative neurocognitive effects in HIV-infected cohorts. Magnetic resonance spectroscopy has suggested the likely existence of a biological basis for these effects. HCV replicative forms have recently been detected in autopsy brain tissue and the infected cells have been identified as CD68-positive (macrophages/microglia). These findings raise the possibility that HCV infection of the brain could be directly related to the reported neuropsychological and cognitive changes. HCV is not strictly hepatotropic, as it can also replicate in leukocytes, including monocytes/macrophages. The latter cells could provide access of HCV into the central nervous system ('Trojan horse' mechanism) in a process similar to that postulated for HIV-1. In support of this hypothetical mechanism come reports showing a close relationship between HCV sequences present in the brain and cerebrospinal fluid and sequences found in lymph nodes and peripheral blood mononuclear cells. However, despite some similarities there is a fundamental difference between HIV-1 and HCV infection as the latter does not progress into AIDS-type dementia.

Management and treatment of hepatitis C virus infection in HIV-infected adults: recommendations from the Veterans Affairs Hepatitis C Resource Center Program and National Hepatitis C Program Office

Nearly 40% of human immunodeficiency virus- (HIV-) infected veterans on highly active antiretroviral therapy (HAART) in the United States are coinfected with hepatitis C virus (HCV). With the increased survival due to declining opportunistic infections as a result of HAART, HCV-associated liver disease has become a leading cause of death in HIV-infected individuals. HCV infection has been shown to lead to rapid progression of HCV-related liver disease in HIV infection. Results from recent clinical trials in HIV/HCV-coinfected patients show improved response rates using pegylated formulations of interferon plus ribavirin when compared to standard interferon plus ribavirin. However, the treatment of HCV in HIV/HCV-coinfected patients can be complicated by the hepatotoxic and myelosuppressive effects of HIV therapy and HIV infection itself. Prior to initiating HCV therapy, HIV therapy should be optimized by improving immune suppression and avoiding specific antiretroviral drugs that may cause hepatotoxicity and myelosuppression. In the event of treatment-related neutropenia or anemia during HCV therapy, the use of growth factors should be considered to maximize sustained virologic response to HCV therapy. In HIV/HCV-coinfected patients with end-stage liver disease, liver transplantation is being investigated and shows promise as a potential therapeutic option. With the recent advances in the treatment of HCV in HIV/HCV-coinfected individuals, all HIV/HCV-coinfected patients eligible for HCV treatment should be evaluated for HCV combination therapy with careful consideration of their HIV disease.

Impact of Hepatitis C Virus on Immune Restoration in HIV-Infected Patients Who Start Highly Active Antiretroviral Therapy: A Meta-analysis

BACKGROUND

There are conflicting data in the medical literature regarding the degree of immune restoration (as measured by CD4 cell count) in patients who commence highly active antiretroviral therapy (HAART) when coinfected with human immunodeficiency virus (HIV) and hepatitis C virus (HCV), compared with those with HIV infection alone.

METHODS

We performed a meta-analysis that compared CD4 cell count increases after HAART initiation in HCV-negative and HCV-positive patients who were infected with HIV. Published studies in the English-language medical literature that involved cohorts of HCV-negative and HCV-positive patients who were coinfected with HIV were obtained by searching the Medline, Embase Drugs and Pharmacology, and EBM Review-Cochrane Central Register of Controlled Trials databases. Data were extracted independently from relevant studies by 3 investigators and were used in a fixed-effects meta-analysis to determine the mean difference in the expected CD4 count change in the 2 groups.

RESULTS

Eight trials involving 6216 patients were analyzed. Patients with HIV-HCV coinfection had a mean increase in the CD4 cell count that was 33.4 cells/mm3 (95% CI, 23.5-43.3 cells/mm3) less than that for HIV-infected patients without HCV infection. The results of the meta-analysis were independent of any one study and were not influenced by the year in which HAART was started.

CONCLUSIONS

This meta-analysis shows that patients with HIV-HCV coinfection do, in fact, have less immune reconstitution, as determined by CD4 cell count after 48 weeks of HAART, than do patients with HCV infection alone. Future research should examine whether an impaired immunologic response corresponds with meaningful virologic and clinical outcomes.

HIV and hepatitis C co-infection

HIV/HCV co-infection is emerging as a major cause of morbidity and mortality in the 21st century. This editorial reviews the prevalence of co-infection, the factors involved in acquisition of HCV, and the influence of co-infection on disease progression. We examine the results of the major co-infection trials including APRICOT, ACTG 5071 and RIBAVIC. These trials, in association with emerging evidence for future therapies currently undergoing investigation, have led to increased hope of treatment success in co-infected individuals.

Management of HIV Infection in Persons Co-infected With Hepatitis

Co-infection with hepatitis C virus (HCV) and/or hepatitis B virus (HBV) is becoming a rampant disparity in HIV-infected patients. The advent of antiretroviral therapy has led to agents that are effective for suppression of both HIV and HBV; however, this can not be extrapolated to patients who are coinfected with HCV. Treatment of HCV disease is often strenuous and can lead to untoward adverse effects. Co-infection with HIV often leads to higher rates of cirrhosis and liver failure in patients with HBV or HCV, compromising antiretroviral treatment in this patient population due to the hepatotoxicity of these agents. The purpose of this review is to familiarize health care providers to the management of HIV infection in patients who are also co-infected with HBV or HCV.

Therapeutic Drug Monitoring: Role for a Pharmacist in Multidisciplinary Antiretroviral Management

The current treatment guidelines for HIV pharmacotherapy recommend combinations of antiretrovirals (ARVs) to achieve optimal suppression of HIV replication. However, the initiation and long-term management of ARV therapy in a patient is often complicated by variable medication adherence, complex medication use with multiple drug interactions, the occurrence of drug toxicity, and drug therapy for comorbid conditions that require additional patient education and laboratory monitoring. For these reasons, the inclusion of a well-trained pharmacist in multidisciplinary health system management strategies has been increasing. Furthermore, the use of fixed-dose ARVs is accompanied by considerable interpatient variation in pharmacokinetics yielding a range of drug exposures from any given ARV dose. One approach to overcoming this variable drug exposure is to use plasma concentration monitoring (eg, therapeutic drug monitoring [TDM]) as a clinical tool to adjust doses to achieve targeted concentration ranges, often in conjunction with HIV resistance tests. While data in support of TDM are emerging, the development of programs that include an HIV pharmaceutical care specialist and an adherence program with an integrated clinical pharmacology resource that can provide reliable TDM assays has been reported and provides the rationale for including pharmacists in the implementation of ARV TDM programs.

Effect of IL-2 on hepatitis C virus RNA levels in patients co-infected with human immunodeficiency virus receiving HAART

The effect of interleukin-2 (IL-2) on the plasma levels of hepatitis C RNA (HCV-RNA) has varied in published reports. We measured the impact of IL-2 on plasma HCV RNA levels in 54 human immunodeficiency virus (HIV)/HCV coinfected patients enrolled in a randomized trial of 512 participants designed to compare the virologic and immunologic effects of cycled IL-2 plus antiretroviral therapy (ART) vs ART alone in the treatment of HIV in patients with CD4 cell counts > or =300 cells/mm(3). The mean decreases in average HCV RNA levels (copies/mL, log (10)) were 0.28 log in the IL-2 group (n = 26) and 0.04 log in the ART alone group (n = 28) at 12 months (P = 0.18). The changes in HCV RNA level were not associated with baseline or nadir CD4 cell counts, baseline aspartate aminotransferanse, CD4 cell response to IL-2, or changes in plasma HIV RNA values. Compared with those participants who only had HIV, the HIV/HCV co-infected patients did not have a significantly different CD4 cell response to IL-2 therapy. Intermittent IL-2 therapy does not produce a significant sustained decrease in plasma HCV RNA levels among patients co-infected with HIV/HCV who are on highly active ART.

Role of hepatitis C virus (HCV) viremia and HCV genotype in the immune recovery from highly active antiretroviral therapy in a cohort of antiretroviral-naive HIV-infected individuals

BACKGROUND

The roles of hepatitis C virus (HCV) viremia and HCV genotype in the immune response to highly active antiretroviral therapy (HAART) are poorly understood. Our aim was to assess the CD4+ cell count recovery after HAART in human immunodeficiency virus (HIV)-infected patients with HCV viremia and HIV-infected patients who tested negative for HCV antibody (HCV-Ab). We also aimed to assess whether the response to HAART in these patients varied according to HCV genotype.

METHODS

The analysis focused on 1219 HCV-Ab-negative patients and 284 HCV-viremic patients from a cohort of HIV-infected subjects that includes persons who were antiretroviral naive before initiating HAART after cohort enrollment. HCV RNA load and HCV genotype were determined in plasma specimens obtained and stored during the 6-month period preceding the initiation of HAART.

RESULTS

The chance of achieving a CD4+ cell count increase of > or = 100 cells/microL from the pre-HAART level tended to be poorer in HCV-viremic patients than in patients who tested negative for HCV-Ab (adjusted relative hazard [RH], 0.82; 95% confidence interval [CI], 0.66-1.01; P = .06). In contrast, a comparison of patients who had a HCV RNA load >1 x 10(6) IU/mL with patients who had a HCV RNA load of 5-1 x 10(6) IU/mL revealed no significant association between HCV RNA load and achievement of an increased CD4+ cell count (adjusted RH, 0.97; 95% CI, 0.75-1.27; P = .83). There was no clear association between HCV genotype and the probability of achieving a CD4+ cell count increase.

CONCLUSIONS

An association between the presence of HCV-Ab and immune reconstitution after HAART has been shown elsewhere. Results of our large, prospective study support a direct role of HCV viremia in the CD4+ cell count response to HAART. Moreover, our results underline the fact that, in individuals coinfected with HIV and HCV, the goal of treating HCV infection is to eradicate HCV, to both slow the rate of HCV progression and limit potential interference with the response to HAART.

Management of Hepatitis C in HIV-infected Patients

As the survival of HIV-infected patients has been lengthening over the past 10 years as a consequence of effective antiretroviral therapy, hepatitis C virus (HCV) coinfection has emerged as a major cause of morbidity and mortality in this population. HCV/HIV coinfection is associated with accelerated progression of liver disease, untoward effects on the immunologic and virologic response to antiretroviral medications, and possibly with a more aggressive course of HIV disease. The results of major trials of combination therapy for HCV in coinfected patients have clearly established the combination of pegylated interferon-alpha with ribavirin as the treatment of choice in this population. However, the effectiveness and tolerability of this regimen remains suboptimal, particularly in patients with genotype 1 HCV infection. This paper reviews the impact of HCV coinfection in HIV-infected patients, outlines current concepts on management and antiviral treatment, and discusses some of the newer agents, currently in the therapeutic pipeline, that are directed against novel molecular targets.

Hepatitis B and HIV: prevalence, AIDS progression, response to highly active antiretroviral therapy and increased mortality in the EuroSIDA cohort

BACKGROUND

Whether hepatitis B (HBV) coinfection affects outcome in HIV-1-infected patients remains unclear.

OBJECTIVE

To assess the prevalence of HBV (assessed as HBsAg) coinfection and its possible impact on progression to AIDS, all-cause deaths, liver-related deaths and response to highly active antiretroviral therapy (HAART) in the EuroSIDA cohort.

METHODS

Data on 9802 patients in 72 European HIV centres were analysed. Incidence rates of AIDS, global mortality and liver-related mortality, time to 25% CD4 cell count increase and time to viral load < 400 copies/ml after starting HAART were calculated and compared between HBsAg-positive and HBsAg-negative patients.

RESULTS

HBsAg was found in 498 (8.7%) patients. The incidence of new AIDS diagnosis was similar in HBsAg-positive and HBsAg-negative patients (3.3 and 3.4/100 person-years, respectively) even after adjustment for potential confounders: the incidence rate ratio (IRR) was 0.94 [95% confidence interval (CI), 0.74-1.19; P = 0.61]. The incidences of all-cause and liver-related mortalities were significantly higher in HBsAg-positive subjects (3.7 and 0.7/100 person-years, respectively) compared with HBsAg-negative subjects (2.6 and 0.2/100 person-years, respectively). The adjusted IRR values were 1.53 for global (95% CI, 1.23-1.90; P = 0.0001) and 3.58 for liver-related (95% CI, 2.09-6.16; P < 0.0001) mortality. HBsAg status did not influence viral or immunological responses among the 1679 patients starting HAART.

CONCLUSIONS

The prevalence of HBV coinfection was 9% in the EuroSIDA cohort. Chronic HBV infection significantly increased liver-related mortality in HIV-1-infected patients but did not impact on progression to AIDS or on viral and immunological responses to HAART.