Evolution of coinfection with human immunodeficiency virus and hepatitis C virus in patients treated with highly active antiretroviral therapy

Impact of HIV infection in patients infected with chronic HCV (genotypes 1a and 3a): virological and clinical changes

BACKGROUND

Human immunodeficiency virus (HIV)/hepatitis C virus (HCV) coinfection has become a serious public health problem. The influence of HIV/HCV coinfection on plasma HCV RNA loads and clinical criteria which are usually regarded as a predictor of the progress of liver disease have not been reliably evaluated.

OBJECTIVES

This study investigated the impact of HIV infection on HCV RNA load and clinical indexes in Yazd and Tehran.

MATERIALS AND METHODS

HCV/HIV-coinfected patients and HCV-monoinfected controls were examined and compared for plasma HCV RNA and related risk factors such as HCV genotypes, liver enzymes, and transmission routes.

RESULTS

A total of 54 HCV/HIV-coinfected patients and 88 HCV-monoinfected controls were studied. The HCV RNA load mean was significantly higher in HCV/HIV-coinfected patients than in HCV-monoinfected patients (p < 0.001). HCV RNA load mean in patients infected with HCV without anti-HCV therapy was lower than HIV/HCV patients with and without highly active antiretroviral therapy that this difference was significant (p < 0.001). The HCV RNA levels were significantly higher in HIV/HCV genotype 3a coinfected patients than in genotype 3a monoinfected patients (p < 0.001). HIV RNA levels were lower in genotype 1a infected patients than in genotype 3a infected patients, but this difference was not significant statistically. The ALT mean levels were significantly higher in genotype 3a HIV/HCV-coinfected patients than in genotype 3a HCV-monoinfected patients (p < 0.001).

CONCLUSIONS

HIV/HCV coinfection leads to a significant increase in plasma HCV RNA. Further evaluations of the effects of ART and HIV infection on the course of HCV infection and the response to treatment against HCV infection in other and different genotypes are also needed. Moreover, HIV-infected patients should be screened regularly for HCV coinfection, particularly if they are in high-risk groups such as IDUs and recipients of blood transfusions.

Virologic and immunologic aspects of HIV-hepatitis C virus coinfection

HIV/hepatitis C virus (HCV) coinfection is estimated to affect 2 million individuals globally. The acceleration of HCV-associated complications, particularly hepatic fibrosis, because of HIV coinfection has been well established, whereas the impact of HCV on HIV progression remains unclear. In this review, we summarize the current evidence on the impact of coinfection on the transmission and clinical progression of each infection. We focus on the virological and immunological alterations that contribute to HIV and HCV pathogenesis in coinfection and also review the disease-modifying effects of antiretroviral therapy as they pertain to HCV.

HIV antiretroviral medications and hepatotoxicity

PURPOSE OF REVIEW

This review considers the differential diagnosis, pathophysiology and risk of hepatotoxicity of specific antiretroviral medications.

RECENT FINDINGS

Currently prescribed antiretroviral medications are associated with an incidence of grade 3/4 liver enzyme elevation of less than 5%. Clinically apparent hepatotoxicity rates are much lower. The risk of adverse events with combination HIV and hepatitis C virus treatments is low, assuming that several nucleosides including didanosine and stavudine are avoided.

SUMMARY

Irrespective of the HIV antiretroviral regimen prescribed, careful observation of liver function and enzymes is advised, especially in those with comorbid liver disease. The majority of patients do not experience treatment-limiting liver toxicities, achieve virological suppression, and realize immunological restoration.

Plasma Hepatitis C Virus Viral Load Among Hepatitis C Virus Mono-Infected and HCV/HIV Co-Infected Individuals in Yunnan Province,China

BACKGROUND

Hepatitis C virus (HCV)/human immunodeficiency virus (HIV) co-infection has become a serious public health problem especially in high risk groups such as injection drug users in China. However, the impact of HIV infection and antiretroviral therapy (ART) on HCV viral load which is usually regarded as a predictor of liver disease progress had not been well studied in this country.

OBJECTIVES

To explore correlations of HIV co-infection and ART with plasma HCV load among HCV-infected patients in an ethnic minority area in Yunnan Province, China.

PATIENTS AND METHODS

HCV/HIV co-infected patients and HCV mono-infected controls were examined and compared for plasma HCV RNA and related risk factors.

RESULTS

A total of 145 HCV/HIV co-infected patients and 25 HCV mono-infected controls were studied. The majority of the participants were male, belonged to an ethnic minority and were younger than 45 years old. HCV viral suppression rate with undetectable plasma HCV viral load was 28.3% in the HCV/HIV co-infected patients, 36% among HCV mono-infected controls and 29.4% overall. ART-prescribed HCV/HIV co-infected patients had significantly higher HCV viral loads (IQR: (3.80-6.44)*log(10) copies ml-1) than those naïve to ART (IQR: (undetectable-6.41)*log(10) copies ml-1) and HCV mono-infected patients (IQR: (undetectable-5.44)*log(10) copies ml-1). Men, from the Dai minority and those with more than six years education, were also shown to have a higher plasma HCV viral load,according to multiple logistic regression analysis.

CONCLUSIONS

ART potentially increases the plasma HCV viral load among HCV/HIV coinfected patients in an ethnic minority area in China. Future large scale prospective cohort studies are needed to address the controversy associated between HIV co-infection and the natural history of HCV.

Meta-analysis: increased mortality associated with hepatitis C in HIV-infected persons is unrelated to HIV disease progression

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.

Predictors of insulin resistance among Hispanic adults infected with or at risk of infection with the human immunodeficiency virus and hepatitis C virus

Both the human immunodeficiency (HIV) and hepatitis C (HCV) viruses have been associated with insulin resistance (IR). However, our understanding of the prevalence of IR, the underlying mechanisms and predisposing factors is limited, particularly among minority populations. We conducted a study of 333 Hispanic adults including: 76 HIV monoinfected, 62 HCV monoinfected, 97 HIV/HCV co-infected and 98 uninfected controls with a specific focus on HCV infection and liver injury as possible predictors of IR. IR was measured using the Quantitative Insulin Sensitivity Check Index (QUICKI). The majority (55-69%) of participants in all groups had QUICKI values <0.350. Body mass index was associated with IR in all groups. Triglycerides were associated with IR in the uninfected control group only (-1.83, SE = 0.58, P = 0.0022). HCV was associated with IR in participants infected with HIV (-0.012, SE = 0.0046, P = 0.010). Liver injury, as measured by score to assess liver injury (FIB-4) score, was significantly associated with IR independently of HCV infection (-0.0035, SE = 0.0016, P = 0.027). In the HIV/HCV co-infected group, treatment with nucleoside reverse-transcriptase (RT) inhibitors plus non-nucleoside RT inhibitors (-0.021, SE = 0.080, P = 0.048), but not protease inhibitors (-0.000042, SE = 0.0082, P = 0.96) was associated with IR. HCV infection and antiretroviral agents, including nucleoside RT inhibitor plus non-nucleoside RT inhibitor treatment are contributors to IR in HIV infection. Liver injury, as measured by the FIB-4 score, is a predictor of IR independently of HCV infection.

Inflammation and repair in viral hepatitis C

Hepatitis C viral infection (HCV) results in liver damage leading to inflammation and fibrosis of the liver and increasing rates of hepatic decompensation and hepatocellular carcinoma (HCC). However, the host's immune response and viral determinants of liver disease progression are poorly understood. This review will address the determinants of liver injury in chronic HCV infection and the risk factors leading to rapid disease progression. We aim to better understand the factors that distinguish a relatively benign course of HCV from one with progression to cirrhosis. We will accomplish this task by discussion of three topics: (1) the role of cytokines in the adaptive immune response against the HCV infection; (2) the progression of fibrosis; and (3) the risk factors of co-morbidity with alcohol and human immunodeficiency virus (HIV) in HCV-infected individuals. Despite recent improvements in treating HCV infection using pegylated interferon alpha (PEGIFN-alpha) and ribavirin, about half of individuals infected with some genotypes, for example genotypes 1 and 4, will not respond to treatment or cannot be treated because of contraindications. This review will also aim to describe the importance of IFN-alpha-based therapies in HCV infection, ways of monitoring them, and associated complications.

An overview of HIV and chronic viral hepatitis co-infection

Combination antiretroviral therapy often controls HIV disease, may indirectly slow HCV progression, and creates an immune environment which may optimize HCV drug therapy response. Monitoring for antiretroviral-related liver adverse events is vital. However, this complication infrequently causes clinically significant liver toxicity. HCV antiviral therapy should, in most cases, be reserved for those abstaining from alcohol and achieving HIV RNA suppression and immune restoration on combination antiretroviral therapy or for those with nadir CD4 counts above 350 cells/mul. Given the high prevalence of HBV and HCV co-infection, chronic viral hepatitis will influence the health and treatment of HIV-infected individuals for the foreseeable future.

Management and treatment of hepatitis C virus in patients with HIV and hepatitis C virus coinfection: A practical guide for health care professionals

Concomitant HIV and hepatitis C virus (HCV) is a common yet complex coinfection. The present document is a practical guide for treating HCV infection in people coinfected with HIV. Effective antiretroviral therapies have prolonged survival rates for HIV-infected people over the past decade, which have made latent complications of HCV major causes of morbidity and mortality in these patients. Advances in the treatment of HCV (eg, combined pegylated interferon and ribavirin) offer the possibility of eradicating HCV infection in coinfected persons. The treatment of HCV must be considered in all cases. Intensive management of the adverse effects of HCV treatment is one of the factors for the success of these therapies. HCV eradication is predicted to decrease the mortality associated with coinfection and reduce the toxicity of HIV treatment.

Effect of alcohol use and highly active antiretroviral therapy on plasma levels of hepatitis C virus (HCV) in patients coinfected with HIV and HCV

BACKGROUND

The interactions between human immunodeficiency virus (HIV), hepatitis C virus (HCV), alcohol, and antiretroviral therapy are complex.

METHODS

We retrospectively assessed persons coinfected with HIV and HCV who achieved HIV suppression to < 500 copies/mL and continued to take antiretrovirals for > or = 6 months. Frozen plasma specimens were retrieved for quantitation of HCV RNA levels at baseline and 3, 6, and 12 months after beginning antiretroviral treatment.

RESULTS

Median HCV RNA levels increased (0.35 log10 IU/mL) at month 3 (n = 44). HCV RNA levels decreased to below baseline by 12 months in patients consuming < 50 g of alcohol/day, whereas patients consuming > or = 50 g/day had a sustained increase (> 0.6 log10 IU/mL) from baseline (P = .04).

CONCLUSIONS

Because low levels of HCV RNA are predictive of a virological response to therapy for HCV infection, it may be advantageous to first achieve suppression of HIV RNA and then initiate treatment for HCV infection in patients coinfected with HIV and HCV. Excess alcohol consumption with therapy for HIV infection increases HCV RNA levels and may impede the effectiveness of this treatment strategy.

Changes in hepatitis C virus (HCV) viral load and interferon-alpha levels in HIV/HCV-coinfected patients treated with highly active antiretroviral therapy

BACKGROUND

Reports are mixed as to whether highly active antiretroviral therapy (HAART) increases liver transaminase levels or hepatitis C virus (HCV) titers in HIV/HCV-coinfected individuals. It is hypothesized that increases in HCV RNA titers may result from changes in endogenous interferon-alpha (IFN-alpha) production.

METHODS

HIV/HCV-coinfected patients receiving HAART were tested at baseline, 1, 2, 3, 6, and 9 months for liver transaminase levels, HIV and HCV viral loads, and IFN-alpha. Linear regression analysis was used to determine the effect of HAART on liver transaminase levels, HCV viral load, and IFN-alpha.

RESULTS

Initiating HAART did not increase liver transaminase levels in majority of cases. In patients (n = 30) with baseline HIV titer >10,000 copies/mL, HCV titers increased 0.69 log10 and IFN-alpha decreased -0.96 log10 during HAART, in association with a > or =0.5 log10 decrease in HIV titer. As HIV titers reached their nadir approximately 4 months after initiation of HAART, HCV titers remained 0.54 log10 and IFN-alpha -0.71 log10 above and below baseline levels, respectively. HCV titers and IFN-alpha levels did not change from baseline in patients with baseline HIV titer < or =10,000 copies/mL.

CONCLUSIONS

Coinfected patients did not have evidence of hepatoxicity HAART. In patients with baseline HIV titer >10,000 copies/mL, suppression of HIV replication by HAART was associated with an increase in HCV titer and a decrease in endogenous IFN-alpha levels.

The future face of coinfection: prevalence and incidence of HIV and hepatitis C virus coinfection among young injection drug users

The purpose of this study was to determine the prevalence and incidence of HIV and hepatitis C virus (HCV) coinfection among young (aged 29 years or younger) injection drug users (IDUs) and to compare sociodemographic and risk characteristics between (HIV/HCV) coinfected, monoinfected, or HIV- and HCV-negative youth. Data were collected through the Vancouver Injection Drug Users Study (VIDUS). To date, more than 1400 IDUs have been enrolled and followed, of whom 479 were aged 29 years or younger. Semiannually, participants have completed an interviewer-administered questionnaire and have undergone serologic testing for HIV and HCV. Univariate and multivariate logistic regression analyses were undertaken to investigate predictors of baseline coinfection. Cox regression models with time-dependent covariates were used to identify predictors of time to secondary infection seroconversion. A Cochran-Armitage trend test was used to determine risk associations across 3 categories: no infection, monoinfection, and coinfection. Of the 479 young injectors, 78 (16%) were coinfected with HIV and HCV at baseline and a further 45 (15%) with follow-up data became coinfected during the study period. Baseline coinfection was independently associated with being female, being aboriginal, older age, greater number of years injecting, and living in the IDU epicenter. Factors independently associated with time to secondary infection seroconversion were borrowing needles and greater than once-daily cocaine injection, and accessing methadone maintenance therapy in the previous 6 months was protective. There were clear trends across the 3 categories for increasing proportions of female subjects, aboriginal subjects, older age, greater number of years injecting, living in the IDU epicenter, and daily cocaine use. There were a shocking number of youth living with coinfection, particularly female and aboriginal youth. The median number of years injecting for youth seroconverting to a secondary infection was 3 years, suggesting that appropriate public health interventions should be implemented immediately.

Longitudinal analysis of CD8 T-cell responses to HIV and hepatitis C virus in a cohort of co-infected haemophiliacs

OBJECTIVE

To investigate CD8 T-cell responses to HIV and hepatitis C virus (HCV) over time in a group of co-infected children with haemophilia to assess the influence of the virus infections on each other and on clinical outcome.

DESIGN

The HIV and HCV CD8 T-cell response of HLA-A2 co-infected individuals in the cohort were analysed at two time points, looking at the frequency and phenotype of HIV-specific T cells and assessing overall responses to the two viruses.

METHODS

Peripheral blood mononuclear cells (PBMC) from 72 HLA-A2 co-infected individuals were analysed using an HIV HLA-A2 tetramer and by IFN-gamma ELISpot using a panel of HIV and HCV antigens. PBMC from a group of 26 HLA-A2 HIV mono-infected adults were also analysed as a comparison.

RESULTS

We identified two distinct patterns of response: some patients had a limited response to either virus whilst others made responses to a range of HIV epitopes. HCV responses were detected only in those who made multiple responses to HIV epitopes (P<0.0001). HCV infection had an influence on the phenotype of HIV-specific CD8 T cells, with a reduction in relative perforin and CD57 expression. Lack of functional or tetramer-positive HIV-specific T cells was associated with a decline in absolute CD4 T-cell counts between the time points (up to 7 years; P = 0.005).

CONCLUSION

HCV infection has an impact on the phenotype of HIV-specific CD8 T cells. In this well-defined cohort, failure to maintain effective CD8 T-cell responses against HIV may contribute to disease progression.

Impact of highly active antiretroviral therapy on organ-specific manifestations of HIV-1 infection

In the last 10 years, interesting results have been reported concerning the impact of highly active antiretroviral therapy (HAART) on the changing pattern of organ‐specific manifestations of HIV‐1 infection. There has been a clear step‐wise reduction in the incidence of several opportunistic infections (OIs), particularly Pneumocystis carinii pneumonia, whereas a nonsignificant reduction in incidence has been observed for other organ‐specific diseases, including invasive cervical cancer and Hodgkin disease. In addition, several organ‐specific manifestations, including HIV‐associated nephropathy, wasting syndrome and cardiomiopathy, are a direct consequence of damage by HIV‐1, and so HAART may have a therapeutic effect in improving or preventing these manifestations. Finally, the introduction of HAART has seen the emergence of several complications, termed immune reconstitution inflammatory syndrome, which includes OIs such as cytomegalovirus vitritis, Mycobacterium avium complex lymphadenitis, paradoxical responses to treatment for tuberculosis, and exacerbation of cryptococcosis. Because not all HIV‐1 organ‐specific manifestations are decreasing in the HAART era, this review will analyse the influence of HAART on several organ‐specific manifestations, and in particular OIs related to several organs, cerebral disorders and HIV‐1‐related neoplasia.

Therapeutic Interventions for HIV Infection and Chronic Viral Hepatitis

Combination antiretroviral therapy reduces overall and liver-specific morbidity and mortality in coinfection with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) and represents the most beneficial pharmaceutical treatment intervention for most coinfected patients. Antiviral therapy for HCV infection is potentially organ- and life-saving but, in general, should be reserved for patients who achieve suppression of HIV RNA and immune restoration from combination antiretroviral therapy or for patients with nadir CD4+ T lymphocyte levels of >350 cells/microL. Safe and virologically active treatment of coinfection with HIV and hepatitis B virus can be concurrently achieved by the use of combination antiretroviral therapy regimens containing lamivudine and/or tenofovir.

Coinfection with HIV and Hepatitis C Virus in Injection Drug Users and Minority Populations

Coinfection with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) is common. In the United States, it has been estimated that 25% of persons infected with HIV are also infected with HCV. The prevalence of coinfection with HIV and HCV is highest among those infected via percutaneous routes. In fact, in urban areas in the United States, 50%-90% of persons infected with HIV via injection drug use are coinfected with HCV. In addition, limited data from drug treatment centers in these urban areas suggest that the prevalence of coinfection with HIV and HCV may be highest among African Americans and Hispanics. Little information is available with regard to the epidemiology of coinfection with HIV and HCV among injection drug users (IDUs) or minority populations. Likewise, although there is a growing body of data on the potential complexities of treating HCV among IDUs and the poor response to current anti-HCV treatment among African Americans, few data address the therapy of coinfection with HIV and HCV among IDUs and minority populations.

Prevalence of diabetes mellitus and dyslipidemia among antiretroviral naive patients co-infected with hepatitis C virus (HCV) and HIV-1 compared to patients without co-infection

OBJECTIVE

An increased prevalence of type 2 diabetes mellitus (DM) has been associated with HCV in the non-HIV infected populations. To describe a similar association among HIV subjects, and explore the biological mechanisms.

METHODS

In a cross-sectional analysis, we compared the prevalence of DM (using American Diabetes Association criteria) and insulin resistance (HOMA IR) and dyslipidemia among ARV naive patients with HIV and HIV/HCV infected patients enrolled in CPCRA FIRST (058) and the Metabolic Substudy (061).

RESULTS

Among 1389 enrolled in the FIRST study and had HCV serology, the prevalence of diabetes was higher (5.9%) among HCV/HIV as compared to 3.3% among those with HIV alone (p=0.04). Among 417 enrolled in the metabolic substudy, 88 (21%) had HIV/HCV co-infection. As in the main study, the prevalence of DM was higher in HIV/HCV group (9 vs. 3%, p=0.03). The HIV/HCV infected were significantly older (43 vs. 37 years), non-white (83 vs. 70%), with a history of IDU (55 vs. 3%), had higher AST (61 vs. 39 U/l), ALT (55 vs. 43 U/l,) and lower cholesterol levels (3.97 vs. 4.25 mmol/l). By multivariate analysis among subjects <50 years, association between HCV and diabetes remained significant after adjusting for BMI, family history of diabetes (OR=3.7, 95% CI: 1.3-11.1, p=0.02). The insulin resistance (HOMA IR) was not different between the two groups, however, the prevalence of dyslipidemia was lower among HCV co-infected subjects.

CONCLUSIONS

Subjects with HIV/HCV co-infection have a higher prevalence of diabetes and thus may need to be screened for it prior to initiation of anti-retroviral therapy, particularly if it is a PI based regimen.

Therapies for HIV and viral hepatitis coinfection

The natural history of chronic viral hepatitis is altered by HIV coinfection. Liver fibrosis rates and clinical features of liver disease develop more rapidly. Although HIV-hepatitis C virus coinfected subjects may progress more rapidly to AIDS, this is probably explained by comorbid illness, substance abuse and socioeconomic circumstances. Safe and virologically active treatment of HIV-hepatitis B virus coinfection can be concurrently achieved by the use of highly active antiretroviral therapy regimens containing lamivudine and/or tenofovir. In most cases, highly active antiretroviral therapy represents the most beneficial initial pharmaceutical intervention for HIV-hepatitisC virus coinfection. HepatitisC virus antiviral therapy should, in most cases, be reserved for those achieving HIV RNA suppression and immune restoration from highly active antiretroviral therapy or with nadir CD4 T-lymphocytes above 350 cells/microl.

Longitudinal study in HIV/HCV-coinfected HAART-naive patients and role of HCV genotype

To evaluate the impact of highly active antiretroviral therapy (HAART) on the course of hepatitis C (HCV) infection, we studied the biological and virological characteristics of 23 HCV/HIV-coinfected HAART-naive patients. The HCV genotype, HCV and HIV viral loads, serum alanine aminotransferase, CD4+ and CD8+ cell/mm3 were determined at baseline, 1 month, 6 months and 12 months after initiation of HAART. Results were analyzed both in terms of total population and of HCV genotype. The study of the total population suggests that this therapy did not determine a significant alteration of HCV viremia and levels of ALT, while a significant decrease in HIV viremia (-1.7log10 at one year from the start of HAART) and increase in CD4+ counts was observed (P < 0.005). The biological and virological parameters of HCV/HIV coinfection differed according to the HCV genotype. In particular, only genotype 4 showed a significant inverse correlation between HCV and HIV viral loads.

Hepatotoxicity of Antiretrovirals

Hepatotoxicity is a relevant adverse effect derived from the use of antiretrovirals that may increase the morbidity and mortality among treated HIV-infected patients and challenges the treatment of HIV infection. Although several antiretrovirals have been reported to cause fatal acute hepatitis, they most often cause an asymptomatic elevation of transaminase levels. In addition to ruling out a variety of processes not related to the use of antiretrovirals or to the HIV infection, for appropriate management of the complication it is necessary to deduce the possible pathogenic mechanisms of the hepatotoxicity. Among these mechanisms, direct drug toxicity, immune reconstitution in the presence of hepatitis C virus (HCV) and/or hepatitis B virus (HBV) co-infections, hypersensitivity reactions with liver involvement and mitochondrial toxicity play a major role, although several other pathogenic pathways may be involved. Liver toxicity is more frequent among subjects with chronic HCV and/or HCB co-infections and alcohol users. Complex immune changes that alter the response against hepatitis virus antigens might be involved in the elevation of transaminase levels after suppression of the HIV replication by highly active antiretroviral therapy (HAART) in patients co-infected with HCV/HBV. The contribution of each particular drug to the development of hepatotoxicity in a HAART regimen is difficult to determine. The incidence of liver toxicity is not well known for most of the antiretrovirals. Although it is most often mild, fatal cases of acute hepatitis linked to the use of HAART have been reported across all families of antiretrovirals. Acute hepatitis is related to hypersensitivity reactions in the case of non-nucleosides and to mitochondrial toxicity in the case of nucleoside analogues. Alcohol intake and use of other drugs are other co-factors that increase the incidence of transaminase level elevation among HIV-infected patients. The management of liver toxicity is based mainly on its clinical impact, severity and pathogenic mechanism. Although low-grade HAART-related hepatotoxicity most often spontaneously resolves, severe grades may require discontinuation of the antiretrovirals, for example when there is liver decompensation, hypersensitivity reaction or lactic acidosis.

Hepatitis C Virus Coinfection Increases Mortality in HIV-Infected Patients in the Highly Active Antiretroviral Therapy Era: Data from the HIV Atlanta VA Cohort Study

BACKGROUND

We compared survival among patients coinfected with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) with that among patients infected solely with HIV.

METHODS

Descriptive, bivariate, and survival analyses were conducted using data for all HIV-positive patients who were seen during the period of January 1997 through May 2001 in the HIV Atlanta VA Cohort Study (HAVACS) and who had been tested for HCV antibody since 1992 (n=970).

RESULTS

The prevalence of HCV coinfection was 31.6%, and coinfected patients were significantly more likely to be older, black, and injection drug users. In multivariate analysis, the duration of survival from the time of diagnosis of acquired immunodeficiency syndrome (AIDS) was significantly shortened for HIV-HCV-coinfected patients (hazard ratio [HR], 1.84; 95% confidence interval [CI], 1.09-3.10), as was time from HIV diagnosis to death (HR, 2.47; 95% CI, 1.26-4.82). Recovery of CD4+ cell count from the time of initiation of HAART did not differ significantly by coinfection status.

CONCLUSIONS

HCV coinfection is common in this HIV-infected population and negatively affects survival from the time of both HIV and AIDS diagnoses, although this is apparently not associated with a difference in CD4+ cell recovery while receiving HAART. These findings differ from those of a previous study that was conducted in this cohort in the pre-HAART era, which found no association between HIV-HCV coinfection and HIV disease progression.

The management of chronic viral hepatitis: A Canadian consensus conference 2004

Several government and nongovernment organizations held a consensus conference on the management of acute and chronic viral hepatitis to update previous management recommendations. The conference became necessary because of the introduction of new forms of therapy for both hepatitis B and hepatitis C. The conference issued recommendations on the investigation and management of chronic hepatitis B, including the use of lamivudine, adefovir and interferon. The treatment of hepatitis B in several special situations was also discussed. There were also recommendations on the investigation and treatment of chronic hepatitis C and hepatitis C-HIV coinfection. In addition, the document makes some recommendations about the provision of services by provincial governments to facilitate the delivery of care to patients with hepatitis virus infection. The present document is meant to be used by practitioners and other health care providers, including public health staff and others not directly involved in patient care.

Treatment of the hepatitis C virus in patients coinfected with HIV

Hepatitis C virus (HCV) coinfection is common among individuals with HIV, and the progression of liver disease is accelerated in coinfected individuals compared with those with HCV alone. HCV coinfection also can decrease tolerability of highly active antiretroviral therapy. Additionally, the presence of HCV appears to increase morbidity and mortality in these individuals, and as such the management of both HCV and HIV in coinfected individuals requires careful consideration. Although coinfected patients should be considered for HCV therapy, the limited information to date indicates a lower rate of virologic response with current HCV therapies. Moreover, interactions between HCV and HIV antiviral medications may occur and potentially affect treatment efficacy. Thus, the decision to undertake HCV treatment must be individualized.

Longitudinal effect of antiretroviral therapy on markers of hepatic toxicity: impact of hepatitis C coinfection

To characterize longitudinal hepatic toxicity of antiretroviral therapy in HIV-infected women with and without hepatitis C virus (HCV) infection, we measured alanine and aspartate aminotransferase values among women initiating highly active antiretroviral therapy (HAART). For 312 HIV/HCV coinfected women who received HAART for a mean of 1.8 years, the prevalence of elevated aminotransferase levels >3 times and >5 times the upper limit of normal (ULN) was low (<12% and <4%, respectively), and the prevalence of elevated aminotransferase levels declined over time. When we analyzed trends in aminotransferase levels according to type of HAART received among HCV-infected and uninfected women, we found that mean aminotransferase levels declined among 539 women receiving therapy with protease inhibitors (decreases of 5.34%-4.23% of the ULN per year; P values for trend of.007-.06), but mean values among 128 women receiving therapy with nonnucleoside reverse-transcriptase inhibitors remained stable (from decreases of 1.65% to increases of 7.57% of the ULN per year; P values of.19-.71). Our findings lend support to assertions that antiretroviral therapy is safe for women with HCV infection.

[Genetic variability of hepatitis C virus in the health area of Elche (Spain). Correlation between core antigen and viral load]

We investigated the prevalence of the various genotypes of hepatitis C virus (HCV) in 281 patients evaluated between March, 2000 and March, 2002 in the health area of Elche. Of these patients, 55 were coinfected with human immunodeficiency virus (HIV). The genotype was related to viral load and the co-existence of HIV infection. Likewise, the relationship between these parameters and the presence of the HCV core antigen was established. The results indicate that genotype 1b was the most prevalent (38.4%) followed by genotype 3a (23.1%). Patients coinfected with HIV presented fewer infections due to group 1 genotypes (p < 0.05).Patients with HIV presented a greater viral load in all the genotypes, with genotype 3 presenting a high viral load. Detection of the HCV core antigen showed a close correlation with viral load determinations. Although not yet sufficiently assessed, determination of the HCV core antigen constitutes a simple technique that could eventually contribute to improving the management of patients with chronic HCV hepatitis.

Reciprocal influence of HIV and HCV infections in co-infected patients and the involvement of HAART

The reciprocal influence of HIV-HCV co-infection was established prior to the era of highly active retroviral therapy (HAART) and continues to be a topic of debate, including the question of which infection to treat first.

Progression of chronic hepatitis C to liver fibrosis and cirrhosis in patients coinfected with hepatitis C virus and human immunodeficiency virus

To evaluate the factors associated with the evolution of chronic hepatitis C in human immunodeficiency virus (HIV)-infected patients, a cross-sectional analysis of 41 HIV-infected patients with chronic hepatitis C (known as "HIV-HCV [hepatitis C virus]-coinfected patients") and a control group of patients with chronic hepatitis C who did not have HIV infection (known as "non-HIV-infected patients") was performed. The association of histological variables with demographic parameters, HCV load and genotype, HIV load, CD4(+) T cell count, and response to highly active antiretroviral therapy (HAART) was evaluated. HIV-HCV-coinfected patients showed a significantly higher HCV load, more-advanced fibrosis, and a higher liver fibrosis progression rate (FPR) than did non-HIV-infected patients. A high HCV load and a low CD4(+) T cell count were associated with a higher FPR. The immune response induced by HAART did not influence this progression. In conclusion, HIV-HCV-infected patients, mainly such patients with a high HCV load and an immunodepressed state, have a higher FPR. An independent effect of the immune response to HAART was not evident.

Impact of highly active antiretroviral therapy and immunologic status on hepatitis C virus quasispecies diversity in human immunodeficiency virus/hepatitis C virus-coinfected patients

This study analyzes the effect of highly active antiretroviral therapy (HAART), and thus immunologic status, on hepatitis C virus (HCV) load and quasispecies diversity in patients coinfected with the human immunodeficiency virus (HIV) and HCV. Three cohorts of coinfected patients were analyzed retrospectively over a period of 7 to 10 months: group A was antiretroviral drug naïve at baseline and then on HAART for the remainder of the study, group B did not receive antiretroviral therapy at any point, and group C was on HAART for the entire study. HCV quasispecies diversity was analyzed by sequencing hypervariable region 1. In a longitudinal analysis, there was no significant change from baseline in any immunologic, virologic, or quasispecies parameter in any of the three groups. However, in comparison to groups A and B, group C had significantly higher CD4+- and CD8+-cell counts, a trend toward a higher HCV load, and significantly increased number of HCV clones, entropy, genetic distance, and ratio of nonsynonymous substitutions per nonsynonymous site to synonymous substitutions per synonymous site (Ka/Ks). In addition, CD4+-cell count was positively correlated with HCV load, genetic distance, and Ka. Interestingly, patients infected with HCV genotype 2 or 3 had a significantly higher CD4+-cell count, HCV load, genetic distance, and Ka/Ks than those infected with genotype 1. These results suggest that there is no immediate effect of HAART on HCV but that, with prolonged HAART, immune restoration results in an increase in HCV load and quasispecies diversity.

Influence of coinfection with hepatitis C virus on morbidity and mortality due to human immunodeficiency virus infection in the era of highly active antiretroviral therapy

To ascertain the impact of hepatitis C virus (HCV) infection on human immunodeficiency virus (HIV) disease progression and associated death in the era of highly active antiretroviral therapy (HAART), we examined mortality rates, the presence of other diseases, and antiretroviral use in an observational cohort of 823 HIV-infected patients with and without HCV coinfection during the period of January 1996 through June 2001. Analyses were used to compare patient characteristics, comorbid conditions, and survival durations in HIV-infected and HIV-HCV-coinfected patients. HIV-HCV-coinfected persons did not have a statistically greater rate of acquired immunodeficiency syndrome or of renal or cardiovascular disease, but they did have more cases of cirrhosis and transaminase elevations. There were proportionately more deaths in the HIV-HCV-coinfected group. Age, baseline CD4+ cell count, and duration of HAART were significantly associated with survival, but HCV infection was not. HAART use was a strong predictor of increased duration of survival, suggesting that treatment is more important to survival than is HCV coinfection status.

Efecto del tratamiento antirretroviral de gran actividad en la carga viral del virus de la hepatitis C en los primeros tres años de seguimiento

BACKGROUND AND OBJECTIVE

Highly active antiretroviral therapy (HAART) has been considered to be ineffective in controlling hepatitis C viremia in the first year of treatment. The present study evaluates the effect of prolonged HAART upon HCV-VL.

PATIENTS AND METHOD

We selected those cases with positive serology for HCV, never been treated with protease inhibitors (PIs) at baseline, which after the introduction of HAART maintained undetectable HIV viral loads (HIV-VL) uninterruptedly for at least three years. Determinations were made of HCV-VL at baseline and after two and three years of HIV-VL suppression. Spearman coefficient and Friedman test were used.

RESULTS

Of these patients, 21 satisfied the inclusion criteria. HCV-VL remained without significant changes and with relatively stable levels throughout the three-year follow-up period. However, two patients showed HCV-VL negative conversion after two years, that persisted after three years.

CONCLUSIONS

Patients who respond to HAART maintain stable HCV-VL. Some subjects may exhibit HCV RNA clearance in the first two years of treatment, maintaining this situation after three years.

The clinical spectrum of hepatitis C virus in HIV coinfection

The biochemical, virologic, and histologic spectrum of hepatitis C virus (HCV) in 66 consecutive patients with HIV-HCV coinfection and 119 HCV controls was compared: 86% of coinfected patients had CD4 counts >200 cells/mm3, 51% had a normal alanine aminotransferase (ALT) value, the mean HCV RNA titer was 5.7 log IU/mL, 92% of coinfected patients were of genotype 1, and the mean histologic activity index was 6.86 with advanced fibrosis in 32% of patients. The biochemical, virologic, and histologic findings of HCV in coinfected patients were similar to those observed in HCV controls. For both groups of patients, no clinical, biochemical, or virologic factors could reliably identify patients with advanced fibrosis or cirrhosis, underscoring the importance of liver biopsy in the evaluation of these patients. The spectrum of liver disease in coinfection includes a significant proportion of patients with normal ALT values, and excluding these patients from previous studies has led to an overestimation of HCV disease severity.

Review of the effect of highly active antiretroviral therapy on hepatitis C virus (HCV) RNA levels in human immunodeficiency virus and HCV coinfection

The effect of anti-human immunodeficiency virus (HIV) treatment on hepatitis C virus (HCV) RNA levels in HIV-HCV-coinfected persons is uncertain. Although it is commonly believed that, with the initiation of HIV treatment, there may be an initial increase followed by a gradual decrease of HCV RNA levels to lower than those at pretreatment, the published studies evaluating this are of small and heterogeneous populations, are limited in follow-up, and have conflicting results. A prospective clinical trial of sufficient size and duration may help clarify this issue. This may be clinically relevant, because lower HCV RNA levels are a predictive factor for favorable response to HCV antiviral therapy.

Factors related to the chronicity and evolution of hepatitis C infection in patients co-infected by the human immunodeficiency virus

OBJECTIVES

This work analyses the influence of immune status, serum human immunodeficiency virus (HIV) load and hepatitis C virus (HCV) genotypes on the probability of resolution of HCV infection in HIV-co-infected patients, as well as the evolution of HCV viremia after antiretroviral therapy.

PATIENTS AND METHODS

Forty-five patients with anti-HIV and anti-HCV antibodies were classified into two groups as a function of the positivity or persistent negativity of HCV RNA detection (active or recovered HCV infection, respectively). They were treated with highly active antiretroviral therapy (HAART). Serum HCV RNA was quantified by the reverse transcription-polymerase chain reaction. HCV genotypes were detected by line probe assay or by detection of type-specific antibodies.

RESULTS

HCV RNA was detectable in 30 (66.6%) out of 45 HIV-infected patients. CD4+ T-cell counts, HIV viremia, or HCV genotypes were similar in patients with active or recovered HCV infection. Patients with active HCV infection had a non-significant decrease of HCV viremia during a follow-up of 12 months (from 6.15 +/- 6.32 to 5.96 +/- 6.05 log copies/mL). This was not influenced by baseline HCV or HIV viral load, HCV genotype, or CD4+ T-cell count. The non-significant decrease was present in patients with or without an immunological response to HAART.

CONCLUSION

HCV genotypes, immune status, or serum HIV load did not influence the resolution or chronicity of HCV infection in HIV-co-infected individuals. A non-significant decrease of HCV viremia in these patients treated with combinations including antiproteases could be expected.