Missed opportunities for hepatocellular carcinoma screening in an HIV/hepatitis C virus-coinfected cohort

Liver-related Events in Human Immunodeficiency Virus-infected Persons With Occult Cirrhosis

BACKGROUND

Human immunodeficiency virus (HIV)-infected patients are at increased risk of liver-related mortality. The effect of occult cirrhosis (OcC), defined as preclinical compensated cirrhosis without any clinical findings, on liver-related events is unknown.

METHODS

HIV-infected patients from 2 Canadian cohorts underwent transient elastography (TE) examination and were classified as (1) OcC (TE ≥13 kPa with no sign of cirrhosis, including absence of thrombocytopenia and signs of advanced liver disease on ultrasound or gastroscopy); (2) overt cirrhosis (OvC) (TE ≥13 kPa with signs of cirrhosis); or (3) noncirrhotic patients (TE <13 kPa). Incidence and risk factors of liver-related events were investigated through Kaplan-Meier and Cox regression analyses, respectively. We estimated monitoring rates according to screening guidelines for hepatocellular carcinoma (HCC) by OcC and OvC status.

RESULTS

A total of 1092 HIV-infected patients (51% coinfected with hepatitis C virus) were included. Prevalence of OcC and OvC at baseline was 2.7% and 10.7%, respectively. During a median follow-up of 1.8 (interquartile range, 1.5-2.8) years, the incidence of liver-related events in noncirrhosis, OcC, and OvC was 3.4 (95% confidence interval [CI], 1.2-7.3), 34.0 (95% CI, 6.0-104.0), and 37.0 (95% CI, 17.0-69.1) per 1000 person-years, respectively. Baseline OcC (adjusted hazard ratio [aHR], 7.1 [95% CI, 1.3-38.0]) and OvC (aHR, 8.5 [95% CI, 2.8-26.0]) were independently associated with liver-related events. Monitoring rates for HCC were lower in patients with OcC (24%) compared to those with OvC (40%).

CONCLUSIONS

HIV-infected patients with OcC have a high incidence of liver-related events. Greater surveillance and earlier recognition with appropriate screening strategies are necessary for improved outcomes.

Treatment of hepatitis C in coinfected patients

HCV and liver disease have emerged as major causes of morbidity and mortality in HIV-positive patients. Treating HCV in patients with HIV has been challenging up until a few years ago due to poorer outcomes with interferon-based therapies in this population. The direct-acting antiviral (DAA) agents offer a new era in the treatment of HCV for all patients regardless of HIV status. This article reviews multiple aspects of the care of the coinfected patient with a focus on the modern DAA agents. HCV clinical treatment trials involving HIV-positive patients and antiretroviral therapy/DAA drug–drug interactions are reviewed in detail.