HCV cure: an appropriate moment to reduce cannabis use in people living with HIV? (ANRS CO13 HEPAVIH data)

BACKGROUND

Thanks to direct-acting antivirals, hepatitis C virus (HCV) infection can be cured, with similar rates in HCV-infected and HIV-HCV co-infected patients. HCV cure is likely to foster behavioral changes in psychoactive substance use, which is highly prevalent in people living with HIV (PLWH). Cannabis is one substance that is very commonly used by PLWH, sometimes for therapeutic purposes. We aimed to identify correlates of cannabis use reduction following HCV cure in HIV-HCV co-infected cannabis users and to characterize persons who reduced their use.

METHODS

We used data collected on HCV-cured cannabis users in a cross-sectional survey nested in the ANRS CO13 HEPAVIH cohort of HIV-HCV co-infected patients, to perform logistic regression, with post-HCV cure cannabis reduction as the outcome, and socio-behavioral characteristics as potential correlates. We also characterized the study sample by comparing post-cure substance use behaviors between those who reduced their cannabis use and those who did not.

RESULTS

Among 140 HIV-infected cannabis users, 50 and 5 had reduced and increased their use, respectively, while 85 had not changed their use since HCV cure. Cannabis use reduction was significantly associated with tobacco use reduction, a decrease in fatigue level, paying more attention to one's dietary habits since HCV cure, and pre-HCV cure alcohol abstinence (p = 0.063 for alcohol use reduction).

CONCLUSIONS

Among PLWH using cannabis, post-HCV cure cannabis reduction was associated with tobacco use reduction, improved well-being, and adoption of healthy behaviors. The management of addictive behaviors should therefore be encouraged during HCV treatment.

Elevated fatty liver index as a risk factor for all-cause mortality in HIV-HCV co-infected patients

Background

Thanks to innovation in treatment, people living with HIV and/or HCV now live longer but are growingly facing non-communicable disease burden. HIV-HCV co-infected patients are at high risk of metabolic complications and liver-related events, which are both associated with hepatic steatosis and its progressive form, non-alcoholic steatohepatitis (NASH), a known risk factor for mortality. The fatty liver index (FLI), a non-invasive steatosis biomarker, has recently drawn attention for its clinical prognostic value, but has never been applied to HIV-HCV co-infected patients. We aimed at testing whether elevated FLI (≥60) was associated with all-cause mortality in co-infected patients.

Methods

Our study is based on data from ANRS CO13 HEPAVIH, a French national prospective cohort of HIV-HCV co-infected patients. Socio-behavioral and clinical data from patients clinically followed-up were used in the analysis. Using a Cox proportional hazards model for mortality from all causes (983 patients; 4,432 visits), we computed hazard ratios associated with risk factors and confounders.

Results

After multiple adjustment, individuals with FLI≥60 had almost double the risk of all-cause mortality (adjusted hazard ratio [95% confidence interval]: 1.91 [1.17-3.12], p = 0.009), independently of HCV cure (0.21 [0.07-0.61], p = 0.004), advanced fibrosis (1.77 [1.00-3.14], p = 0.05), history of hepatocellular carcinoma and/or liver transplantation (7.74 [3.82-15.69], p < 10-3), history of indirect clinical signs of cirrhosis (2.80 [1.22-6.41], p = 0.015), and HIV CDC clinical stage C (2.88 [1.74-4.79], p < 10-3).

Conclusions

An elevated fatty liver index is a risk factor for all-cause mortality in HIV-HCV co-infected patients independently of liver fibrosis and HCV cure. In the present era of nearly 100% HCV cure rates, these findings encourage the more systematic use of non-invasive steatosis biomarkers to help identify co-infected patients with higher mortality risk.

Key messages

A FLI≥60 is strongly associated with mortality in HIV-HCV co-infected patients. FLI could be calculated routinely to identify most at-risk patients.

Untreated alcohol use disorder in people who inject drugs: a major barrier to HCV treatment uptake

Aims

Although people who inject drugs (PWID) are the core at-risk population in the hepatitis C (HCV) epidemic in industrialized countries, few initiate treatment. Alcohol use disorder (AUD), common within this population, has been identified as a barrier to HCV treatment uptake in the general population. We investigated whether the arrival of new and well-tolerated HCV treatments (direct-acting antivirals: DAA) has improved HCV treatment uptake in French PWID compared with former treatments (pegylated interferon-based treatments: Peg-IFN).

Methods

Analyses were based on exhaustive care delivery data collected between 2012 and 2016 (study period) in the French national healthcare reimbursement database. Chronic HCV-infected individuals who received opioid agonist therapy (OAT) at least once during the study period were included. Separate analyses were performed for 2012-2013 (Peg-IFN era, 19,700 patients) and 2014-2016 (DAA era, 22,545 patients). Using discrete-time Cox proportional hazards models, we tested for associations between AUD (i.e. AUD-related long-term illness status, diagnosis coding during hospitalization or AUD pharmacological treatment) and first HCV treatment delivery, after adjusting for gender, age, complementary universal health cover, liver disease severity and type of OAT received.

Results

Incidence rate of HCV treatment uptake per 100 person-years [95% confidence interval] was 6.56 [6.30-6.84] and 5.70 [5.51-5.89], for Peg-IFN-based treatment (2012-2013) and DAA (2014-2016), respectively. After multiple adjustment, people with AUD not receiving related medication had 30% and 14% lower Peg-IFN-based treatment and DAA uptake, respectively, than those without AUD (hazard ratio [95%CI]: 0.70 [0.62-0.80] and 0.86 [0.78-0.94]). No difference was observed between those treated for AUD and those without AUD.

Conclusions

Despite the benefits of DAA, untreated AUD is still a major barrier to HCV treatment access for PWID in France.

Key messages

AUD is still a barrier to HCV treatment for French PWID. DAA availability improved HCV treatment uptake for PWID with AUD.