HCV Increases Mortality of People with HIV Despite Antiretroviral Treatment

Alexander Breskin, PhD

Hepatitis C virus (HCV) increases mortality of persons with HIV despite antiretroviral treatment but is associated with less harm when treated with direct-acting antivirals (DAAs), according to a 10-year follow-up study.

Although an estimated 25% of persons living with HIV (PLwH) are co-infected with hepatitis C, the effect of HCV on the mortality of PLwH has been unclear, according to Alexander Breskin, PhD, Department of Epidemiology, University of North Carolina at Chapel Hill, and colleagues.

"Without estimates of the long-term impacts of HCV co-infections and DAA treatments on mortality, it is difficult for clinicians and policy-makers to properly prioritize HCV care among PLwH," Breskin and colleagues wrote.

To ascertain what mortality risk treated versus untreated HCV poses to people with HIV receiving antiretroviral treatment, the investigators analyzed data for over 3,000 individuals from the Women's Interagency HIV Study and the Multicenter AIDS Cohort Study who had started antiretroviral treatment for HIV without acquired immunodeficiency syndrome (AIDS). They compared 10-year all-cause mortality between those with and without HCV co-infection, and between co-infected persons who did or did not receive DAA treatment for their hepatitis C.

The investigators determined that hepatitis C co-infection increased risk for all-cause mortality in PLwH receiving antiretroviral treatment by 4.3% (95% CI, .4-8.9%) with risk ratio (RR) of 1.4 (95% CI of 1.0-1.9%). This risk difference, the investigators explained, indicates that if 23 PLwH had HCV when initiating antiretroviral treatment, there would be 1 additional death over 10 years compared with PLwH without HCV.

In the PLwH with co-infection who received DAA treatment for their hepatitis C, that risk was reduced to -3.8% (95% CI of -9.2-.9%), corresponding to an RR of .8. The investigators speculate that the persistence of harm from hepatitis C co-infection, albeit reduced with DAA treatment, reflects that liver fibrosis does not immediately resolve after sustained viral response (SVR) is achieved.

They note that their estimated effect of treating hepatitis C co-infection with HIV is smaller than previous estimates when hepatitis C was treated with pegylated interferon (PEG-IFN), when hazard ratios comparing those achieving SVR on PEG-IFN with those not treated ranged from .12 to .22.

"Those who were successfully treated with a PEG-IFN-plus ribavirin regimen were able to tolerate the (more toxic) drugs and complete the course of therapy, and thus likely differed from those for whom treatment was unsuccessful on important, unmeasured factors related to treatment adherence and success," Breskin and colleagues suggest.

Although the estimated beneficial effect of DAA treatment in the current study was also smaller than the harmful effect of hepatitis C, the investigators emphasize that DAA treatment is clearly indicated for hepatitis C co-infection in people with HIV.

"Our results suggest that successful interventions to prevent and treat HCV will reduce mortality among people with HIV," Breskin told MD Magazine®.

"These findings reinforce the need for HIV care providers to address hepatitis C co-infection among their patients. They especially highlight the need for policy-makers to expand access to these (DAA) new drugs," he said.

The study, The Effects of Hepatitis C Infection and Treatment on All-cause Mortality Among People Living with Human Immunodeficiency Virus , was published in October in Clinical Infectious Diseases.