Racial Difference in Mortality Among US Veterans with HCV/HIV
Racial Difference in Mortality Among US Veterans with HCV/HIV
Objectives: This study was performed to examine the impact of viral coinfections and race on clinical and virological outcome of hepatitis C virus (HCV) infection.
Methods: Three groups of patients (265 HCV/HIV coinfected, 251 HCV monoinfected, 227 HIV monoinfected) were identified between 2000 and 2002 from the computerized patient record system at the Philadelphia VA Medical Center and analyzed for clinical and virological parameters.
Results: HCV/HIV coinfection was associated with higher frequency of liver function abnormalities (37% vs 21% vs 20%; p < 0.0003) and greater mortality (17% vs 6% vs 9% over 3 yr period, p = 0.0003, p = 0.027) compared to HCV or HIV monoinfection, respectively. However, HCV/HIV coinfection was not associated with worsened HIV-related parameters (CD4 count, HIV titer, and use of antiretroviral therapy) or increased HCV titers compared to HIV or HCV monoinfection in our population, respectively. Interestingly, mortality among HCV/HIV coinfected patients was significantly greater in white than in black patients (31% vs 15%, p = 0.011). This racial disparity in mortality was not apparent in the monoinfected groups and not explained by HBV coinfection or history of alcohol use disorder.
Conclusions: We conclude that HCV/HIV coinfection is associated with worsened liver disease and higher mortality than HCV- or HIV-monoinfection without directly influencing CD4 count and HCV or HIV titers. Furthermore, we demonstrated a racial disparity in survival of HCV/HIV-coinfected patients that needs further investigation.
Hepatitis C virus (HCV) is a highly persistent virus causing chronic necroinflammatory liver disease that can progress to cirrhosis and liver cancer over many years. The natural history and treatment responsiveness of HCV infection is determined by various host, viral, and environmental factors. One relevant factor is coinfection with human immunodeficiency virus (HIV), another highly persistent virus with a similar route of transmission as HCV. Indeed, over a third of HIV-infected patients are coinfected with HCV and HCV coinfection has emerged as a major comorbid factor in HIV-infected patients with their improved survival on highly active antiretroviral therapy. For example, liver fibrosis may be accelerated in HCV-infected patients coinfected with HIV in association with low CD4 count and heavy alcohol use. Furthermore, antiretroviral therapy may be more hepatotoxic in HCV-infected patients due to direct drug toxicity or immune reconstitution. As for the overall survival, there are studies that show a greater progression to AIDS and death with HCV/HIV coinfection as well as those that do not. Similarly, an inverse relationship between CD4 count and HCV RNA was observed in some but not all studies.
In this study, we examined the clinical and virological outcomes of HCV and/or HIV-infected U.S. veterans identified in the Philadelphia Veterans Affairs Medical Center (PVAMC) in 2000-2002, further exploring the contribution of hepatitis B virus (HBV) exposure and race in their outcomes. Our results show that HCV/HIV coinfection is associated with worsened overall morbidity and mortality but without significant changes in antiretroviral therapy, HIV, or HCV viral titers or CD4 counts. This worsened outcome was not due to increased HBV coinfection in HCV/HIV coinfected patients although chronic HBV infection was independently associated with increased mortality. Finally, we identified an unexpected racial difference in mortality with higher mortality in HCV/HIV coinfected white patients compared to black patients.
Abstract and Introduction
Abstract
Objectives: This study was performed to examine the impact of viral coinfections and race on clinical and virological outcome of hepatitis C virus (HCV) infection.
Methods: Three groups of patients (265 HCV/HIV coinfected, 251 HCV monoinfected, 227 HIV monoinfected) were identified between 2000 and 2002 from the computerized patient record system at the Philadelphia VA Medical Center and analyzed for clinical and virological parameters.
Results: HCV/HIV coinfection was associated with higher frequency of liver function abnormalities (37% vs 21% vs 20%; p < 0.0003) and greater mortality (17% vs 6% vs 9% over 3 yr period, p = 0.0003, p = 0.027) compared to HCV or HIV monoinfection, respectively. However, HCV/HIV coinfection was not associated with worsened HIV-related parameters (CD4 count, HIV titer, and use of antiretroviral therapy) or increased HCV titers compared to HIV or HCV monoinfection in our population, respectively. Interestingly, mortality among HCV/HIV coinfected patients was significantly greater in white than in black patients (31% vs 15%, p = 0.011). This racial disparity in mortality was not apparent in the monoinfected groups and not explained by HBV coinfection or history of alcohol use disorder.
Conclusions: We conclude that HCV/HIV coinfection is associated with worsened liver disease and higher mortality than HCV- or HIV-monoinfection without directly influencing CD4 count and HCV or HIV titers. Furthermore, we demonstrated a racial disparity in survival of HCV/HIV-coinfected patients that needs further investigation.
Introduction
Hepatitis C virus (HCV) is a highly persistent virus causing chronic necroinflammatory liver disease that can progress to cirrhosis and liver cancer over many years. The natural history and treatment responsiveness of HCV infection is determined by various host, viral, and environmental factors. One relevant factor is coinfection with human immunodeficiency virus (HIV), another highly persistent virus with a similar route of transmission as HCV. Indeed, over a third of HIV-infected patients are coinfected with HCV and HCV coinfection has emerged as a major comorbid factor in HIV-infected patients with their improved survival on highly active antiretroviral therapy. For example, liver fibrosis may be accelerated in HCV-infected patients coinfected with HIV in association with low CD4 count and heavy alcohol use. Furthermore, antiretroviral therapy may be more hepatotoxic in HCV-infected patients due to direct drug toxicity or immune reconstitution. As for the overall survival, there are studies that show a greater progression to AIDS and death with HCV/HIV coinfection as well as those that do not. Similarly, an inverse relationship between CD4 count and HCV RNA was observed in some but not all studies.
In this study, we examined the clinical and virological outcomes of HCV and/or HIV-infected U.S. veterans identified in the Philadelphia Veterans Affairs Medical Center (PVAMC) in 2000-2002, further exploring the contribution of hepatitis B virus (HBV) exposure and race in their outcomes. Our results show that HCV/HIV coinfection is associated with worsened overall morbidity and mortality but without significant changes in antiretroviral therapy, HIV, or HCV viral titers or CD4 counts. This worsened outcome was not due to increased HBV coinfection in HCV/HIV coinfected patients although chronic HBV infection was independently associated with increased mortality. Finally, we identified an unexpected racial difference in mortality with higher mortality in HCV/HIV coinfected white patients compared to black patients.
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