June 19, 2014

Original Research | 18 March 2014

Vincent Lo Re III, MD, MSCE; Michael J. Kallan, MS; Janet P. Tate, ScD; A. Russell Localio, PhD; Joseph K. Lim, MD; Matthew Bidwell Goetz, MD; Marina B. Klein, MD, MS; David Rimland, MD; Maria C. Rodriguez-Barradas, MD; Adeel A. Butt, MD, MS; Cynthia L. Gibert, MD, MS; Sheldon T. Brown, MD; Lesley Park, MPH; Robert Dubrow, MD, PhD; K. Rajender Reddy, MD; Jay R. Kostman, MD; Brian L. Strom, MD, MPH; and Amy C. Justice, MD, PhD

[+-] Article and Author Information

Ann Intern Med. 2014;160(6):369-379. doi:10.7326/M13-1829

Background: The incidence and determinants of hepatic decompensation have been incompletely examined among patients co-infected with HIV and hepatitis C virus (HCV) in the antiretroviral therapy (ART) era, and few studies have compared outcome rates with those of patients with chronic HCV alone.

Objective: To compare the incidence of hepatic decompensation between antiretroviral-treated patients co-infected with HIV and HCV and HCV-monoinfected patients and to evaluate factors associated with decompensation among co-infected patients receiving ART.

Design: Retrospective cohort study.

Setting: Veterans Health Administration.

Patients: 4280 co-infected patients who initiated ART and 6079 HCV-monoinfected patients receiving care between 1997 and 2010. All patients had detectable HCV RNA and were HCV treatment–naive.

Measurements: Incident hepatic decompensation, determined by diagnoses of ascites, spontaneous bacterial peritonitis, or esophageal variceal hemorrhage.

Results: The incidence of hepatic decompensation was greater among co-infected than monoinfected patients (7.4% vs. 4.8% at 10 years; P < 0.001). Compared with HCV-monoinfected patients, co-infected patients had a higher rate of hepatic decompensation (hazard ratio [HR] accounting for competing risks, 1.56 [95% CI, 1.31 to 1.86]). Co-infected patients who maintained HIV RNA levels less than 1000 copies/mL still had higher rates of decompensation than HCV-monoinfected patients (HR, 1.44 [CI, 1.05 to 1.99]). Baseline advanced hepatic fibrosis (FIB-4 score >3.25) (HR, 5.45 [CI, 3.79 to 7.84]), baseline hemoglobin level less than 100 g/L (HR, 2.24 [CI, 1.20 to 4.20]), diabetes mellitus (HR, 1.88 [CI, 1.38 to 2.56]), and nonblack race (HR, 2.12 [CI, 1.65 to 2.72]) were each associated with higher rates of decompensation among co-infected patients.

Limitation: Observational study of predominantly male patients.

Conclusion: Despite receiving ART, patients co-infected with HIV and HCV had higher rates of hepatic decompensation than HCV-monoinfected patients. Rates of decompensation were higher for co-infected patients with advanced liver fibrosis, severe anemia, diabetes, and nonblack race.

Primary Funding Source: National Institutes of Health.

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