October 1, 2014
Only 1 in 10 veterans diagnosed with HCV or HCV and HIV in the Washington, DC Veterans Administration (VA) Medical Center got treated for HCV in a 2008-2013 analysis.1
The HCV/HIV group had significantly worse fibrosis by FIB-4 score than the HCV-only group, but otherwise the groups did not differ much in HCV progression markers, liver cancer, or mortality.
More than 225,000 veterans in the national VA system have HCV infection, according to researchers who conducted this study. They noted that about 40% of HIV-positive people in the Veterans Aging Cohort Study have HCV infection. In some populations, HIV coinfection raises the risk of progression to cirrhosis and death in people with HCV,2-5 and coinfected people get HCV therapy less often than people infected only with HCV. Because research comparing HCV-monoinfected people and HCV/HIV-coinfected people remains scant, the VA team conducted this comparison.
The analysis included 4327 veterans infected only with HCV and 402 coinfected with HCV/HIV. Age averaged 59 in the HCV group and 56 in the HCV/HIV group, and more than 96% in both groups were men. A lower proportion of HCV-only vets was black (71% versus 81%) and a higher proportion white (14% versus 8%). Proportions in the HCV group and the HCV/HIV group who were underweight were 4% and 7%, normal weight 32% and 42%, overweight 36% and 35%, and obese 28.5% and 16%.
Among veterans with HCV/HIV, median CD4 count stood at 472 (interquartile range [IQR] 295 to 667), and 69% had an undetectable viral load.
Alcoholic liver disease was significantly more frequent in the HCV-only group than in coinfected veterans (4.6% versus 1.5%, p=0.0019), as was diabetes (31% versus 25.4%, p=0.0202). But compared with HCV-only veterans, coinfected veterans had a higher frequency of any renal disease (13.3% versus 17.2%, p=0.0335) and end-stage renal disease (5.4% versus 8.2%, p=0.0312).
A significantly higher proportion of coinfected veterans had a FIB-4 above 3.25 (31% versus 26%, p<0.0061). But the groups did not differ in proportions with an APRI above 1.5 (18% and 16%) or in median FIB-4 (2.39 and 2.06) or median APRI (0.6 and 0.52).
Among veterans genotyped, more than 90% in both groups had HCV genotype 1. Among genotyped people, only 272 HCV-only veterans (10%) and 22 HCV/HIV-infected veterans (8%) had received treatment for HCV infection, a nonsignificant difference. Only 10% in each group attained HCV suppression. Proportions of participants with a diagnosis of hepatocellular cancer (4% with HCV, 3% with HCV/HIV) and proportions who died of any cause (14% and 15%) did not differ significantly between groups.
The VA team noted that their findings of similar HCV progression indicators in HCV-monoinfected and HCV/HIV-coinfected veterans are at odds with previous studies showing worse HCV infection in coinfected people.2-5 This difference, they surmised, could reflect better HIV control in the VA population. Because all US military personnel get tested for HIV regularly, their infection is typically diagnosed earlier than in the general population, and they all have ready access to free treatment.
Low HCV treatment rates in this cohort, the researchers stressed, "should be improved given the availability of more effective and less toxic direct-acting agents."
The low take-up of HCV treatment in this cohort with medical coverage indicates the low acceptability of combinations that are based on pegylated-interferon plus ribavirin.
An affordable price for direct acting antivirals, including sofosbuvir, could cure most of these people within months.
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