Rapid Liver Disease Progression

People who are already HIV positive when they become infected with hepatitis C virus (HCV) may experience unusually rapid liver disease progression, according to a poster presented at the American Association for the Study of Liver Diseases (AASLD) annual Liver Meeting, held in Boston October 29-November 2, 2010.

For the past decade, clinicians in the U.K. and Europe, and later the U.S. and Australia, have reported clusters of apparently sexually transmitted acute HCV infection among HIV positive gay and bisexual men. It is known that people with HIV/HCV coinfection tend to experience more rapid liver disease progression than those with hepatitis C alone, especially if they have a low CD4 cell count; however, a subset of coinfected individuals may experience very aggressive liver disease.

Daniel Fierer and colleagues from Mt. Sinai Medical Center in New York City presented follow-up findings on four members of a small cohort of HIV positive men with acute HCV infection and advanced liver disease, first described at the 2007 CROI.

Initially diagnosed during the acute stage of HCV infection (identified due to elevated liver enzyme levels), these four HIV positive men, all with HCV genotype 1a, went on to develop chronic infection. One patient received pegylated interferon plus ribavirin but experienced treatment failure, another could not tolerate therapy, and two refused treatment. The men's ages ranged from 39 to 54 years, and their CD4 counts were highly variable, at 53, 200, 381, and 442 cells/mm³.

Even though they had very early hepatitis C, three of the men already had advanced (stage F3) fibrosis on their first liver biopsy and progressed to liver cirrhosis (stage F4) by the second biopsy; the fourth man had stage F2 fibrosis on the first biopsy and did not receive a second test. The men did not show evidence of tissue damage suggesting liver toxicity due to antiretroviral drugs.

All four men progressed to decompensated cirrhosis (liver failure) within 14 to 78 months after initial liver enzyme elevation -- a process that typically takes many years or even decades in HIV negative hepatitis C patients. Of note, two did so despite relatively high CD4 cell counts. At the time of the report, one man had received a liver transplant, another was still alive after six years but had persistent cirrhosis symptoms, and two had died of liver failure.

These cases indicate that "early onset fibrosis after HCV infection of HIV-infected men is not benign, does not spontaneously resolve, and can quickly progress to cirrhosis, liver failure, and death," the researchers concluded. "It is therefore essential to identify, treat, and cure all HIV-infected men with new HCV infection to prevent these dire outcomes."

Liz Highleyman (liz@black-rose.com) is a freelance medical writer based in San Francisco.