Elsevier

Journal of Hepatology

Volume 42, Issue 6, June 2005, Pages 799-805
Journal of Hepatology

Liver disease as a major cause of death among HIV infected patients: role of hepatitis C and B viruses and alcohol

https://doi.org/10.1016/j.jhep.2005.01.022Get rights and content

Background/Aims

We analyzed the characteristics of HIV infected patients who died from liver disease, focusing on hepatitis virus co-infection.

Methods

One-hundred and eighty-five French hospital departments involved in HIV/AIDS management prospectively notified all deaths occurring in 2000. Patients whose hepatitis C (HCV) and hepatitis B (HBV) serostatus was known were classified as being infected by HCV alone, HBV alone (HBsAg positive), both HCV and HBV, or neither HCV nor HBV.

Results

Among 822 HIV infected patients, 29% were infected by HCV alone, 8% by HBV alone, and 4% by both HCV and HBV. The most frequent causes of death were liver disease (31% of cases) and AIDS (29%) among HIV–HCV co-infected patients, and AIDS (38%) and liver disease (22%) among HIV-HBV co-infected patients. Liver disease was a more frequent cause of death among patients co-infected by both HCV and HBV (44% of cases). Hepatocellular carcinoma was present in 15% of patients who died from liver disease, and was associated with HBV co-infection. Nearly half the patients who died from liver disease had more than 200 CD4/mm3.

Conclusions

Liver disease is now a leading cause of death among HIV-HCV co-infected patients and is becoming an important cause of death among HIV-HBV co-infected patients. The risk of death from liver disease is highest in patients co-infected by both HCV and HBV.

Introduction

With the advent of highly active antiretroviral therapy (HAART), the mortality rate associated with human immunodeficiency virus (HIV) infection has declined sharply in Europe and the United States [1], [2]. About 25–28% of HIV-infected persons in western countries are co-infected by hepatitis C virus (HCV) [3], [4], [5], [6], and about 6–8% are chronically infected by hepatitis B virus (HBV) [3], [7]. The prevalence of anti-HCV antibodies varies widely among the different HIV transmission groups, ranging from 7–8% in homosexual men to 60–70% in hemophiliacs and 80–90% in injecting drug users [4], [5], [6]. The increased life expectancy conferred by HAART has increased the number of HIV-infected patients in whom HCV or HBV disease progresses to liver fibrosis and cirrhosis. In addition, HIV itself accelerates the progression of HCV and HBV liver disease by increasing HCV and HBV load and hastening the onset of cirrhosis [7], [8].

Numerous studies have shown an increased risk of mortality from liver disease (LD) in HIV-infected patients with hepatotropic virus co-infection [9], [10], [11], [12], [13], [14], [15], [16]. According to an American study, the risk of death from liver disease is multiplied by about 13 in HIV-HBV co-infected patients as compared to HBV-infected HIV-seronegative patients, and the risk even increases as the CD4 cell count decreases [7]. Similar results have been reported for HIV-HCV co-infected patients [11], [12], [13], [14], [15], [16]. In the ‘Mortality 2000’ survey, designed to describe causes of death among French HIV-infected patients died in 2000, HCV and HBV disease was the second most frequent underlying cause of death, accounting for 11% of deaths [17].

However, whether proportions of deaths due to liver disease differ among HIV-infected patients according to the presence of HCV or HBV infection remains unknown as well as the prevalence of specific risk factors for death from liver disease, such as alcohol consumption, since they have been rarely studied in this setting. The aim of our study was to compare causes of death and characteristics of deceased HIV-infected patients according to the presence of HCV and/or HBV infection, and to compare the characteristics of patients who died from liver disease (LD) and those who died from other causes.

Section snippets

Methods

‘Mortality 2000’ was a national survey of deaths among HIV-infected patients occurring in France during the year 2000 [17]. All hospital wards known to be involved in the case management of HIV infection in France were contacted at the beginning of each trimester of 2000. Physicians who agreed to participate were asked to record all deaths prospectively and to describe the precise causes of death, using a standardized case report form also including sociodemographic characteristics (gender,

Results

The 185 wards participating in the survey reported a total of about 64,000 HIV-infected patients with at least one contact in 2000. Participants notified 964 deaths among HIV-infected patients in 2000. Case report forms were completed for 924 deaths (96%). Patients died in their forties, most of them were men (78%), HIV transmission group was heterosexuality in 34% of cases, injecting drug use in 28% and homo/bisexuality in 27%. Median time between the diagnosis of HIV infection and death was

Discussion

This study confirms that, among HIV-infected patients with hepatitis virus infection, liver disease is currently as frequent as AIDS. All categories of hepatitis virus co-infected patients are concerned, although this trend is more obvious in HCV co-infected patients and in patients co-infected by both HCV and HBV than in HBV co-infected patients.

Among HCV-HIV co-infected patients, the proportion of LD-related deaths was higher in patients with reported HCV-RNA positivity (36%) than in patients

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