Published online Feb 7, 2018. doi: 10.3748/wjg.v24.i5.613
Peer-review started: November 29, 2017
First decision: December 20, 2017
Revised: December 26, 2017
Accepted: January 15, 2018
Article in press: January 15, 2018
Published online: February 7, 2018
Following the introduction of highly effective antiviral therapy (HAART) against human immunodeficiency virus (HIV), the survival of affected patients improved considerably. In this scenario, liver diseases have gained prominence, especially viral hepatitis and hepatocellular carcinoma (HCC). Current data suggest an unfavorable evolution both in the natural history of liver disease and in the outcome after hepatitis treatment in coinfected patients.
The data about the outcomes in HIV/viral hepatitis association are conflicting, especially with regard to the incidence of HCC, mainly in South America. Thus, we believe it is extremely important to have data clarifying the profile of this association in our environment.
The main objective of this study is to assess the incidence of HCC in patients with chronic liver disease due to HBV or HCV and coinfected with HIV. These data are extremely important in order to implement more appropriate policies of HCC screening and prevention in this population.
A retrospective cohort study was conducted with individuals with chronic viral hepatitis B or C, with and without HIV coinfection. Patients were selected from the viral hepatitis notification bank at the epidemiology department of Hospital Nossa Senhora da Conceição, a tertiary public care center in Porto Alegre - Brazil, between January 2007 and June 2014. These individuals were split into two groups, according to their HIV infection status. Individuals under 18 years of age, patients with insufficient data on their medical records, those who did not attend monitoring exams, pregnant women, those with other types of hepatitis or who did not have at least one annual appointment during the monitoring period were excluded from the study. We assessed demographic and clinical data, including lifestyle habits, specific treatments for viral hepatitis, HAART use in patients coinfected with HIV, presence of liver cirrhosis and its complications and the HCC diagnosis.
A total of 6567 medical records of patients referred to this tertiary care center with viral hepatitis were analyzed; of these, 804 patients were included in the study (399 coinfected with HIV/HBV or HCV and 405 monoinfected with HBV or HCV). In general, patients were monitored for a median time of 10.54 years (95%CI: 9.58-11.50, P = 0.005). The total follow-up was 7498.8 patient-years (3901.9 patient-years in HIV-positive patients and 3596.9 patient-years in HIV-negative patients). The development of HCC was observed in 36 patients - 10 cases in HIV-positive patients and 26 in HIV-negative patients. All patients who developed HCC had liver cirrhosis at the time of diagnosis. The incidence density of HCC in coinfected and monoinfected patients was 0.25 cases per 100 patient-years (95%CI: 0.12-0.46) and 0.72 cases per 100 patient-years (95%CI: 0.47-1.05) (long-rank P = 0.002), respectively. The ratio of incidence rates of HCC of HIV negative when compared to HIV positive was 2.98. When adjusted for age, the role of HIV is no longer statistical significant for the development of HCC.
The present study found no significant association between the presence of HIV and the development of HCC. The data from this study suggests that the time of exposure to hepatic injury factors, such as HBV and HCV, is much more relevant to the development of HCC than the presence of HIV per se.
The present study demonstrates the need to study more deeply the consequences of the association of HIV with chronic liver diseases, especially in the era of HAART. The data presented here indicate the need for further prospective studies to better evaluate the consequences of HIV/viral hepatitis coinfection.