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Greater than the sum of its parts : issues in the diagnosis and management of individuals co-infected with HIV and hepatitis C initiating antiretroviral therapy Braitstein, Paula

Abstract

Objectives: To determine the prevalence of hepatitis C co-infection among previously antiretroviral naive HIV-infected individuals initiating antiretroviral treatment (ART) in a population-based program; to describe the effect of HCV co-infection on immunologic response to ART; adherence to ART; and the effect of HCV co-infection on non-accidental mortality among this population. Methods: British Columbia's HIV/AIDS Drug Treatment Program (DTP) provides antiretroviral therapy to all eligible HIV positive persons in British Columbia free of charge. Data were drawn from a nested cohort within the DTP of previously ART naive individuals whose first ever ART was a triple-combination and who began treatment between August 1996 - July 2000. Retrospective HCV testing was performed on stored plasma samples from before and, in some cases, after ART initiation. Results: Of the 1136 individuals whose stored baseline plasma samples were tested, 606 (51%) tested HCV antibody-positive (Ab+) and 580 (49%) were HCV antibody-negative. At baseline, 179 (30%) of the antibody positive results were HCV RNA negative. Of these, 118 samples were re-tested for HCV RNA on a sample taken 6-12 months post- ART initiation; 24 (20%) were now found to be HCV RNA positive. In this study population, people with positive HCV antibodies have an attenuated absolute CD4 response to ART, but a preserved CD4 fraction response; increased biochemical markers of hepatic injury, and are independently less likely to adhere to antiretroviral medication, after controlling for biochemical markers of hepatic injury and injection drug use. Finally, HCV antibody positive adults are nearly three times more likely to die a non-accidental death, after controlling for age, gender, injection drug use, and adherence to ART, and are twice as likely to die an HIV-related death. Conclusions: Due to shared routes of transmission and the infectiousness of the hepatitis C virus, there is a very high prevalence of HCV in this population-based cohort of HIV-infected individuals. HCV adversely affects the effectiveness of ART, including immunologic response and ability to adhere. This has significant implications for the survival of HIV/HCV co-infected patients.

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