HIV, hepatitis B virus, and hepatitis C virus co-infection in patients in the China National Free Antiretroviral Treatment Program, 2010-12: a retrospective observational cohort study

Abstract

Background: Hepatitis-related liver diseases are a leading cause of mortality and morbidity among people with HIV/AIDS taking combination antiretroviral therapy. We assessed the effect of hepatitis B virus (HBV) and hepatitis C virus (HCV) co-infection on HIV outcomes in patients in China.

Methods: We did a nationwide retrospective observational cohort study with data from the China National Free Antiretroviral Treatment Program from 2010-11. Patients older than 18 years starting standard antiretroviral therapy for HIV who had tested positive for HBV and HCV were followed up to Dec 31, 2012. We used Kaplan-Meier analysis and Cox proportional hazard models to evaluate survival, and logistic regression models to estimate virological failure, immunological response, and retention in care.

Findings: 33 861 patients with HIV met eligibility criteria. 2958 (8·7%) participants had HBV co-infection, 6149 (18·2%) had HCV co-infection, and 1114 (3·3%) had triple infection. All-cause mortality was higher in participants with triple infection (adjusted hazard ratio 1·90, 95% CI 1·53-2·37) and HCV co-infection (1·46, 1·25-1·70) than in those with HIV only, but not in those with HBV co-infection (1·06, 0·89-1·26). People with triple infection were also more likely to have virological failure (adjusted odds ratio [OR] 1·26, 95% CI 1·02-1·56) than were those with HIV only, whereas the difference was not significant for those with HBV co-infection (0·93, 0·80-1·10) or HCV co-infection (1·10, 0·97-1·26). No co-infection was significantly associated with a difference in CD4 cell count after 1 year of treatment. Loss to follow-up was more common among participants with triple infection (OR 1·37, 95% CI 1·16-1·62) and HCV co-infection (1·30, 1·17-1·45), but not HBV co-infection (0·93, 0·82-1·05), than among those with HIV only.

Interpretation: Screening for viral hepatitis is important in individuals diagnosed as HIV positive. Effective management for viral hepatitis should be integrated into HIV treatment programmes. Long-term data are needed about the effect of hepatitis co-infection on HIV disease progression.

Funding: The National Center for AIDS/STD Control and Prevention, China Center for Disease Control and Prevention.

Figure 1. Cumulative probability of death, by hepatitis virus infection status

(A) All-cause mortality and (B) non-injury mortality. HBV=hepatitis B virus. HCV=hepatitis C virus.

Figure 2. Outcomes after 12 months of combination antiretroviral therapy

(A) Viral load response, (B) change of CD4 cell count, and (C) retention status. HBV=hepatitis B virus. HCV=hepatitis C virus.

Figure 3. Multivariable analyses of association between hepatitis co-infection and outcomes

Controlled for age, sex, treatment centre, CD4 cell count, HIV transmission mode, and initial antiretroviral treatment regimens. *Includes death and stopping.