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Incidence of liver cancer is increasing in patients with HIV/HCV co-infection
Michael Carter, 2016-07-12 08:50:00
Incidence of liver
cancer is increasing among patients with HIV co-infection, an international
team of investigators report in the online edition of Clinical Infectious Diseases. Researchers from Europe and Canada
pooled data gathered between 2001 and 2014 from six prospective cohorts and
found that incidence of hepatocellular carcinoma (HCC) increased but the
incidence of serious liver related events – decompensated liver disease or
liver-related death – declined.
paradoxical that improvements in liver-related morbidity in HIV/HCV co-infected
patients, demonstrated by a lower incidence of other events, would
simultaneously yield a higher incidence of HCC,” comment the authors. “Perhaps
an improved management of liver cirrhosis and HIV treatment can increase the
threshold for liver decompensation in the cirrhotic HIV/HCV co-infected
individuals, but thus increasing longevity such that viral hepatocarcinogenesis
has enough time to manifest itself as HCC.”
investigators believe their results support additional surveillance of trends
in HCC incidence.
Large numbers of
HIV-positive patients are co-infected with HCV. Chronic HCV infection can lead
to serious liver disease, including HCC. HIV co-infection is known to
accelerate disease progression. However, the prognosis for co-infected patients
has improved significantly in recent years. Some research suggests that the
overall incidence of serious liver disease is declining but rates of HCC are
increasing in co-infected patients.
EuroSIDA, the South Alberta Clinic Cohort, the Canadian Co-infection Cohort and
the Swiss HIV Cohort therefore designed a study to determine incidences of HCC
and other liver events between 2001 and 2014 and identify the risk factors for
liver cancer and serious liver disease/death.
A total of 7,229
co-infected patients were included in the study. Approximately two-thirds (68%)
were male, 90% were while, median age was 38 years, 5% were also infected with
HBV and the main HIV risk group was injecting drug users.
There were 72
cases of HCC and 375 other liver events. Overall incidence of HCC was 1.6 per
1000 person-years of follow-up with other liver events having an incidence of
8.6 per 1000 person-years.
Incidence of HCC
increased by 11% each year, from 0.4 per 1000 person-years in 2001-02 to 2.3
cases per 1000 person years in 2013-14. In contrast, incidence of other liver
events decreased by 4% per year, from 9.9 cases per 1000 person-years in
2003-04 to 6.2 cases per 1000 person years in 2013-14.
“Changes in the
proportion of individuals with cirrhosis – which increased by 8% per year –
most likely explained the increase in HCC per calendar year,” suggest the
In patients with
cirrhosis, incidence of HCC was 7.9 cases per 1000 person-years versus 0.5 per
1000 person years in patients without cirrhosis. For other liver events,
incidence was 35.6 per 1000 person years for those with cirrhosis compared to
2.4 per 1000 person-years for non-cirrhotic individuals.
cirrhosis status, incidence of both HCC and serious liver events was lower in
patients with a CD4 cell count above 350 cells/mm3.
Median age at the
development of HCC was 50 years compared to 44 years for other liver events. A
third of patients with HCC and 18% of individuals with other serious liver
events had ever received therapy for HCV. Almost all patients had received
combination HIV therapy (99% HCC vs. 91% other liver events), however recent
CD4 cell counts were quite low and between 242 and 286 cells/mm3.
Risk factors for
HCC and other liver events included older age, cirrhosis and a low current CD4
“We found a
significant protective effect of a doubling of current CD4 count after
adjustment for cirrhosis, corroborating the independent effect of current
immunosuppression as a risk factor for HCC,” observe the researchers, who
conclude: “New HCV treatment with direct-acting antivirals and earlier HIV
treatment will likely reduce the rates of HCC and other liver events, but as
HCC can develop after achieving SVR [sustained virologic response], or as a
consequence of long-term alcohol abuse, non-alcoholic steatohepatitis, or other
hepatotoxic exposures, continuous surveillance of incidence trends is needed.”