Impact of Chronic HCV Co-infection on HIV Clinical Outcomes in the District of Columbia

681 views

Published on

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
681
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
8
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Impact of Chronic HCV Co-infection on HIV Clinical Outcomes in the District of Columbia

  1. 1. Impact of Chronic HCV Co-infection on HIV Clinical Outcomes in the District of Columbia Sarah Willis, MPH Department of Epidemiology and Biostatistics School of Public Health and Health Services The George Washington University 2011 National HIV Prevention Conference
  2. 2. A Public Health/Academic Partnership between the District of Columbia Department of Health andThe George Washington University School of Public Health and Health ServicesDepartment of Epidemiology and Biostatistics Contract Number POHC-2006-C-0030
  3. 3. Background• An estimated 1/4 of those infected with HIV are also infected with hepatitis C virus (HCV)• Estimates of HIV/HCV co-infection range from 50- 90% among certain sub-populations• Supporting evidence that HIV negatively impacts HCV disease progression and reduces the effectiveness of available treatments
  4. 4. Background (2)• Less research has been conducted regarding role of HCV co-infection on HIV disease and existing studies have conflicting results – Association between HCV/HIV co-infection and worsening liver disease and higher mortality when compared to those with HIV or HCV monoinfection (Merriman et al) – HCV co-infection associated with blunted CD4 cell recovery after initiating HAART yet no effect on virologic response or mortality (Carmo et al)
  5. 5. ObjectivesUtilize routinely reported surveillance data to: 1. Determine the extent of HIV/HCV co-infection in the District of Columbia between 2000-2009 2. Describe potential factors that may be associated with HIV/HCV co-infection 3. Determine the impact that HIV/HCV co- infection has on HIV clinical outcomes and mortality
  6. 6. Methods• Identified name-based HIV/AIDS cases diagnosed and reported to the DCDOH between 2000 – 2009 (n=10,215)• Identified chronic HCV cases reported to DCDOH during the same time period (n=16,235)• Used Link Plus Probability matching program to match cases by: – First and last name – Date of birth – Sex – Race• Reviewed potential matches for accuracy
  7. 7. Methods (2)• Performed bivariate analyses to detect differences among HIV/HCV co-infected and HIV mono-infected individuals based on: – Demographics – Entrance into HIV Care (time between HIV/AIDS diagnosis and first VL or CD4 test reported to DCDOH) – Engagement in HIV Care • Continuous Care - evidence (e.g. HIV-related lab test) of at least 2 visits to an HIV medical provider 10-14 weeks apart • Sporadic care - one visit to a provider or 2 visits but more than 14 weeks apart – Viral load and CD4 count (at time of diagnosis and most recent results) – Mortality
  8. 8. Methods (3)• Assessed timing of HIV/HCV co-infection• Association between HIV/HCV co-infection and mortality (time to death) examined through: – Kaplan-Meier log rank test/log rank survival plots – Cox proportional hazard ratio model
  9. 9. Demographics of Co-Infected and Monoinfected Cases 11.3% of reported HIV cases were HCV co-infected HIV/HCV HIV Chi-square Co-infected Monoinfected p-value (n=1,151) (n=9,017)Sex Male 67.2% 70.5% 0.0189 Female 32.8% 29.5%Race/ethnicity White 4.5% 14.4% Black 90.4% 77.5% <0.0001 Hispanic 3.1% 5.8% Other* 2.0% 2.3%*Other race includes Asian, Alaska Native, American Indian, Native Hawaiian,Pacific Islander, and Mixed and Unknown race
  10. 10. Age and Vital Status of Co-Infected and Monoinfected Cases HIV/HCV HIV Chi-square Co-infected Monoinfected p-value (n=1,151) (n=9,017)Age at HIV diagnosis 13-19 0.2% 3.1% 20-29 3.7% 20.6% 30-39 13.9% 32.4% <0.0001 40-49 48.1% 28.1% 50-59 28.8% 11.8% ≥60 5.3% 4.1%Vital Status* Alive 80.5% 88.5% <0.0001 Dead 19.5% 11.5%*as of December 31st, 2009
  11. 11. HIV Mode of Transmission 45.0% 40.3% 40.0% 36.4%Proportion of Diagnosed Cases 35.0% 31.6% 30.0% 25.0% 23.5% 20.0% 17.6% 17.2% 15.0% 12.1% 13.8% 10.0% 4.6% 5.0% 2.6% 0.0% MSM IDU MSM/IDU Heterosexual Risk Not Identified HIV/HCV Co-infected HIV
  12. 12. Timing of HIV/HCV Infection Concurrent Infections (< 3 months apart) 27.1%HCV Infection 3+ months prior to HIV 58.7% HIV Infection 3+ months prior to HCV 14.2%
  13. 13. HIV Care Seeking Behavior HIV/HCV HIV Chi-square Co-infected Monoinfected p-value (n=1,151) (n=9,017)Entrance into Care < 3 months 56.9% 59.9% 3 – 6 months 5.7% 4.6% <0.0001 6 – 12 months 6.3% 5.6% > 1 year 25.0% 20.4% Not in care 6.0% 9.5%Engagement in Care No care 6.0% 9.5% <0.0001 Sporadic Care 57.7% 61.4% Continuous Care 36.3% 29.1%
  14. 14. HIV Viral Load at Time of HIV Diagnosis 100,000 90,000Median Viral Load at Diagnosis 80,000 70,000 (copies/mL) 60,000 50,000 40,000 30,000 20,000 16,406 10,000 10,551 0 HIV/HCV Co-infection HIV only Kruskal Wallis; p = 0.3031
  15. 15. Most Recent Viral Load Results3,5003,0002,5002,0001,5001,000 500 0 74 74 HIV/HCV coinfection HIV only Kruskal Wallis; p = 0.0119
  16. 16. CD4 Count at HIV Diagnosis 500 450Median CD4 Count at Diagnosis 400 350 300 (cells/µL) 250 200 192 185 150 100 50 0 HIV/HCV coinfection HIV only Kruskal Wallis; p-value = 0.3986
  17. 17. Most Recent CD4 Results 700 600Median CD4 Count (cells/µL) 500 445 400 389 300 200 100 0 HIV/HCV coinfection HIV only Kruskal Wallis; p-value = 0.0002
  18. 18. Survival AmongHIV/HCV and HIV only cases HIV only cases HIV/HCV co-infected cases Log-rank = 47.35 p-value = <0.0001
  19. 19. Adjusted Hazard Ratio for Mortality among HIV/HCV Co-infected Cases Adjusted Hazard 95% Confidence Ratio† IntervalHCV/HIV vs. HIV only 1.20 1.02, 1.40†Adjusted for sex, race/ethnicity, age, engagement in care, HIV modeof transmission, and progression to AIDS
  20. 20. Conclusions• More than half of HIV/HCV co-infections were infected with HCV first• In comparison to HIV monoinfected cases, HIV/HCV co-infected cases in DC were more likely to be: – Black – Over 40 years of age – IDU• HIV/HCV co-infected cases in DC may have poorer HIV clinical outcomes over time – Lower CD4 counts among HIV/HCV co-infected cases at most recent test – Increased mortality among HIV/HCV co-infected cases
  21. 21. Limitations• May have underestimated HIV/HCV co- infections due to errors in data entry, name changes or incorrect spelling• Large proportion of cases with missing CD4 and viral load data at diagnosis and at follow- up (25%-75%) in eHARS, could not assess their clinical outcomes
  22. 22. Recommendations• Subsequent studies should be conducted to better understand the impact of HCV co-infection on HIV disease• Studies utilizing surveillance data for this purpose should: – Improve completeness of VL and CD4 test results data – Obtain data on ART utilization• Prevention and treatment interventions should be developed for sub-populations with high rates of HCV/HIV co-infection, such as IDUs
  23. 23. AcknowledgmentsDC DOH HIV/AIDS, George WashingtonHepatitis, STD, TB University School ofAdministration Public Health and Health – Angelique Griffin* Services – Yujiang Jia – Amanda D. Castel* – Gregory Pappas – Irene Kuo* – Rowena Samala – Alan Greenberg – Tiffany West* *Co-authors

×