HCV Treatment Rates of HIV/HCV Coinfected Patients Remain Low in Europe

Becky McCall

November 17, 2009

November 17, 2009 (Cologne, Germany) — An analysis of treatment rates for patients coinfected with hepatitis C virus (HCV) and HIV shows that despite an increase in the number of patients treated since 2003, overall treatment rates remain low for HCV, with fewer patients starting treatment in Eastern Europe than in other regions of the world. A subanalysis showed that treated individuals had a lower risk for death from any cause or from liver-related causes, which investigators believe is attributable to effective treatment of the HIV component of their disease.

Study results were presented here at the 12th European AIDS Conference/European AIDS Clinical Society and were a follow-up of previous research first published in 2002, which showed that only a limited number of HIV/HCV coinfected patients received anti-HCV treatment. Similar to other studies, this research indicates that typically only 10% to 20% of coinfected patients actually start therapy against both viruses.

Amanda Mocroft, PhD, medical statistician from University College Hospital, London, United Kingdom, led the study. "Since 2003, there has been a gradual increase in treatment use across Europe, so we wanted to investigate how that trend had developed and continued — or not — over time."

This investigation formed part of the EuroSIDA longitudinal cohort study, which has been running since 1994 in 35 countries across Europe, Argentina, and Israel. Approximately 25% of EuroSIDA participants are coinfected with HCV, and 75% of these patients are HCV RNA-positive. Dr. Mocroft's study focused on patients who were HCV-antibody-positive and viraemic (with detectable HCV RNA).

"We tested a group of people over time from 2003 who were registered as receiving anti-HCV treatment including interferon, peg-interferon, or ribavarin. Liver-related deaths and deaths from any cause were monitored.

"Upon analysis, the incidence of starting HCV treatment showed a jump between the years 2003 [and] 2004, but this level remained fairly steady after that time. We also found those patients most likely to start treatment were those with a higher CD4 count — above 200 cells/mL — and who also showed well-controlled HIV viraemia," explained Dr. Mocroft.

Jens Lundgren, MD, from the University of Copenhagen, Denmark, commented that he and his colleagues were surprised that uptake of HCV treatment had not continued to increase over time. "Many patients included in the study were injection drug users (IDUs) because this is the main population infected with HCV, and this may be one of the reasons why we fail to see an increase in treatment use. There is some reluctance on the part of clinicians to start treatment in these patients who are actively injecting."

Dr. Mocroft added that they also conducted an analysis of patients who started treatment before or during 2003 versus during or after 2004. "We found there was trend in Eastern Europe for patients to start more recently, as if treatment in this part of Europe has caught on, although overall, patients in Eastern Europe are less likely to start treatment."

Dr. Lundgren explained how Eastern Europe is beset with obstacles to effective treatment. "The proportion of people living with HIV/HCV coinfection in Eastern Europe is much larger [than in Western Europe,] so they have a much greater HCV problem to begin with. Patients also receive HIV antiretroviral therapy...less frequently, and clinicians also underutilize HCV therapy on top of this."

The analysis of deaths from any cause and events of grade 3/4 hepatic encephalopathy or death from liver-related disease were found to be lower in treated patients. There were 262 deaths from any cause in the untreated group versus 12 in the treated group. There were 80 grade 3/4 hepatic encephalopathy events or deaths from liver-related disease in the untreated group vs 6 in treated patients.

"We couldn't explain these findings by starting [antiretroviral therapy] or improvements in CD4 counts. It seemed to be related to HCV treatment. It was encouraging to see that HCV treatment was having an effect on clinical endpoints. However, we can't rule out the fact that doctors might be picking the patients who are most likely to respond to treatment and are effectively the healthiest to start [with]," added Dr. Mocroft.

Massimo Puoti, MD, from the University of Brescia, Italy, chaired the session at which the results were presented. "There are differences in the propensity to treat depending on geographical distribution across Europe. This is mainly due to different availability of resources, but also, especially in Southern Europe, because many patients with HCV were also IDUs. A few years ago, many clinicians felt that treating an active IDU might be difficult," he said.

"My reservation with this study is that it did not look at the rate of sustained virological response (SVR). We treat many patients, but our major concern with HCV treatment is this low serological response. In many patients, the rate of SVR is completely unsatisfactory because it is below 50%, as well as low tolerability [of treatment]. The treatment also induces flu-like symptoms, which [recur] every week, as well as causing depression, weakness, and irritability in some patients. For these reasons, many patients do not agree to treatment.

"Hopefully, in the future this will change with new drugs active against HCV and with emergent data which shows an improvement in virological response. Some of these drugs [are] showing higher than 70% SVR when used with a combination of peg-interferon and ribavirin." concluded Dr. Puoti.

Dr. Mocroft, Dr. Lundgren, and Dr. Puoti have disclosed no relevant financial relationships.

12th European AIDS Conference/European AIDS Clinical Society: Abstract 13.2. Presented November 12, 2009.

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