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A Cohort Study, 1992-2001

Thomas P. Giordano, MD, MPH; Jennifer R. Kramer, PhD, MPH; Julianne Souchek, PhD; Peter Richardson, PhD; Hashem B. El-Serag, MD, MPH

Arch Intern Med. 2004;164:2349-2354.

Background  Because they develop slowly and infrequently, the incidence and relative risk of cirrhosis and hepatocellular carcinoma (HCC) in patients with the human immunodeficiency virus (HIV) only and in patients coinfected with the hepatitis C virus (HCV) are not known.

Methods  By using national Veterans Health Administration administrative databases, we conducted a retrospective cohort study. Excluding patients with preexisting liver disease, 11 678 HIV-only and 4761 coinfected patients hospitalized between October 1, 1991, and September 30, 2000, were included. Incidence rates and adjusted hazard ratios (HRs) for nonalcoholic cirrhosis and HCC after discharge were calculated through September 30, 2001.

Results  The incidence rates of cirrhosis in the HIV-only and coinfected groups were 1.47 and 15.88 per 1000 person-years, respectively. In a Cox multivariate proportional hazards regression model, coinfected patients had an adjusted HR for cirrhosis of 9.24 compared with HIV-only patients (95% confidence interval, 6.92-12.33; P<.001). The incidence rates of HCC in the HIV-only and coinfected groups were 0.20 and 1.32 per 1000 person-years, respectively. In a Cox multivariate proportional hazards regression model, coinfected patients had an adjusted HR for HCC of 5.35 compared with HIV-only patients (95% confidence interval, 2.34-12.20; P<.001). Among patients identified during the highly active antiretroviral therapy era, the HR for cirrhosis was 19.06 (95% confidence interval, 10.14-35.85; P<.001), while the HR for HCC was 5.07 (95% confidence interval, 1.72-14.99; P = .003).

Conclusions  To our knowledge, this study is the largest longitudinal study to examine the incidence of nonalcoholic cirrhosis and HCC in HIV-only and HCV-coinfected patients. Hepatitis C virus coinfection dramatically promotes the development of HCC (5-fold) and of cirrhosis (10- to 20-fold), and is especially associated with cirrhosis in the highly active antiretroviral therapy era. Treatment of HCV in HIV-infected patients, while often unsuccessful, should be considered.

Author Affiliations: Houston Center for Quality of Care and Utilization Studies, Health Services Research and Development Service, Department of Veterans Affairs Medical Center, Houston, Tex (Drs Giordano, Kramer, Souchek, Richardson, and El-Serag); and the Sections of Infectious Diseases (Dr Giordano), Health Services Research (Drs Giordano, Kramer, Souchek, Richardson, and El-Serag), and Gastroenterology (Dr El-Serag), Department of Medicine, Baylor College of Medicine, Houston.

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