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Mortality in HIV-hepatitis C co-infected patients in Canada compared to the general Canadian population (2003-2013)
Marina B Klein1, Kathleen C Rollet-Kurhajec, Erica E M Moodie
1aDepartment of Medicine, Division of Infectious Diseases/Chronic Viral Illness Service, Royal Victoria Hospital, McGill University Health Centre, Montreal bCIHR Canadian HIV Trials Network, Vancouver cDepartment of Epidemiology & Biostatistics, McGill University, Montreal, Canada dDepartment of Medicine, University of Ottawa, Ottawa eDepartment of Medicine, University of Toronto, Toronto fSouthern Alberta HIV Clinic, Calgary, Canada gCentre Hospitalier de l'Université de Montréal, Notre-Dame, Montreal hUniversity of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada.
Insights
People with HIV and hepatitis C (HIV-HCV) co-infection face significantly higher mortality risks than the general population. Addressing substance use, smoking, and HCV treatment can lower these death rates.
Area of Science:
- Infectious Diseases
- Hepatology
- Public Health
Background:
- Recent research indicates that all-cause mortality in HIV mono-infected individuals is approaching that of the general population.
- This study investigates whether similar mortality improvements are observed in HIV-HCV co-infected patients.
Purpose of the Study:
- To compare mortality rates in HIV-HCV co-infected patients within the Canadian Co-infection Cohort to the general Canadian population.
- To identify factors associated with increased mortality in this co-infected group.
Main Methods:
- A prospective, multicentre cohort study was conducted.
- Deaths were tracked from 2003 to 2013 via case reports and vital statistics linkage.
- Standardized Mortality Ratios (SMRs) were calculated using Canadian Human Mortality Database rates and compared across participant characteristics.
Main Results:
- The study observed 133 deaths among 1150 HIV-HCV co-infected patients, yielding an overall SMR of 12.1.
- Factors associated with excess mortality included low CD4 counts (<200 cells/μl), active injection drug use, and smoking.
- Conversely, clearance of hepatitis C virus (HCV) infection was associated with lower SMRs, while advanced liver disease showed high SMRs.
Conclusions:
- HIV-HCV co-infected individuals remain at a substantially elevated risk of death, even with antiretroviral therapy.
- Interventions focused on modifiable factors like substance use, smoking cessation, adherence to antiretrovirals, and timely HCV treatment are crucial for reducing mortality.
Objective:
Recent studies suggest all-cause mortality in HIV mono-infected patients approaches that of the general population. We aimed to compare participants in the Canadian Co-infection Cohort to the general population to determine if co-infected patients have had similar improvements in mortality.
Design:
Prospective multicentre cohort study.
Methods:
Between 2003 and 2013, deaths were captured using specific case reports and through linkage to provincial vital statistics for participants lost to follow-up. Standardized mortality ratios (SMRs) were calculated using age, sex and province-specific mortality rates from the Canadian Human Mortality Database, 2009, and compared across behavioural and clinical characteristics of participants at their most recent visit.
Results:
Among the 1150 patients, we observed 133 deaths over 3351 person-years (4.0 per 100 person-years, 95% confidence interval 3.3, 4.6). SMRs (95% confidence interval) were: 12.1(10.1, 14.2) overall; 9.3 (7.5, 11.1) for men and 19.4 (12.7, 26.2) for women. CD4 cell counts below 200 cells/μl [25.5 (17.7, 33.3)], active injection drug use [19.9 (13.9, 25.9)] and smoking [14.9 (12.1, 17.7)] were strongly associated with excess mortality. Lowest SMRs were seen for those who had spontaneous [4.5 (-0.6, 9.5)] or treatment-induced clearance of hepatitis C virus (HCV) infection [5.1 (1.3, 8.8)]. Conversely, high SMRs were seen with advanced liver disease [17.0 (11.7, 22.3)]. In no category did SMRs approach mortality seen in the general Canadian population.
Conclusions:
HIV-HCV co-infected persons remain at markedly increased risk for death despite antiretroviral therapy. Interventions targeting modifiable risk factors such as substance use, smoking, adherence to antiretrovirals and timely provision of HCV therapy could substantially reduce death rates.
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