Under current standards of care, doctors can postpone treatment for patients infected with hepatitis C who show minimal liver damage on their first biopsy, as well as normal liver enzymes.¹

However, a new study by a group of doctors at Johns Hopkins University in Baltimore suggests that patients coinfected with hepatitis C (HCV) and HIV may need to consider more aggressive care.² The scientists led by Mark Sulkowski, MD, an assistant professor of Medicine at Hopkins found that within 3-and-a-half years of diagnosis, 28 percent of 67 patients with minimal damage initially had developed significant fibrosis. 

Assessing Liver Health in Co-Infected Patients
In their prospective study, the researchers took two liver biopsies at two different periods, and then compared the biopsy results to examine changes in fibrosis. Of the 67 patients, six were excluded due to evidence of liver cirrhosis on first biopsy.

Eighty-six percent of the patients were taking antiretroviral therapy for their HIV, nearly a third had persistently elevated liver enzymes, and 68 percent had no evidence of steatosis at the beginning of the study. Average time between biopsies was 2.84 years.

The patients who had progressive fibrosis during the study advanced at least two stages. Of those with milder fibrosis, 26 percent had evidence of a two-stage progression. Only four patients had a 1-stage decrease in fibrosis level between biopsies, Sulkowski's team learned. Those who had an increase in fibrosis level of at least 2 stages were more likely to have higher levels of HIV in their blood. These patients also had persistently elevated levels of a liver enzyme known as aspartate aminotransferase (AST)—a biological indicator that doctors use to determine liver disease in a patient—at first biopsy and between biopsies, the researchers wrote.

The study team found that the amount of time between biopsies, a patient's age, gender, amount of alcohol consumption, use of antiretroviral therapy, immune cell count, levels of another liver enzyme known as aspartate aminotransferase (AST), level of steatosis, or exposure to interferon had no effect on fibrosis progression.

"If confirmed by others, these data do not support the application of current HCV treatment guidelines to HIV-infected patients on the basis of a single liver biopsy, and suggest that such patients should be closely monitored for liver disease progression," wrote Sulkowski and his fellow researchers. "Additional research is urgently needed to identify better predictors of liver disease stage and progression in co-infected patients."

Characteristics of Co-Infected Patients
Liver disease is the major cause of death in HIV-infected people. In the United States and Europe, nearly a third of HIV-positive individuals are also infected with the hepatitis C virus. Up to 90 percent of people who acquired HIV through injection drug use are coinfected with HCV, as well.³

Some studies have suggested that people who are coinfected have higher levels of hepatitis in their bloodstream, have rapid progression to liver damage, and face a greater risk of death due to hepatitis compared to people with only HCV infection.⁴

While hepatitis B is the most common form of viral hepatitis in those with coinfection, HCV is more likely to result in chronic or long-term disease, liver failure and death in these cases.4

1. National Institutes of Health Consensus Development Conference Statement. Management of Hepatitis C: 2002. 2002 Jun 10-12. Available at: http://consensus.nih.gov/cons/116/091202116cdc_statement.htm#4. Accessed March 16, 2005.
2. Sulkowski M, Mehta S, Torbenson M, Moore R, Thomas D. Unexpected significant liver disease among HIV/HCV-coinfected persons with minimal fibrosis on initial liver biopsy. 12th Conference on Retroviruses and Opportunistic Infections. 2005 Feb 22-25. Boston, MA.
3. Tossing G. Treating hepatitis C in HIV-HCV coinfected patients. Infection 2002 Oct;30(5):329-31.
4. Hepatitis Neighborhood. Understanding HCV/HIV Coinfection. Available at: http://www.hepatitisneighborhood.com/content/
understanding_hepatitis/what_is_hepatitisc_2111.aspx. Accessed March 16, 2005.

John Martin is a long-time health journalist and an editor for Priority Healthcare. His credits include coverage of health news for the website of Fox Television's The Health Network, and articles for the New York Post and other consumer and trade publications.