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HIV/HCV Coinfection; Hispanics & HCV; Cognitive Impairment
reported by Jules Levin
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Maribel Rodriguez reported in a poster on 100 of her HCV/HIV coinfected
patients referred to her clinic for HCV treatment from the metropolitan area
of San Juan, PR from 1998-2000. She reports here vatious epidemiology data
about this group and the main point is that on the whole the group is fairly
advanced in their liver disease: she concludes that despite overall good
control of HIV a high percentage of her Hispanic patients have end stage
liver disease. The mean age was 43. 76% were men. IVDUs were the main risk
factor for infection 63%. Alcohol use was frequent (65%). 80% were genotype
1. 83% had >200 CD4s, average cd4 was 437. And 45% had undetectable HIV viral
load (<400). Mean HIV-RNA log was 3.2 (about 12,000+). 61% had HCV-RNA
>500,000 (mean 5.7 million) and 76% had elevated ALT (mean 101). She found no
association between cd4 count, HIV-RNA and ALT or HCV-RNA. Here is the key
finding: 55% had either bridging fibrosis (33%) or cirrhosis(22%). Only 22%
had no indication of fibrosis and the rest (33%) had mid fibrosis. 34% were
not using a PI but 16% were on saqunavir, 25% nelfinavir, 22% indinavir.
Using multivariate analysis for progression to cirrhosis, odds ratio was 3.85
(1.45, 10.2) for HCV-RNA, 0.08 for male gender, use of PIs 4.61 (0.51, 41.0),
3.03 (0.39, 23.5) for alcohol use (0.39, 23.5).
Among doctors I've spoken with at this conference who treat coinfected
patients, I think there is an inclination to treat them earlier than patients
with HCV alone. Since HIV accelerates HCV progression, some docs feel stage 1
disease in HCV alone is equal to stage 2 in coinfected, and stage 2 is equal
to stage 3. There also appears concern that many patients are not being
tested early enough for HCV and are not receiving good treatment advice.However, Rodriguez did not report the duration of HCV infection for these
patients. Not having this information makes interpretation of the data more
difficult.
A group from the University of Illionois-Chicago reported on potential
differnces in disease progression between Hispanics and Caucasians. They
performed retrospective analysis of about 198 Hispanics and 435 Caucasian
patients at the liver center at their site from 1996-2001. 21% had IVDU as
risk factor for getting HCV, 34% blood transfusions, 18% tatoos (NS). 70-77%
of both groups were genotype 1. Viral load was high--12 million in both
groups. ALT was 112 among Hispanics and 95 for Caucasians (NS). AST was
higher as well among Hispanics. Caucasians were morelikely to have normal ALT
(32% vs 6.5%). She said there was no difference in progression between
Hispanic and Caucasian men, but there was between women: fibrosis (3.1 vs 2.4
p=0.006), total HAI (10.4 vs 8.0, p=.001), and percent with cirrhosis (59% vs
30%, p=.001) were all higher among Hispanic women compared to Caucasian
women. Alcohol use was 43% vs 37% but the difference was not statistically
significant. I asked if there were differences between the groups that might
account for this such as incidence of diabetes, obesity, elevated lipids and
she said she did not look at all these potential differences. But she feels
her findings are real in that Hispanic women tend to progress more quickly. I
think that the presence of diabetes, overweight and elevated lipids may play
a role. She found no significant differences in the incidence of HCC.
A research group from Henry Ford Health System in Detroit assessed the
psychosocial factors and cognitive evaluation of HCV patients ready to start
HCV therapy. As background authors said many HCV patients subjectively
complain of memory & concentration problems as part of their disease process.
About 30% on IFN will experience neuropsychiatric side effects, including
potential cognitive impairment. Research on the prevalence and causes of
baseline cognitive deficits among HCV patients is lacking. This study group
was treatment-naive with chronic HCV, deemed medically appropriate for
treatment and recruited from their Outpatient GI Clinic. Prior to starying
IFN therapy patients completed a psychological interview. 63% were men. 50%
white, 43% Black. 28% HS degree. 14% less education. 32% some college. 9%
college grad. 16% post college education. 43% had >$50,000 in yearly income.
21% $30-50K. 64% were married. They performed HADS testing (Hospital Anxiety
& Depression Scale), Fatigue Severity Scale, and Health Related Quality of
Life Questionaire for Patients with Chronic Hepatitis (HQLQ-CH) for
psychosocial testing. And they performed cognitive testing as well (Trials A
& B, Hopkins Verbal Learning Test-revised (HVLT-R). Fatigue and Quality of
life measures were worse in HCV-infected persons compared to healthy
controls. Depression and anxiety (5.85 vs 5.1) were higher using HADS for
HCV-infected. Recall scores were worse for HCV-infected. Trails cognitive
test results were worse for HCV-infected. HCV-RNA was 800,000.
Patients had high levels of prior substance abuse: 80% cigarettes, 80%
alcohol, 71% maijuana, 50% IV drugs, 57% cocaine, 35% were in a treatment
program. But these were these past experiences and currently the percentages
using these substances were very low - alcohol 3%, pot 9%, IVDU 0%, cocaine
3%. At least that's what their testing reported. 27-38% had cognitive
impairment compared to 14% of the healthy controls. 7% had moderate-severe
visual spatial concentrstion impairment compared to 1% for healthy controls.
While 20-29% had mild-moderate impairment compared to 13% for healthy
controls. 56% had some impaired total recall, 50% impaired delayed recall,
and 20% impaired recognition memory. Verbal memory was impaired by 10-30%. In
sum the study reported that there was prominent impairment in varbal
learning, short-term memory, and visual spatial concentration. Cognitive
impairment was not significantlt correlated with depression, anxiety, fatigue
or substance abuse history, psychiatric history, or baseline viral load. I
presume the authors are suggesting that the impairments mau be due to HCV.
The authors suggested that these types of tests be performed more often in
patients about to start HCV therapy. And more research be conducted into the
causes for these impairments.
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