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HCV Independently Adds to Hospital, Emergency Room,
and Disability Days With HIV: days in hospital doubled
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16th Conference on Retroviruses and Opportunistic Infections,
February 8-11, 2009, Montreal
Mark Mascolini
HIV-infected people with a positive hepatitis C virus (HCV) antibody test spend twice as many days in the hospital as HCV-seronegative people with HIV, according to results of a 3000-person analysis. HCV seropositivity also independently raised rates of emergency room (ER) visits and disability days.
Benjamin Linas and colleagues scrutinized data from the ACTG Longitudinal Linked Randomized Trials (ALLRT) cohort to determine how HCV seropositivity affects health resource use in distinct CD4-count strata (under 100, 100-200, 201-350, and over 350) and to compare rates of hospitalization, ER use, and disability days in HIV-infected people with and without HCV antibodies. The ALLRT cohort includes antiretroviral-naive and experienced people who enrolled in randomized ACTG trials and agreed to prospective follow-up after the trial ended.
For this study, the investigators asked cohort members to recall over the past 4 months the number of (1) nights spent in the hospital, (2) ER visits made, (3) days spent in bed, and (4) days forced to cut back on work or daily activities. They defined disability days as the larger number of either days spent in bed or days with reduced work or activities. The analysis included 3082 ALLRT participants with at least one CD4 count. When predicting the impact of HCV on health resource use, Linas and coworkers factored in current CD4 count, current viral load, opportunistic infection history, age, gender, race, and history of injecting drug use.
The comparison involved 358 HCV-seropositive people and 2724 only with HIV. Average age was similar in the two groups (43 with HCV, 40 without), as was percentage of men (79% and 84%), baseline median CD4 count (248 and 244), and baseline viral load (40,000 copies in both groups). About half of the HCV/HIV group had injected drugs, compared with 4% of the HIV-only group (P < 0.0001).
Unadjusted incidence of hospital nights was consistently higher in the HCV/HIV group than in the HIV-only group in every CD4 group except the highest. In the adjusted analysis, however, the relative rate (RR) of hospital admission was higher with HCV seropositivity in all four CD4 groups, but significantly higher only in the 201-350 group (RR 2.9) and the over-350 group (RR 2.1).
The adjusted analysis for ER visits was significantly higher with HCV/HIV than with HIV alone in the top three CD4 groups: 100 to 200 (RR 2.2), 201 to 350 (RR 2.2), and over 350 (RR 1.6). The adjusted analysis for disability days was also significantly higher in the top three CD4 clusters for HCV/HIV versus HIV alone: 100 to 200 (RR 1.6), 201 to 350 (RR1.7), and over 350 (RR 1.3).
Overall relative rates were 40% to 90% higher with HCV/HIV than with HIV alone for the three variables:
• Hospital nights: RR 1.9, 95% confidence interval [CI] 1.4 to 2.6
• ER visits: RR 1.7, 95% CI 1.4 to 2.1
• Disability days: RR 1.4, 95% CI 1.1 to 1.8
Linas noted that the analysis is limited by reliance on self-reports. In addition, competing risks in the lowest CD4 group may limit an independent impact of HCV. Finally, the analysis involves people exposed to HCV, not necessarily people with active HCV infection.
The ACTG ALLRT team advised that "HIV programs serving a high proportion of HIV/HCV-coinfected patients can expect 1.5 to 2 times higher rates of hospitalizations, emergency department visits, and disability days than would be expected from a similar population of HIV mono-infected patients."
Reference
1. Linas B, B Wang B, Smurzynski M et al. The effect of HCV co-infection on health care utilization among HIV-infected subjects: the ACTG longitudinal linked randomized trials, study 5001. 16th Conference on Retroviruses and Opportunistic Infections. February 8-11, 2009. Montreal. Abstract 102.
(Slide presentation available online at http://www.retroconference.org/2009/data/files/webcast.htm. Click on Tuesday, then on Play Audio and Slides at Interplay Among Treatment, then on Index, then on Benjamin Linas.)
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