icon_folder.gif   Conference Reports for NATAP  
  AASLD ( American Association for the Study of Liver Diseases)
November 9-13, 2001, Dallas
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HIV/HCV Coinfection; Hispanics & HCV; Cognitive Impairment
reported by Jules Levin
  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.