Liver disease in hbv–hiv co-infection: significant fibrosis is present despite hbv suppression with anti-retroviral therapy
Background: Despite the widespread use of anti-retroviral therapy (ART) active against both HIV and HBV, liver-related mortality remains high among HIV infected persons. Liver biopsy is rarely performed in the setting of suppressed HBVDNA, yet co- infected individuals were at risk of developing liver injury for many years prior to treatment initiation. We sought to better define the spectrum of histologic liver disease, and correlates of liver disease, in HBV–HIV co-infection.
Methods: A retrospective analysis of liver histology in HBV–HIV patients from 5 centers was performed. Those with decompensation, HCV or other liver disease were excluded. Liver biopsy results and demographic and clinical data obtained at the time of the biopsy were recorded. Predictors of fibrosis (comparing those with bridging fibrosis/cirrhosis to those with stage 0–2 fibrosis) were assessed.
Results: Fifty-three patients were included. The mean age was 42, 96% were male, 30% were African American, 66% were on ART and the vast majority (95%) had undetectable HIV RNA. 62% were eAg+, 35% had HBVDNA <1000 U/L and 30% had an undetectable HBVDNA. 6% of those tested for anti-HDV (n = 30) were positive. Mean laboratories were AST 52 U/L, ALT 57 U/L, and CD4 420. Liver histology showed advanced fibrosis in 31 (58%). Compared to those with mild disease, those with advanced histology were more likely to be on ART (p = 0.02), to have a lower CD4 nadir (p = 0.04) and higher AST (p = 08). There was no difference between groups with respect to HBeAg status or presence of HDV. In a subset with available data (n = 46), HBVDNA <1000 IU/mL was not associated with disease severity. FIB-4 performed slightly better than APRI in differentiating advanced fibrosis from mild disease [AUROCs 0.78 (95% CI 0.71–0.85) and 0.68 (95% CI 0.48–089), respectively].
Conclusions: A high proportion of HBV–HIV co-infected patients have advanced fibrosis despite HBV suppression. Those on ART appear to have more advanced liver disease, and this may have masked any benefit associated with HBV treatment. Larger, welldesigned studies of liver histology and its correlates are needed to better define the spectrum of liver disease in this understudied population.