Direct-acting antivirals against hepatitis C would be the main driver of the observed change
A US study published in Transplantation Direct has concluded that survival after liver transplantation has increased significantly in people co-infected with HIV and hepatitis C virus (HCV) after the arrival and widespread use of direct-acting antivirals (DAA, in its acronym in English) against the liver virus.
Because liver damage progresses more rapidly in people coinfected with HIV and HCV than in those monoinfected with HCV, coinfected people are more likely to progress to end-stage liver disease and require a liver transplant.
Before the introduction of DAAs, people coinfected with HIV and HCV had poorer outcomes after transplantation than those with HCV alone. However, the paradigm shift brought about by the arrival of AEDs, with very high cure rates of the liver virus with short treatment cycles, has generated a total paradigm shift, which should have an impact on the results after transplantation of coinfected people who have succeeded in eliminating HCV with DAAs.
To shed more light on this issue, the authors of the present study analyzed the cases registered in the US transplant database to establish whether outcomes after liver transplantation in people with HIV and HCV had improved after the introduction of the DAAs.
The study compared the results of liver transplantation in people with HIV (with or without HCV coinfection) with those of people only infected with HCV and with those without any virus. This generated several subgroups to be compared between them. Comparisons were made in two periods: it was pre DAA (2008-2012) and it was post DAA (2013-2019). The year 2013 was excluded from the analysis because DAAs are still in deployment and with inconsistent use on a large scale. In addition, in that year the first generation DAAs were used mainly, which were less effective than those that appeared later.
Between 2008 and 2019, 64,860 liver transplants were performed in the United States in people with known HIV status. In the pre-DAA era there were 24,238 transplants, of which 68 took place in people with HIV and HCV and 49 in people infected only by HIV. Those transplanted with HIV were younger and had a shorter waiting list, while those without HCV had a more deteriorated health status at the time of transplantation.
People coinfected with HIV and HCV had a significantly higher risk of transplant failure during the pre-AAD era (hazard ratio [HR]: 1.85, 95% confidence interval [95% CI]). %]: 1.31-2.59) to that observed in those people without any viral infection. This significant difference disappeared during the post-AAD era, during which, three years after transplantation, 81% of liver transplant recipients coinfected with HIV and HCV were still alive and without having experienced rejection, a percentage much higher than that observed in this same group during the pre DAA era, where it was 56% (p = 0.006).
Survival without rejection of the transplant at three years of the same during the post AAD era in non-coinfected people was similar: 80% in HIV monoinfected, 83% in HCV monoinfected and 84% in non-infected with HIV. HIV or HCV.
Overall survival did not differ between the groups either: 84% of those coinfected, 81% of those monoinfected with HIV, 84% of those monoinfected with HCV, and 86% of those without viral infections were still alive at three years of transplantation during the post AAD era.
The three-year survival without transplant rejection during the post-AAD era among people with HIV who had received a liver transplant from a person with HIV was 82%, that is, without significant differences with respect to what was observed when the donor was seronegative.
The results of the present study are very encouraging, since they show a clear improvement in the results after liver transplantation in people with HIV and HCV thanks to DAAs and, in addition, they point to an important viability of the livers donated by people with HIV to people with HIV, which increases the likelihood of accessing an organ for the HIV positive community while awaiting a liver transplant.
Source: Aidsmap / Elaboración propia (gTt).
References: Cotter TG et al. “Raising HOPE”: Improved outcomes for HIV/HCV-coinfected liver transplant recipients in the direct-acting antiviral era. Transplantation Direct, 7: e707, 2021.