When HIV and liver disease co-exist

Since successful antiretroviral therapies have made HIV a treatable condition, more HIV patients who are also infected with hepatitis B or C are experiencing the progression of their liver disease.

In the face of this novel challenge, experts in the field convened to share information and opinions on the management of such patients. The conference discussions are summarized in June issue of Hepatology, a journal published by John Wiley & Sons on behalf of the American Association for the Study of Liver Diseases (AASLD) The article is also available online at Wiley Interscience (http://www.interscience.wiley.com/journal/hepatology).

Because of shared modes of transmission, HIV and viral hepatitis infections often coexist. Since therapies have made HIV a manageable condition, hepatologists are seeing more infected patients with complex liver issues. To address questions about care for these co-infected patients, an international forum was convened in Jackson Hole, Wyoming in September 2006. The meeting brought together laboratory and clinical researchers, drug developers and government representatives to discuss the state of the field, research needs, and collaborative possibilities. The conference topics are summarized by Kenneth Sherman, MD, PhD, of the University of Cincinnati and colleagues in the current issue of Hepatology.

An estimated 3 to 4 million people are infected with both HIV and hepatitis B (HBV) while 4 to 5 million people have HIV and chronic hepatitis C (HCV). "The natural history of coinfection, particularly for HCV/HIV in the era of highly active antiretroviral therapies is still a matter of debate, and is important as it influences intervention strategies," the authors report. However, recent studies have shown increasing rates of liver disease and related death among those with HIV.

Conference attendees discussed immune responses to hepatic disease in patients with HIV as well as how the viruses interact to result in liver injury. They also considered how treatment options, including antiretroviral agents, might affect the liver.

In treating HIV/HCV co-infected patients, studies have shown that pegylated interferon with ribavirin is better than interferon-only regimens. For patients with HIV/HBV, combination therapy is routine, though viral mutation and drug resistance remain troubling issues. A key topic of conversation was the development of new agents for treating viral hepatitis in patients with HIV. Challenges include the risk of hepatic injury and low patient tolerance which limits compliance. All agreed that new agents should be tried.

Until recently, liver transplantation was not an option for patients with HIV; however, it is now a possibility. "It is imperative not to wait until the patient is moribund," the authors report, adding that successful outcomes depend on the collaboration of surgeons, hepatologists, infectious disease specialists and pharmacologists.

"In summary, a number of areas were identified as needing further research," they conclude. "A close cooperation between clinicians and researchers is required to ensure high quality translational research."