Objective: Although discrepancies between histological and virological responses to anti-hepatitis C virus (HCV) therapy are well-established in HIV-negative patients, the liver histological outcome has never been assessed in HIV–HCV co-infected patients receiving anti-HCV therapy. We compared histological responses to interferon (IFN) α therapy between HIV-positive and HIV-negative injecting drug users (IDU) and determined factors associated with histological response.
Design: Retrospective cohort study.
Setting: Hepatology unit of a tertiary referral hospital.
Patients/interventions: Seventy-nine HCV-infected IDU (32 HIV-positive) receiving a 6-month course of IFN-α2b therapy, 3 × 106 U three times a week.
Primary outcome measure: Histological response, defined by a ≥ 2 point decrease in total Knodell score measured on paired liver biopsies over a 2-year follow-up period.
Results: The sustained response rate to IFN therapy was lower in HIV-positive patients than in HIV-negative patients (6.2% versus 29.8%;P = 0.012). Conversely, the rates of histological response (40.6% versus 36.2%) were not different between HIV-positive and HIV-negative patients. Independent factors associated with histological response were first total Knodell score (P = 0.0007) and sustained response to IFN therapy (odds ratio, 12.34;P = 0.005). Histological response was observed in 25% of IFN non-responders whatever their HIV status. In HIV-positive patients, the CD4 cell count did not influence the histological response.
Conclusions: in HIV–HCV co-infected patients treated with IFN, liver histological improvement is frequently observed, similarly to that observed in HIV-negative patients. Such beneficial effect of interferon therapy supports early treatment of chronic hepatitis C in HIV-infected patients.
From the Service d'Hépatologie, INSERM U481 et Centre de Recherche Claude Bernard sur les hépatites virales, and aService d'anatomopathologie, Hôpital Beaujon, 92110 Clichy, France.
Requests for reprints to: P. Marcellin, 100 Bd du Général Leclerc, Hôpital Beaujon, 92110 Clichy, France.
Received: 20 July 2001;
revised: 17 September 2001; accepted: 19 September 2001.
Hepatitis C virus (HCV) infection is highly prevalent among HIV-infected individuals and has been shown to favor mortality both by compromising CD4-cell recovery in patients receiving antiretroviral therapy  and by inducing rapidly evolving cirrhosis [2–4]. These data support early treatment of hepatitis C in HIV-infected patients. Unfortunately, interferon (IFN) α therapy in HIV–HCV coinfected patients gave disappointing results with regard to virological or biochemical sustained responses [5–12], and no sequential liver biopsy evaluation was provided in previous studies. However, IFN therapy alone or in combination with ribavirin can induce a decrease in liver necroinflammatory lesions or fibrosis in HIV-negative patients even in the absence of a virological response [13–15]. Hence, liver histology outcome is the best endpoint for evaluating whether anti-HCV therapy is able to prevent HCV-related cirrhosis in HIV–HCV coinfected patients. We thus performed a comparative histological follow-up study between HIV-positive and HIV-negative patients with chronic hepatitis C treated with IFN-α, to assess the outcome of liver lesions and to identify the factors associated with liver histological improvement.
Patients and methods
Thirty-two HBsAg-negative HIV–HCV coinfected patients who received IFN-α therapy and underwent a second liver biopsy after the end of treatment were included in the study. The year of initiating IFN therapy ranged between 1989 and 1994. A control group consisted of 47 HIV-negative patients, treated with IFN during the same period with the same schedule and with available paired liver biopsy samples. All of the studied patients were injecting drug users (IDU), with a mean age of 31 years and a mean duration of hepatitis C of 10 years. The overall distribution of HCV genotypes, the proportion of heavy alcohol consumers and cirrhotic patients at baseline were not different between HIV-positive and HIV-negative patients. The HIV-positive patients had higher serum aspartate aminotransferase (AST), gammaglutamyl transpeptidase (GGT), HCV RNA levels and total Knodell scores than did the HIV-negative patients. In HIV-positive patients, the CD4 cell count was 482 ± 261 × 106/l (range, 165 × 106 − 1360 × 106/l) at baseline (Table 1). The only antiretroviral therapies used were zidovudine (n = 22) or didanosine (n = 2).
All patients received a 6-month course of IFN-α (Schering-Plough, Kenilworth, New Jersey, USA) therapy, 3 × 106 U three times a week, that was the standard regimen used at this time.
Serological and virological markers
HIV infection was assessed by the positivity of two serological tests including ELISA and Western blot. HCV infection was assessed by the positivity of two serological tests (EIA-3.0 and RIBA; Ortho Diagnostics, Raritan, New Jersey, USA), retrospectively from stored sera in patients seen before 1993. Quantification of serum HCV RNA was performed using branched-DNA signal amplification assay (Quantiplex-HCV, Chiron, Emeryville, California, USA) from 54 sera (21 HIV-positive, 33 HIV-negative) harvested at baseline and stored in optimal condition at −80°C. HCV genotype was determined according to the Simmonds’ classification in the 54 stored serum samples using probe-hybridization assay (InnoLipa HCV, Innogenetics, Ghent, Belgium).
The first liver biopsy samples were obtained 3 ± 2 months before the initiation of IFN and the second liver biopsy 23 ± 16 months after the end of IFN therapy. Histological examination was performed retrospectively by the same pathologist (C.D.) without knowledge of name, HIV status and date of liver sample. All biopsies were formalin-fixed and paraffin-embedded. Sections 5 μm thick were stained with haematoxylin and eosin. Liver necroinflammatory lesions and fibrosis were scored according to the Knodell scoring system .
Definition of histological response to interferon therapy
The histological response was defined by a decrease in total Knodell score ≥ 2 points between the first and the second liver biopsy evaluation. A decrease in fibrosis was defined by a decrease in the fibrosis score of ≥ 1 point. Factors associated with histological response and decrease in fibrosis score were assessed separately.
Quantitative results were expressed by mean ± SD, or median (range) in case of abnormal distribution. Univariate analyses were performed using the chi-squared, Fisher, Student, and Mann–Whitney U tests. A P value < 0.05 was considered as statistically significant. Multivariate analysis was performed using logistic regression model on the basis of univariate analysis results and absence of colinearity.
Biochemical response to IFN therapy
Virological response to IFN therapy was not analyzed because numerous stored serum samples were not available for retrospective PCR analysis. A primary biochemical response to IFN therapy, defined by the normal serum ALT at the end of treatment, was observed in 17 HIV-positive and 30 HIV-negative patients (53% versus 64%; non-significant). A sustained biochemical response to IFN therapy, defined by normal serum ALT levels during the 6 months after the end of treatment, was observed in two HIV-positive and 14 HIV-negative patients (6.2% versus 29.8%;P = 0.012). In HIV-positive patients, the median (range) CD4 cell count was not significantly higher in patients who achieved biochemical sustained response compared to those who did not (855 × 106/l (range, 350 × 106 −1360 × 106/l) versus 443 × 106/l (range, 165 × 106 −1100 × 106/l); non-significant). The other factors associated with sustained response to IFN therapy were low serum HCV RNA level (P = 0.022), HCV genotype other than genotype 1 (P = 0.050), and low serum GGT activity (P = 0.031).
Histological response to interferon therapy
Variation of the total Knodell score
The total Knodell score varied from 8.2 ± 2.4 to 7.7 ± 2.9 in HIV-positive patients, and from 6.3 ± 2.1 to 5.8 ± 2.8 in HIV-negative patients. Although the last Knodell score was still higher in HIV-positive patients as compared with HIV-negative patients (P = 0.006), the magnitude of the decrease was not different between both groups (Table 2). Histological response to interferon therapy, as defined by a decrease of ≥ 2 points in total Knodell score, was observed in 13 HIV-positive patients and 17 HIV-negative patients (40.6% versus 36.2%; non-significant). In HIV-positive patients, the median (range) CD4 cell count was not different between patients who achieved a histological response to IFN therapy and those who did not (377 × 106/l (range, 180 × 106 −1360 × 106/l) versus 540 × 106/l (range, 165 × 106 −710 × 106/l); non-significant).
Factors associated with histological response
Histological response to IFN therapy was more frequent in patients who achieved sustained biochemical response to IFN therapy than in those who did not [68.8% versus 30.9%; odds ratio (OR), 4.9;P = 0.008]. Nevertheless, in non-responders, histological response to IFN was observed in eight cases, without significant influence of HIV status [three HIV-positive (20%) and five HIV-negative (29.4%) patients; non-significant NS]. Histological response was more frequent in patients with HCV RNA level < 1 × 106 genome equivalents/ml (55.6% versus 23.5%; OR, 4.1;P = 0.023), and in patients with a high total Knodell score at baseline (P = 0.0002). Conversely, sex, age, duration of chronic hepatitis C, alcohol consumption, baseline liver biochemistry, time elapsing the two biopsies or HCV genotype had no significant influence on the histological response. Through multivariate analysis, two independent factors were associated with histological response: pretreatment total Knodell score (P = 0.0007) and sustained response to IFN therapy (OR, 12.34;P = 0.005). HIV coinfection had no influence.
Variation of the fibrosis score
The Knodell fibrosis score varied from 1.8 ± 2.4 to 1.7 ± 1.2 in HIV-positive patients, and from 1.3 ± 1.0 to 1.4 ± 1.0 in HIV-negative patients (non-significant). Among the 32 HIV-positive patients, the fibrosis score decreased in six, did not change in 19, and increased in seven. This distribution was similar in the 47 HIV-negative patients (seven, 32, and one, respectively; non-significant). In HIV-positive patients, the median (range) CD4 cell count of patients who experienced a decrease in liver fibrosis was similar to that of patients who did not (440 × 106/l (range, 200 × 106 −510 × 106/l) versus 375 × 106/l (range, 180 × 106 −1360 × 106/l); non-significant).
Factors associated with a decrease in fibrosis score
Decrease in fibrosis score was more frequent in patients who achieved primary biochemical response to IFN therapy than in others (23.4% versus 6.2%; OR, 4.6;P = 0.039). Decrease in fibrosis score was nevertheless observed in three non-responders, irrespective of HIV status [one HIV-positive (6.7%) versus two HIV-negative (11.8%); non-significant]. Decrease in fibrosis score was less frequent in HCV genotype 1-infected patients as compared to others (5% versus 29.4%; OR, 8.6;P = 0.023), and was more frequent in patients with high fibrosis score at baseline (P < 0.0001). Conversely, age, HCV duration, alcohol consumption, liver biochemistry or HCV RNA level had no significant influence on liver fibrosis score outcome.
Our results show substantial liver histological improvement in 41% of HIV–HCV coinfected patients treated with IFN. This relatively high rate of histological improvement was observed despite the low rate of sustained biochemical response to IFN observed in HIV-positive patients, which reflected low sustained virological response rates reported previously [10,11]. The low rate of sustained response found in our HIV-infected patients may be the consequence of high serum HCV RNA levels and a high proportion (52%) of HCV genotype 1 .
The improvement in liver histology concerned mainly liver necroinflammatory lesions and was similar whatever the HIV status. Rapid liver fibrosis progression was reported in HIV-positive patients . In our study, a 6-month course of IFN therapy was associated with the stabilization or decrease in liver fibrosis in the majority of HIV-infected patients (78%). This resulted in a 0.1 point decrease in fibrosis score which is lower than the estimated liver fibrosis progression in HIV–HCV untreated patients (0.4 point increase in fibrosis score) during a comparable follow-up period . Because histological assessment was performed 2 years after the end of IFN therapy, we may hypothesize that the effect of IFN therapy on liver histology may be long lasting in some patients and may substantially decrease the risk for HCV-related cirrhosis in both HIV–HCV coinfected patients and in HIV-negative patients [13,14].
Our study has some limitations. First, the anti-HCV therapy used was not the currently preferred treatment for HCV infection, i.e., IFN plus ribavirin . Recent studies suggest that a combination of IFN and ribavirin is more effective than IFN alone in HIV–HCV coinfected patients [6,12,18]. Hence, the benefit of IFN therapy on liver histology reported in the present study should be still true for patients receiving IFN–ribavirin combination therapy, as already shown in HIV-negative patients [14,15]. Ribavirin might be associated with intolerance, drug interactions and increased mitochondrial toxicity in HIV-positive patients [12,19,20]. Therefore, in this setting, IFN monotherapy might be an acceptable alternative to combination therapy. Another limitation is that the HIV-infected population of the present study does not reflect the present HIV-positive population that often receives highly active antiretroviral therapy (HAART). However, this fact allowed a better demonstration of the liver histology improvement in IFN-treated HIV-positive patients, since HAART should confuse histological findings [21–25]. In the present study, the majority of HIV-positive patients had a high CD4 cell count at baseline. This did not allow complete investigation of whether CD4 cell count may influence histological response to IFN therapy. In untreated patients, the CD4 cell count has been shown to strongly influence liver fibrosis progression in HIV–HCV coinfected patients . In our study, baseline CD4 cell count was not different between HIV-positive patients who experienced histological improvement and those who did not; however, the small number of patients considered for this analysis should have induced a type-2 error. We thus cannot rule out that low CD4 cell count may reduce the IFN-induced histological improvement in liver fibrosis.
In conclusion, our study shows that IFN therapy is associated with histological improvement in patients with HIV–HCV coinfection, even in the absence of HCV clearance. This observation supports the treatment of chronic hepatitis C at an early stage of HIV infection.
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