Division of Infectious Diseases and Chronic Viral Illness Service, Department of Medicine.
Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec.
AIDS. 2019 May 1;33(6):1013-1022. doi: 10.1097/QAD.0000000000002156.
Hepatitis C virus (HCV) treatment may reduce liver-related mortality but with competing risks, other causes of mortality may undermine benefits. We examined changes in cause-specific mortality among HIV-HCV coinfected patients before and after scale-up of HCV treatment.
Prospective multicentre HIV-HCV cohort study in Canada.
Cause-specific deaths, classified using a modified 'Coding of Cause of Death in HIV' protocol, were determined for two time periods, 2003-2012 and 2013-2017, stratified by age (20-49; 50-80 years). Comparison of trends between periods was performed using Poisson regression. To account for competing risks, multinomial regression was used to estimate the cause-specific hazard ratios of time and age on cause of death, from which end-stage liver disease (ESLD)-specific 5-year cumulative incidence functions were estimated.
Overall, 1634 participants contributed 8248 person-years of follow-up; 273 (17%) died. Drug overdose was the most common cause of death overall, followed by ESLD and smoking-related deaths. In 2013-2017, ESLD was surpassed by drug overdose and smoking-related deaths among those aged 20-49 and 50-80, respectively. After accounting for competing risks, comparing 2003-2012 to 2013-2017, ESLD deaths declined (adjusted hazards ratio: 0.18, 95% confidence interval 0.05-0.62). However, both early and late period cumulative incidence functions demonstrated increased risk of death from ESLD for patients with poor HIV control and advanced fibrosis.
The gains made in overall mortality with HCV therapy may be thwarted if modifiable harms are not addressed. Although ESLD-related deaths have decreased over time, treatment should be further expanded, prioritizing those with advanced fibrosis.
丙型肝炎病毒（HCV）治疗可能降低与肝脏相关的死亡率，但由于存在竞争风险，其他死亡原因可能会削弱治疗的益处。我们研究了 HCV 治疗扩大规模前后 HIV 合并 HCV 感染患者的特定病因死亡率的变化。
加拿大前瞻性多中心 HIV-HCV 队列研究。
使用改良的“HIV 中死因编码”方案对两个时间段（2003-2012 年和 2013-2017 年）的特定病因死亡进行分类，按年龄（20-49 岁；50-80 岁）分层。使用泊松回归比较两个时期的趋势。为了考虑竞争风险，使用多分类回归估计时间和年龄对死亡原因的特定危险比，从这些特定危险比中估计终末期肝病（ESLD）的 5 年累积发生率函数。
共有 1634 名参与者贡献了 8248 人年的随访时间；273 人（17%）死亡。药物过量是总体上最常见的死因，其次是 ESLD 和与吸烟相关的死亡。在 2013-2017 年，20-49 岁和 50-80 岁人群中，ESLD 分别被药物过量和与吸烟相关的死亡所取代。在考虑竞争风险后，与 2003-2012 年相比，2013-2017 年 ESLD 死亡减少（调整后的危险比：0.18，95%置信区间 0.05-0.62）。然而，无论是早期还是晚期的累积发病率函数都表明，HIV 控制不佳和纤维化程度较高的患者发生 ESLD 相关死亡的风险增加。
如果不能解决可改变的危害，HCV 治疗带来的整体死亡率的提高可能会受到阻碍。尽管随着时间的推移，ESLD 相关的死亡人数有所减少，但仍应进一步扩大治疗范围，优先考虑纤维化程度较高的患者。
