Most SF HIV-infected urban poor have Hepatitis C; few treated for it

By Jeff Sheehy

Seventy percent of HIV-infected urban poor in San Francisco are co-infected with the hepatitis C virus, according to UCSF researchers.  And while half are currently on antiretroviral therapy to treat HIV, only four percent of those who are co-infected had received treatment for hepatitis C.

“San Francisco, like most urban centers, simply has not risen to the challenge of making hepatitis C therapy available in the same way it made HIV therapy available in the 80s and 90s.  HIV/hepatitis C co-infection leads to more severe and challenging disease than either infection alone.  Untreated hepatitis C complicates HIV disease and treatment, in particular leading to increased antiretroviral liver toxicities,” said the study’s lead author, Christopher S. Hall, MD, MS, infectious disease fellow at the UCSF Epidemiology and Prevention Interventions (EPI) Center at San Francisco General Hospital Medical Center (SFGHMC).

The study, published in the April 2004 issue of the Journal of General Internal Medicine, also found that HIV-infected urban poor persons in San Francisco will become newly infected with hepatitis C at a rate of four-and-a-half percent a year, or nearly 17 percent a year among those who use injection drugs.

“Hepatitis C therapy is difficult to take, there can be severe side effects, and it is expensive.  However, unlike HIV therapy, hepatitis C therapy cures some people of their infection. Imagine that we had a treatment for HIV that cured 30-50 percent of individuals but only made it available to a precious few,” said study co-author, David R. Bangsberg, MD, MPH, UCSF associate professor of medicine and director of the EPI Center at SFGHMC.

The study found that HIV-infected urban poor in San Francisco had good access to care—94 percent had a primary care physician and 40 percent had a case manager. However, access to hepatitis C specialty referral was more limited. People of color were less likely to receive both hepatitis C testing and referral for treatment. The researchers noted other potential barriers to treatment for hepatitis C such as marginalized housing status, provider doubts about co-infected patients’ ability to adhere to anti-hepatitis C therapies, and high rates of under-treated depression in the co-infected patient population.

“One of the limitations of this study is the inability to identify those patients clearly needing treatment for hepatitis C.  Only 21 percent of the co-infected patients had been referred to a liver specialist who could make that determination,” said Hall.

The study also found that 13 percent of the co-infected patients did not produce antibodies that enabled their hepatitis C infection to be detected by the commonly used test for it.

“This finding, which is associated with lower CD 4 T-cell counts, has important implications for screening HIV/hepatitis C co-infection. It means that routine diagnostic tests for hepatitis C may be missing infection in HIV co-infected individuals,” said Bangsberg.

Study co-authors are Edwin Charlebois, PhD, MPH, UCSF assistant professor of medicine at the AIDS Policy Research Center of the UCSF AIDS Research Institute; Judith A. Hahn, PhD, MA, specialist at the UCSF EPI Center at SFGHMC; and Andrew R. Moss, PhD, UCSF professor of epidemiology and medicine.

The study was funded by grants from the Centers for Disease Control and Prevention Post-Doctoral Fellowship Training Program in Infectious Diseases, the National Institute of Mental Health, and The Doris Duke Charitable Foundation, and an unrestricted grant from Agouron Pharmaceuticals, Inc.