This study analyzed surveillance data from 2000-2009 in DC to examine the impact of chronic HCV co-infection on HIV clinical outcomes. It found that 11.3% of reported HIV cases were co-infected with HCV. Co-infected individuals were more likely to be black, over age 40, and infected through injection drug use. They had lower CD4 counts at most recent tests and higher mortality, even after adjusting for covariates. While over half of co-infections were with HCV first, co-infection negatively impacts HIV disease progression. Improved data and prevention/treatment programs for high-risk groups are recommended.

1. Impact of Chronic HCV Co-infection
on HIV Clinical Outcomes in the
District of Columbia
Sarah Willis, MPH
Department of Epidemiology and Biostatistics
School of Public Health and Health Services
The George Washington University
2011 National HIV Prevention Conference

2. A Public Health/Academic Partnership
between the
District of Columbia Department of Health
and
The George Washington University School of
Public Health and Health Services
Department of Epidemiology and Biostatistics
Contract Number POHC-2006-C-0030

3. Background
• An estimated 1/4 of those infected with HIV are
also infected with hepatitis C virus (HCV)
• Estimates of HIV/HCV co-infection range from 50-
90% among certain sub-populations
• Supporting evidence that HIV negatively impacts
HCV disease progression and reduces the
effectiveness of available treatments

4. Background (2)
• Less research has been conducted regarding
role of HCV co-infection on HIV disease and
existing studies have conflicting results
– Association between HCV/HIV co-infection and
worsening liver disease and higher mortality
when compared to those with HIV or HCV
monoinfection (Merriman et al)
– HCV co-infection associated with blunted CD4
cell recovery after initiating HAART yet no effect
on virologic response or mortality (Carmo et al)

5. Objectives
Utilize routinely reported surveillance data to:
1. Determine the extent of HIV/HCV co-infection
in the District of Columbia between 2000-2009
2. Describe potential factors that may be
associated with HIV/HCV co-infection
3. Determine the impact that HIV/HCV co-
infection has on HIV clinical outcomes and
mortality

6. Methods
• Identified name-based HIV/AIDS cases diagnosed
and reported to the DCDOH between 2000 – 2009
(n=10,215)
• Identified chronic HCV cases reported to DCDOH
during the same time period (n=16,235)
• Used Link Plus Probability matching program to
match cases by:
– First and last name
– Date of birth
– Sex
– Race
• Reviewed potential matches for accuracy

7. Methods (2)
• Performed bivariate analyses to detect differences
among HIV/HCV co-infected and HIV mono-infected
individuals based on:
– Demographics
– Entrance into HIV Care (time between HIV/AIDS diagnosis
and first VL or CD4 test reported to DCDOH)
– Engagement in HIV Care
• Continuous Care - evidence (e.g. HIV-related lab test) of at least 2
visits to an HIV medical provider 10-14 weeks apart
• Sporadic care - one visit to a provider or 2 visits but more than 14
weeks apart
– Viral load and CD4 count (at time of diagnosis and most
recent results)
– Mortality

8. Methods (3)
• Assessed timing of HIV/HCV co-infection
• Association between HIV/HCV co-infection
and mortality (time to death) examined
through:
– Kaplan-Meier log rank test/log rank survival plots
– Cox proportional hazard ratio model

9. Demographics of Co-Infected
and Monoinfected Cases
11.3% of reported HIV cases were HCV co-infected
HIV/HCV HIV
Chi-square
Co-infected Monoinfected
p-value
(n=1,151) (n=9,017)
Sex
Male 67.2% 70.5% 0.0189
Female 32.8% 29.5%
Race/ethnicity
White 4.5% 14.4%
Black 90.4% 77.5% <0.0001
Hispanic 3.1% 5.8%
Other* 2.0% 2.3%
*Other race includes Asian, Alaska Native, American Indian, Native Hawaiian,
Pacific Islander, and Mixed and Unknown race

10. Age and Vital Status of
Co-Infected and Monoinfected Cases
HIV/HCV HIV
Chi-square
Co-infected Monoinfected
p-value
(n=1,151) (n=9,017)
Age at HIV diagnosis
13-19 0.2% 3.1%
20-29 3.7% 20.6%
30-39 13.9% 32.4% <0.0001
40-49 48.1% 28.1%
50-59 28.8% 11.8%
≥60 5.3% 4.1%
Vital Status*
Alive 80.5% 88.5% <0.0001
Dead 19.5% 11.5%
*as of December 31st, 2009

11. HIV Mode of Transmission
45.0%
40.3%
40.0%
36.4%
Proportion of Diagnosed Cases
35.0%
31.6%
30.0%
25.0% 23.5%
20.0% 17.6% 17.2%
15.0% 12.1% 13.8%
10.0%
4.6%
5.0% 2.6%
0.0%
MSM IDU MSM/IDU Heterosexual Risk Not
Identified
HIV/HCV Co-infected HIV

12. Timing of HIV/HCV Infection
Concurrent
Infections
(< 3 months
apart)
27.1%
HCV Infection
3+ months
prior to HIV
58.7% HIV Infection
3+ months
prior to HCV
14.2%

13. HIV Care Seeking Behavior
HIV/HCV HIV
Chi-square
Co-infected Monoinfected
p-value
(n=1,151) (n=9,017)
Entrance into Care
< 3 months 56.9% 59.9%
3 – 6 months 5.7% 4.6%
<0.0001
6 – 12 months 6.3% 5.6%
> 1 year 25.0% 20.4%
Not in care 6.0% 9.5%
Engagement in Care
No care 6.0% 9.5%
<0.0001
Sporadic Care 57.7% 61.4%
Continuous Care 36.3% 29.1%

14. HIV Viral Load at Time of HIV Diagnosis
100,000
90,000
Median Viral Load at Diagnosis
80,000
70,000
(copies/mL)
60,000
50,000
40,000
30,000
20,000
16,406
10,000 10,551
0
HIV/HCV Co-infection HIV only
Kruskal Wallis; p = 0.3031

15. Most Recent Viral Load Results
3,500
3,000
2,500
2,000
1,500
1,000
500
0 74 74
HIV/HCV coinfection HIV only
Kruskal Wallis; p = 0.0119

16. CD4 Count at HIV Diagnosis
500
450
Median CD4 Count at Diagnosis
400
350
300
(cells/µL)
250
200 192
185
150
100
50
0
HIV/HCV coinfection HIV only
Kruskal Wallis; p-value = 0.3986

17. Most Recent CD4 Results
700
600
Median CD4 Count (cells/µL)
500
445
400 389
300
200
100
0
HIV/HCV coinfection HIV only
Kruskal Wallis; p-value = 0.0002

18. Survival Among
HIV/HCV and HIV only cases
HIV only cases
HIV/HCV co-infected cases
Log-rank = 47.35
p-value = <0.0001

19. Adjusted Hazard Ratio for
Mortality among HIV/HCV Co-infected Cases
Adjusted Hazard 95% Confidence
Ratio† Interval
HCV/HIV vs. HIV only 1.20 1.02, 1.40
†Adjusted for sex, race/ethnicity, age, engagement in care, HIV mode
of transmission, and progression to AIDS

20. Conclusions
• More than half of HIV/HCV co-infections were
infected with HCV first
• In comparison to HIV monoinfected cases, HIV/HCV
co-infected cases in DC were more likely to be:
– Black
– Over 40 years of age
– IDU
• HIV/HCV co-infected cases in DC may have poorer
HIV clinical outcomes over time
– Lower CD4 counts among HIV/HCV co-infected cases at
most recent test
– Increased mortality among HIV/HCV co-infected cases

21. Limitations
• May have underestimated HIV/HCV co-
infections due to errors in data entry, name
changes or incorrect spelling
• Large proportion of cases with missing CD4
and viral load data at diagnosis and at follow-
up (25%-75%) in eHARS, could not assess their
clinical outcomes

22. Recommendations
• Subsequent studies should be conducted to better
understand the impact of HCV co-infection on HIV
disease
• Studies utilizing surveillance data for this purpose
should:
– Improve completeness of VL and CD4 test results data
– Obtain data on ART utilization
• Prevention and treatment interventions should be
developed for sub-populations with high rates of
HCV/HIV co-infection, such as IDUs

23. Acknowledgments
DC DOH HIV/AIDS, George Washington
Hepatitis, STD, TB University School of
Administration Public Health and Health
– Angelique Griffin* Services
– Yujiang Jia – Amanda D. Castel*
– Gregory Pappas – Irene Kuo*
– Rowena Samala – Alan Greenberg
– Tiffany West*
*Co-authors