INSTI and DAA Approval Improved Posttransplant Survival for Patients With HIV, HCV

These findings suggest INSTI and direct-acting antiviral use has improved the safety of liver transplantation for HIV-positive patients with and without hepatitis C coinfection,

Results of a study published in Clinical Infectious Diseases found that survival after liver transplantation (LT) improved among HIV-positive patients with and without hepatitis C virus (HCV) coinfection following the approval of integrase strand transfer inhibitor (INSTI) and direct-acting antiviral (DAA) therapies.

Researchers at Baylor College of Medicine in Texas conducted this retrospective analysis using data from the United Network for Organ Sharing (UNOS). The analysis included HIV-positive adults (N=532) with and without HCV coinfection who underwent liver transplantation between 2002 and 2020. Patients were evaluated for survival outcomes on the basis of undergoing transplantation prior to or after the approval of INSTIs in 2012 and DAAs in 2013.

There were 246 patients with HIV monoinfection and 286 with HIV and HCV coinfection included in the analysis, of whom the median age at transplant receipt was 53 (IQR, 45-58) and 56 (IQR, 49-62) years, 78.5% and 79.7% were men, 56.1% and 57.7% were White, and the median Model for End-stage Liver Disease (MELD) score was 22.5 (IQR, 13-32) and 17 (IQR, 12-25) respectively.

Among patients with HIV monoinfection, 68.3% underwent transplantation in the pre-INSTI period. With the exception of a lower rate of hepatitis B antigen positivity, these patients were older and had higher rates of  nonalcoholic steatohepatitis, portal venous thrombosis, previous spontaneous bacterial peritonitis, and obesity compared with patients who underwent transplantation in the pre-INSTI period.

The overall survival rates at 1 and 2 years were 86% and 81%, respectively, among patients with HIV monoinfection. Stratified by INSTI approval, the 2-year survival rate was higher for these patients in the post-INSTI period compared with the pre-INSTI period (87% vs 83%, respectively).

Among patients with HIV and HCV coinfection, 42.0% underwent liver transplantation in the post-DAA period. These patients were older, had higher MELD scores, waited longer for transplant receipt, and had higher rates of hepatocellular carcinoma and portal venous thrombosis compared with those who underwent transplantation in the pre-DAA period.

The overall posttransplant survival rates at 1 and 2 years were 84% and 78%, respectively, among patients with HCV coinfection. However, the 2-year survival rate was significantly higher among patients who underwent transplantation in the post-DAA vs pre-DAA period (83% vs 75%; P =.018).

[T]he posttransplant mortality has greatly improved after the adoption of INSTI and DAA therapy, with an increased number of patients across the country receiving transplantation.

Further analysis was performed after patients with HIV monoinfection were propensity-score matched against patients with chronic liver disease without HIV or HIV and HCV infection. In comparing these patients, the risk of mortality was higher among those with HIV monoinfection who underwent transplantation in the pre-INSTI period (hazard ratio [HR], 2.060; 95% CI, 1.172-3.621; P =.012). However, for transplantations performed in the post-INSTI period, no significant difference in mortality risk was observed between these 2 patient groups (HR, 0.767; 95% CI, 0.419-1.402; P =.389).

Similar results were observed when patients with HIV and HCV coinfection were compared with a propensity-scored matched cohort of healthy control patients. The comparison showed a significantly increased mortality risk among HIV-positive patients with and without HCV coinfection in the pre-DAA period (HR, 2.497; 95% CI, 1.670-3.733; P <.001) but not in the post-DAA period (HR, 0.935; 955 CI, 0.481-1.814; P =.842).

Study limitations include the retrospective design, potential selection bias, and the inability to confirm INSTI and DAA use for each patient.

Despite prior reports of poor transplantation outcomes among HIV-positive patients with and without HCV coinfection, “the posttransplant mortality has greatly improved after the adoption of INSTI and DAA therapy, with an increased number of patients across the country receiving transplantation,” the researchers noted. “It is important to ensure that people with HIV have fair access to liver transplants when indicated,” they concluded.

This article originally appeared on Infectious Disease Advisor

References:

Jacob JS, Shaikh A, Goli K, et al. Improved survival after liver transplantation for patients with human immunodeficiency virus (HIV) and HIV/hepatitis C virus coinfection in the integrase strand transfer inhibitor and direct-acting antiviral eras. Clin Infect Dis. Published online October 12, 2022. doi:10.1093/cid/ciac821