1. Impact of Hepatitis C, HIV, or Both on Survival in Veterans in Care Before and After the Introduction of HAART (1996)
SL Fultz, MD, MPH
CH Chang, PhD
AA Butt, MD
M Skanderson, MSW
D Rimland, MD
MO Rigsby, MD
AC Justice, MD, PhD

2. Background HIV and hepatitis C (HCV) coinfection common
Mortality in HIV+ decreased due to HAART
Management of comorbid conditions important

3. Background Studies have reported conflicting results
HCV infection
More aggressive in HIV+ patients
Leads to faster HIV progression
HCV coinfection has no effect on survival
No study compared HCV monoinfection with HIV/HCV coinfection
1st – decreased time to HCC
2nd – increased mortality

4. Objective To determine:
Whether a survival difference exists between patients diagnosed with HCV, HIV or both compared to general medical controls
Whether these differences were affected by the introduction of HAART in 1996

5. Methods Adapted algorithm used by Fasciano, et al (1998)
Search based on ICD-9 codes:
AIDS ( )
Asymptomatic HIV (044.9 and V08)
Inconclusive HIV test results (795.8)
Diagnostic Related Group codes ( )
Found to be sensitive (93%) for HIV+ state
Only inpatient codes before FY 1997

6. Methods Identified HIV- controls matched for:
Age
Race
VISN
FY of HIV diagnosis
End of FY 1996 marker for introduction of HAART
Could cross over from pre- to post-1996 period and be analyzed in both
Censored at end of pre-1996 period if match did not cross over into post-1996 period

7. Methods HCV-related ICD-9 codes
Hepatitis C virus (070.41, , , and )
Hepatitis C carrier (V02.62)
Period of Service (POS) categorized as ‘Vietnam era and before’ versus ‘Post-Vietnam’
Used as surrogate for time of HCV infection
Same codes as used by HCV ICR
As being a Vietnam-era veteran is associated with HCV infection in the VA system

8. Methods Death information obtained from:
VA inpatient administrative data
BIRLS (Beneficiary Identification and Records Locator System)
As complete as National Death Index (NDI)

9. Methods Kaplan-Meier curves stratified pre-, post-1996
Cox proportional hazards regression
Model 1: HIV, HCV, HIV/HCV, age, race, POS, stratified pre and post-1996
Model 2: HIV, HCV, 1996 time period, POS, and interaction terms
Explain why interaction terms

10. Results - Demographics
Pre-1996
Post-1996
HIV+
HIV- N
15,685
16,161
26,521*
25,482**
Age (mean)
43.7
43.8
47.7
48.2
Race
White
40.5
41.8
42.6
44.9
African-American
49.6
48.0
45.7
Other
9.9
10.2
9.4
Observation Time
(median years)
1.39
2.76
3.96
4.54
Deaths (#)
6696
1131
4837
1987
Deaths/100 person-years
24.7
2.6
5.0
1.9
Hep C (%)
18.4
10.7
23.6
9.1
Mention that no p values because even small differences were statistically significant
*Includes 6245 crossovers
**Includes 6732 crossovers

11. Mention sample size is large, and walk through each line.

13. Cox – Stratified Model*
Pre-1996
Post-1996 HR
95% CI
HIV Infection
10.2
9.58 – 10.91
2.7
2.53 – 2.84
HCV Infection
0.3
0.22 – 0.42
1.2
1.05 – 1.39
HIV/HCV Coinfection
2.2
1.93 – 2.43
2.6
2.43 – 2.82
Post-Vietnam**
0.8
0.71 – 0.79
0.6
0.56 – 0.64
*Model also controls for age and race.

14. Cox – Model with InteractionsHR
95% CI
HIV Infection
10.4
9.75 – 11.09
HCV Infection
0.3
0.20 – 0.38
Post-1996
0.7
0.66 – 0.77
HIV, Post-1996 Interaction
0.24 – 0.28
HCV, Post-1996 Interaction
4.0
2.83 – 5.64
HIV, HCV Interaction
0.50 – 0.97
HIV, HCV, Post-1996 Interaction
1.2
0.84 – 1.73
Post-Vietnam*
0.6
0.55 – 0.59
*Baseline is ‘Vietnam era or before’

15. Conclusions HIV monoinfection HCV monoinfection HIV/HCV coinfection
Lower survival in both time periods
HCV monoinfection
“Protective” pre-1996
Increased risk of mortality post-1996 period
HIV/HCV coinfection
Similar risk of mortality as HIV monoinfection
State which analysis for each

16. Limitations Administrative data No lab or pharmacy data
Only inpatient codes before FY 1997
No information on non-VA visits
Retrospective study
Relatively short follow-up

17. Future Work Perform analysis while examining impact of: Lab data
ALT/AST
HCV Screening
CD4, HIV-1 viral load
Hemoglobin
HCV genotype
Pharmacy data
Drug and alcohol use
Medical comorbidities
Why is HCV protective?
Pharmacy data – HAART, toxicity, HCV treatment

18. Questions?