Coinfection of Hepatitis C Virus with Human Immunodeficiency Virus: Not the End of the Story: A Multicenter Egyptian Study

AST level and the mean baseline CD4 level. There is no difference between 2 groups as regard response to antiretroviral treatment. The percentage of change in the CD4 level was statistically significantly higher in the HIV group, after treatment. No statistically significant difference between the two groups regarding the overall survival analysis. Increased ALT level, basal CD4 level, and adherence to treatment were shown as independent predictors for negative PCR-HIV. Conclusion: HIV has no effect on treatment of HCV infection while HCV infection has negative impacts on HIV patients’ ability to recover their CD4 cells .


INTRODUCTION
Worldwide, 33.3 million individuals are infected with HIV. Hepatitis C (HCV) infection affects 20-30% of HIV patients, according to estimates. The blood-borne route is the primary route of HCV transmission, which accounts for the high frequency of HIV/HCV co-infection among IV drug users. The danger of transmitting HCV through percutaneous route is ten times greater than the risk of transmitting HIV [1].
Egypt was known to have the highest prevalence of HCV infection in the healthy population in the world at 13.9% in the past century.
Approximately 15% -25% are found in rural communities. An estimated 9.8% of Egyptians suffer from chronic HCV infection [2]. According to the 2008 Demographic and Health Survey, 1 in 10 Egyptians between the ages of 15 and 59 had chronic HCV infection, and 15% of the adult population of Egypt had antibodies to HCV (seropositive), and According to a second survey conducted in 2015, 7% of Egyptians between the ages of 19 and 65 were seropositive to HCV [3].
Due to their great effectiveness and safety, DAAs have recently been included to HCV infection regimens both internationally and in Egypt.
This has improved the prognosis of HCVinfected patients and reduced complications [4].
HCV is non-cytopathic in nature and does not integrate with the host genome. Liver damage resulting from HCV infection is caused by a reaction cascade triggered by host defense mechanism against HCV-related substances. To combat the viral onset, both innate and adaptive immunity are stimulated. The cell-mediated immune response involving CD4+ Th1 cells and CD8+ cytotoxic Tlymphocyte (CTL) cells was discovered to have a significant role in generating liver damage during the establishment of host immunity [5].
About 11,000 those are presently living with HIV in Egypt, according to UN AIDS (2016) figures. According to the Ministry of Health and Population (MHP), more than 13000 Egyptians was estimated to be HIV/AIDS positive in 2020. Egypt has a low HIV prevalence, with less than 0.1 % of the population being HIV positive. [6].
Because HCV is a blood-borne virus that is transmitted through direct contact with the blood of an infected person, HIV and HCV coinfection is common (62%-80%) among HIV-infected injecting drug users [7].
The indication for HCV therapy, particularly in those who have co-infected with HIV, has been enhanced due to direct-acting antivirals (DDA), which exhibit higher antiviral efficacy, less side effects, pangenotypic action, and are coformulated. It is often preferable to begin dual therapy concurrently by sequentially initiating antiretroviral (ARV) and then DAA as fast as possible [8].
In patients with HIV infection, viral coinfections are frequently observed, especially in those who have contracted HIV through a common pathway some of those co-infections may go unnoticed and have little to no effect on the HIV disease or persons who have it. In contrast, HIV coinfection with certain viral illnesses can alter the course of HIV infection naturally and vice versa. When co-infecting the same host, some infectious agents, such as HCV, HBV, human Tcell lymphotropic virus-1 (HTLV-1), human herpes virus-8 (HHV-8), and human papilloma virus (HPV), can alter both their own natural histories and the course of HIV infection and illness [9].
The primary end-point of this study is to fulfill adequate number of patients participated in both groups in this study and met the inclusion criteria based on medical record.

Secondary end-points
Feasibility of HCV impact on HIV patients and vice versa

Sample size
Sample calculation: We assume that the HCV positive antibody prevalence is 10% according to the last Egyptian HCV Health Survey [3] , HIV prevalence was about 0.1%. [6] and HCV prevalence among HIV patient was about 20-30% [1]. To provide approximately 95% power, 0.05 alpha level and, ratio (n2/n1) = 3, based on that the prevalence of HCV among HIV patient was about is approximately one third. The calculated sample size was about 311 Participants depend on that we started by 400 patients as following: 300 consecutive patients with HIV infection for group I and 100 consecutive patients with HIV & HCV coinfection for group II, all patients must fulfill all following criteria.

Inclusion criteria:
1-Adult patients above 18 years old 2-+VE PCR for HCV and HIV in group I

3-+VE PCR for HIV in group II
4-Medical records that contain all required data.
Then we had excluded any of these criteria: Exclusion criteria: 1-Medical records that missing any required necessary data.
2-Any patient died or loss of follow up (did not follow up the routine hospital visits) for three months before January 2018.

Patient assessment:
After taking the all ethical consideration, the following data were collected from medical record of patients under the study: 1. Socio-demographic data and full history taking: Personal history data (age, sex, residence, and special habits)

2.
Full clinical data and examination.

Laboratory data:
• Complete blood count.
• Polymerase Chain Reaction for hepatitis C virus.
• Polymerase Chain Reaction for human immunodeficiency virus.

4.
Treatment and follow up data.

8.
Death and its cause if possible.
Definitions of diagnostic and therapeutic protocols: The first step in hepatitis C evaluation is often blood work to check for HCV antibodies using an enzyme immunoassay.

Statistical analysis
Statistical analysis of the data was done by using Statistical Package for Social Science (SPSS) version 25.0 was applied for data analysis in the present study. The hypothesis will be tested by comparison the two groups using Fisher's exact test and Chi-square to compare two category variables. Using independent x2 tests, the Hardy-Weinberg equilibrium (HWE) of each group was assessed. The continuous data (age), will be described by mean ± (SD). The binary data (the outcome, exposure, and, potential risk factors), will be described by frequency and percentage. Nonparametric data was presented by median (min-max) with mann-whitney test for significance. The log rank test was used to test the one part of null hypothesis that was no difference in survival between two independent groups (Group I: HIV group and Group II: HIV-HCV group). Univariate and multivariate logistic regression was used to test many variables to determine which of treatment response to HAAR. P < 0.05 was considered to be statistically significant.

Study participants
Two hundred eighty-six patients joined this study out of the four hundred who fulfilled the inclusion criteria and were initially registered. Ninety-three participants served as exclusion criteria at baseline, thus three hundred and seven patients remaining in this study. We note that 21 patients can't be contacted within 3 months, 17 patient considered as early loss of follow-up and 3 patients were died as displayed in Figure (1). The mean age of the cases in the HIV group was 39.9 ± 8.7 years while the mean age in the combined HIV+HCV group was 42.8 ± 11.4 years with no statistically significant difference between the two groups, the majority of the patients in the two study groups were males, HIV group was 63.9% while the combined HIV+HCV group was 74.6%, with no statistically significant difference between the two groups, in addition there was no statistically significant difference between the two study groups as regards of residence, DM, HTN, TB and CMV infections, cirrhosis, and malignancy. As shown in (table 1).

Multivariable and Univariate Cox Regression analysis were done for all HIV patients for predicting high treatment response within the Two Years Follow-Up Period
The Multivariable and Univariate Cox regression analysis show that, increased ALT level, increased basal CD4 level, and adherence to treatment were shown as dependent and independents predictors for negative PCR, as shown in (table 2).

Comparison of biochemical data among HIV and HIV+HCV groups
Regardig the laboratory analysis, there was no statistically significant difference between the two study groups as regards of hemogloin level, platelets count, TLC count, level of ALT, serum creatinine and baseline HIV as detected by PCR. There was a statistically significant difference between the two groups regarding the AST level. The mean baseline CD4 level in the HIV group was 413.8 ± 148.7 while the mean level in the combined HIV+HCV was 276.8 ± 132.7, the mean level was statistically significantly higher in the HIV group, as shown in (table 3).

Therapeutic Findings
Data for two years observation of 3 regiments as therapeutic deferent lines were available for 286 patients 1st scheme of ART by combination of tenofovir (TDF), emtricitabine (FTC), and efavirenz (EFV) was conducted in 268 patients, 2nd scheme of ART by combination of tenofovir (TDF), emtricitabine (FTC), and dolutegravir (DTG) were conducted in 5 patients, and 3rd scheme of ART by combination of lamivudine (3TC), Azidovodine (AZT), and lopinavir/ritonavir (LPV/r) were conducted in 13 patients. We fouund that there was no statistically significant difference between two groups regarding the drug therapy.The highest percentage in the two study groups used combination of TDF/FTC/EFV and represented 94.5% and 91% in the HIV group and combined HIV+HCV group, as shown in (table 4).
The cases in the two study groups were adherent to treatment and represented 99.1% and 95.5% in the HIV group and combined HIV+HCV group respectively with no statistically significant difference between the two groups. The CD4 level after treatment in the HIV group was 600.4 ± 156.7 while the mean level in the combined HIV+HCV was 386.6 ± 163.8, the mean level was statistically highly significantly increase in the HIV group. The percentage of change in the CD4 level was statistically significantly higher in the HIV group. After treatment, HIV was positive by PCR in 1.8% and 4.5% in the HIV group and combined HIV+HCV group respectively with no statistically significant difference between the two groups, as shown in (table 5).
There was no statistically significant difference between the two groups regarding the incidence of mortality. Only 9 cases died in the two study groups; 8 cases in HIV group and 1 case only in the combined HIV+HCV group The causes of death ordered by higher incidence were Opportunistic infection, suicide and IRIS, there was no statistically significant difference between the two groups regarding the overall survival after 24 months and represented 94.1% and 92.5% in the HIV group and combined HIV+HCV group respectively, as shown in (table 6)

DISCUSSION
The main aim of this study was describing the HIV-HCV epidemiology with a focus on trends over time appears essential to understand the epidemic at the global level and better target preventive measures especially with the lack of these studies in Egypt. Therefore, the current study was conducted to highlight the situation of coinfection with hepatitis C virus and human immunodeficiency virus in Egypt as regard progress of the disease, response to therapy, comorbid conditions and Mortality rates.
One of most important finding of our study was that, the increased ALT level, increased basal CD4 level, and adherence to treatment were considered as prognostic factors for HIV treatment outcome according to the Multivariable and Univariate Cox regression analysis; this could be explained as following: Although the exact mechanisms by which HIV damages the liver are still unknown, the most significant ones may involve apoptosis (caused by caspases 2, 7, and 8), mitochondrial dysfunction, and a reduction in mitochondrial DNA in several tissues. HIV proteins may also alter the mitochondrial membrane's permeability, which can also trigger an inflammatory response that lead to elevated liver enzymes [15]. whereas the hepatotoxic effect of HAART drugs as showed in Tesfa et al. 2019 study found that, 9.2% of treatment-unaware controls saw modest liver enzyme elevation, almost 25% of HAART patients experienced mild and severe hepatic enzyme increase, in addition of HCV coinfection hepatotoxicity [16].
The use of HAART has been linked to immune reconstruction. According to the theory, a rise in CD4 cell counts would result in a strong intrahepatic immune response against HCV, most likely because of the rise in CD4 cell population. Sadly, there is little evidence to support the existence of this occurrence. In reality, this topic has been seriously questioned by a number of hypothetical case studies [17]. A quicker rate of immunological success can be attained by starting ART with higher CD4 cell counts. As compared to NVP-containing regimens, efavirenz-containing regimens enhance CD4 cell counts of the patient more quickly when baseline CD4 cell counts are greater. Hence, those with greater baseline CD4 cell counts can start an EFV-containing regimen [18].
In the current study, the mean baseline CD4 level in the HIV group was statistically significantly higher than combined HIV+HCV (P< 0.01). This agreed with Akhtar and his colleagues 2022, who showed that the mean CD4 count of HIV-HCV coinfected patients was 230 cells/mm3 while in HIV monoinfected patients, the mean CD4 count was raised to 243 cells/mm3 [19]. This is in accordance with a study by [21,22].
In the current study, there was an increase in the CD4 count after treatment compared to before treatment level. In patients with HCV genotypes 1 or 4, HIV coinfection impairs the sustained virological response and viral kinetics during pegylated interferon plus ribavirine therapy. However, for the majority of the commonly used direct-acting antiviral medication combinations, the SVR difference between HIV/HCV co-infected and HCV mono-infected individuals has diminished [26]. However, our findings surpass those of Milazzo and colleagues' (2017) and Hezode et al., 2016 practical applications investigations, which showed that the SVR 12 in HIV/HCV coinfected individuals using antivirals was about 91% SVR. This variation may result from genotypic variation or adherence among patients [27,28].
In the current study, there was no statistically significant difference between the two groups as regarding the mortality. Only 9 cases died in the two study groups; 8 cases in HIV group and 1 case only in the combined HIV+HCV group. The causes of death were Opportunistic infection, suicide and IRIS. The overall survival after 24 months and represented 94.1% and 92.5% in the HIV group and combined HIV+HCV group respectively. This agreed with Mehta et al., 2016 who included 851 patients with HIV and among them, there were 36.9% of cases were infected with HCV. They reported that those without HCV had comparable mortality rates with those who were HIV/HCV uninfected [29].
This was in accordance with Dold et al., 2019 who showed that for both patient groups, the typical observation times were comparable. (HIV 3047 days vs. 3147 days). During the monitoring period, 46 patients overall (14.3%) passed away (HIV infection: 23 (13.1%), HIV/HCV coinfection: 23 (15.8%). The two leading causes of mortality in HIV-mono-infected people were infections (n = 6, of which 4 were not linked to AIDS and 2 were), and cardiovascular disease (n = 6) [30]. The higher mortality rate in that latter study, as they analyzed the data in case without application of DAAs treatment. The lower rate of mortality was a considerable drop in liver-related mortality has been linked to effective DAA

CONCLUSION
HIV has no effect on response to treatment of HCV infection while HCV infection negatively impacts the patients on HAART's ability to recover their CD4 cells. Increased ALT levels, increased basal CD4 levels, and adherence to treatment may be good predictors of HIV treatment response, but more research with larger patient numbers is required.

Limitations
 Despite that the number of recruited patients was reasonable but not enough for considering the nature of the Egyptian society.  The main limitation of the current study was the short duration of the study that couldn't reflect the actual course in the disease progression