PD-3 Hepatocellular carcinoma in HIV-infected patients: Clinical presentation and outcomes in a racially diverse urban population

Abstract

As life expectancy for HIV patients improves in the highly active antiretroviral treatment (HAART) era, hepatocellular carcinoma (HCC) has become a non-AIDS-defining illness with a high impact on morbidity and mortality of HIV-infected patients. We sought to compare outcomes in HIV versus non-HIV patients diagnosed with and treated for HCC at a multiethnic urban academic medical center. A retrospective chart review of patients diagnosed with HCC from 1/1/2005 to 12/31/2016 was performed. Subjects included had at least one-week of follow-up and were censored at last point of contact. Variables collected included HIV status, HIV viral load, CD4 count, Hepatitis B virus (HBV) and Hepatitis C virus (HCV) infection, TMN stage, ECOG performance status, MELD score, and AFP level at diagnosis, as well as treatments received. Bivariate associations comparing characteristics between HIV and non-HIV subjects were assessed using t-tests or non-parametric equivalents for continuous variables and chi-square tests for categorical variables. Associations between HIV status, viral load and CD4 count, and overall survival (OS) were assessed using Cox proportional hazards regression as well as the Kaplan-Meier method with log-rank test. We identified 819 non-HIV and 73 HIV-infected subjects. Race was 17.3% white and 26.7% black for non-HIV versus 2.7% white and 43.8% black for HIV subjects (p=0.001). Ethnicity was 34.1% Hispanic in non-HIV versus 26.0% in HIV subjects. Mean age was 64.2 versus 57.2 years in non-HIV versus HIV subjects (p< 0.001). Rates of HBV (6.7 versus 17.8%, p< 0.001), HCV (59.8 versus 75.3%, p=0.022), and alcohol use (17.6 versus 38.4%, p< 0.001) were lower in non-HIV compared to HIV subjects. Of non-HIV subjects, 34.7% had AFP level >100 at diagnosis versus 49.3% of HIV subjects (p=0.015). Stage, MELD, and ECOG score at diagnosis showed no significant associations with HIV status. While rates of resection and regional treatments were similar, transplantation occurred more often in non-HIV compared to HIV subjects (10.4 versus 2.7%, p< 0.022). Median follow-up was 18.2 months. The 3-year actuarial OS for all patients was 49.7%, and significantly worse for those with HIV infection (37.0 vs. 50.9%, p=0.024). Patients with HIV also had worse OS on multivariable analysis (HR=1.90, p=0.001) when adjusting for age, MELD, AFP, stage and performance status. Viral load, but not CD4 count showed a significant association with survival (p=0.017 and p=0.070, respectively by log-rank test). HIV-infected HCC subjects have lower survival rates compared with those without HIV. Despite younger age and similar MELD, ECOG, and stage at diagnosis, HCC subjects with HIV have worse outcomes compared to non-HIV counterparts. In our study, HIV-infected subjects had significantly higher rates of HBV, HCV, alcohol use, and lower rates of transplantation--all factors that could mediate the increased mortality observed in these subjects. While the etiology of survival differences between HIV and non-HIV patients with HCC remains unclear, robust efforts should be made to offer the subset of those with HIV not only transplants but also novel systemic therapies, given the profound potential for benefit.