Co-infection Cohort

Published 21, Nov, 2012

Heiko Decosas, Communication and Information Officer. CIHR Canadian HIV Trials Network on research that is looking at treatment in a cohort of people co-infected with HIV and Hep C.

As a Communications and Information Officer at the CTN, one of my key tasks is to take scientific writing on CTN trials and new developments in HIV and make these accessible to a larger audience. In this role, I am often confronted with challenging reports and trial protocols that take time to unpack and understand.

Amidst all the complicated science underpinning clinical research, every now and again a paper is published that is abundantly clear and seemingly requires little interpretation. One such paper was published this summer by some of Canada’s leading HIV and hepatitis C researchers. In the paper, the researchers suggest that after having observed over a thousand Canadians living with HIV and hep C for a number of years, over 50 per cent of the deaths recorded might have been preventable. This is a devastating statistic, one that is hard to truly comprehend. 

To learn more about what these findings signal, I spoke to Dr. Marina Klein. She is a clinician and researcher based at McGill University at the Montreal Chest Institute and she is the lead author of the study for the group that was observed to have such high rates of preventable deaths. For the last several years, she has also been the co-leader of the Co-Infections and Concurrent Diseases Core at the CTN and the Principal Investigator for the Canadian Co-infection Cohort (CTN 222).

Health Canada suggests there are 250,000 Canadians living with hep C. Dr. Klein says that up to 30 per cent of Canadians living with HIV also contend with hep C. “We started the cohort study,” she says, “with the aim of understanding how the two viruses, HIV and hep C interact to affect health outcomes and their treatments. It is clear to us that people with co-infections are often not included in key studies evaluating HIV and hepatitis C medications. As a result, there is limited or no information to base treatment recommendations on except expert opinion. The end result is that co-infected patients are often not included in treatment recommendations or the medication are not advised until additional data becomes available.”

The cohort began recruiting participants in Quebec in 2003 with infrastructure funding from the Fonds de la recherche en santé du Québec (FRSQ). With additional CIHR funding awarded in 2006, Dr. Klein with the support of the CTN expanded the study across Canada. It is now one of the largest observational cohorts of its kind, recruiting participants from 16 centres from coast to coast, and following over 1,100 co-infected people. Within the cohort there are extremely high rates of social instability, poverty, mental illness, and alcohol and drug use. Most of the participants live below the poverty line and only 13 per cent have achieved more than a high school education. Aboriginal peoples are disproportionately represented in the cohort and more than 75 per cent of the participants reported a history of injection drug use. Forty per cent report that they continue to inject drugs and over half of the cohort has been previously incarcerated. 

The cohort study has been instrumental in giving researchers a sense of what is going right and what is going wrong with HIV/hepatitis C treatment in Canada. “We have spent a lot of time describing the situation and understanding it,” Dr. Klein says, “ and now we are looking to move to action and intervention. Building on our research we are developing a community-focused health initiative targeted at interventions geared to improving treatment, access to care, and overall health outcomes.”

In terms of addressing what the researchers indicated as preventable deaths, Dr. Klein says “we really need to start targeting interventions aimed at minimizing vulnerabilities and improve social circumstances, reduce the harms from drug and alcohol use and increase the delivery of hepatitis C treatment.” 

With the many new developments in hepatitis C treatments, the management of HIV/hepatitis C co-infection has become more complex. However, as Klein notes, “Because medication-funding criteria is often based on guidelines, co-infected patients end up being denied medications. This is currently being seen with the new hepatitis C protease inhibitors, which are not funded for people living with HIV- hepatitis C co-infection in many Canadian provinces.” 

Working with key partners, Dr. Klein is part of a collaborative CTN initiative led by Dr. Mark Hull (BC Centre for Excellence in HIV/AIDS) to release the first Canadian consensus statement on HIV/hepatitis C co-infection treatment early next year. The new initiative will consist of a set of state of the art guidelines for selecting treatments, treatment timing, and information on drug-drug interactions and will become influential in terms of clinical practice as well as Canadian health policy.  Thankfully, in addition to these guidelines there are many new hepatitis C treatments currently being tested and the future looks very promising for increasing success, reducing the duration of treatment and improving the safety and tolerability of hepatitis C medications. Ultimately we hope, saving lives.

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