Concurrent Hepatitis C and B Virus and Human Immunodeficiency Virus Infections Are Associated With Higher Mortality Risk Illustrating the Impact of Syndemics on Health Outcomes

Zahid A Butt; Stanley Wong; Carmine Rossi; Mawuena Binka; Jason Wong; Amanda Yu; Maryam Darvishian; Maria Alvarez; Nuria Chapinal; Geoff Mckee; Mark Gilbert; Mark W Tyndall; Mel Krajden; Naveed Z Janjua

doi:10.1093/ofid/ofaa347

Concurrent Hepatitis C and B Virus and Human Immunodeficiency Virus Infections Are Associated With Higher Mortality Risk Illustrating the Impact of Syndemics on Health Outcomes

Open Forum Infect Dis. 2020 Aug 13;7(9):ofaa347. doi: 10.1093/ofid/ofaa347. eCollection 2020 Sep.

Authors

Zahid A Butt^{1

2

3}, Stanley Wong², Carmine Rossi², Mawuena Binka², Jason Wong^{2

3}, Amanda Yu², Maryam Darvishian⁴, Maria Alvarez², Nuria Chapinal⁴, Geoff Mckee², Mark Gilbert^{2

3}, Mark W Tyndall³, Mel Krajden^{2

3

5}, Naveed Z Janjua^{2

3}

Affiliations

¹ School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada.
² British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada.
³ School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.
⁴ BC Cancer Agency, Vancouver, British Columbia, Canada.
⁵ BCCDC Public Health Laboratory, Vancouver, British Columbia, Canada.

Abstract

Background: Hepatitis C virus (HCV), hepatitis B virus (HBV), and human immunodeficiency virus (HIV) infections are associated with significant mortality globally and in North America. However, data on impact of concurrent multiple infections on mortality risk are limited. We evaluated the effect of HCV, HBV, and HIV infections and coinfections and associated factors on all-cause mortality in British Columbia (BC), Canada.

Methods: The BC Hepatitis Testers Cohort includes ~1.7 million individuals tested for HCV or HIV, or reported as a case of HCV, HIV, or HBV from 1990 to 2015, linked to administrative databases. We followed people with HCV, HBV, or HIV monoinfection, coinfections, and triple infections from their negative status to date of death or December 31, 2016. Extended Cox proportional hazards regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for factors associated with all-cause mortality.

Results: Of 658 704 individuals tested for HCV, HBV, and HIV, there were 33 804 (5.13%) deaths. In multivariable Cox regression analysis, individuals with HCV/HBV/HIV (HR, 8.9; 95% CI, 8.2-9.7) infections had the highest risk of mortality followed by HCV/HIV (HR, 4.8; 95% CI, 4.4-5.1), HBV/HIV (HR, 4.1; 95% CI, 3.5-4.8), HCV/HBV (HR, 3.9; 95% CI, 3.7-4.2), HCV (HR, 2.6; 95% CI, 2.6-2.7), HBV (HR, 2.2; 95% CI, 2.0-2.3), and HIV (HR, 1.6; 95% CI, 1.5-1.7). Additional factors associated with mortality included injection drug use, problematic alcohol use, material deprivation, diabetes, chronic kidney disease, heart failure, and hypertension.

Conclusions: Concurrent multiple infections are associated with high mortality risk. Substance use, comorbidities, and material disadvantage were significantly associated with mortality independent of coinfection. Preventive interventions, including harm reduction combined with coinfection treatments, can significantly reduce mortality.

Keywords: all-cause mortality; coinfections; observational cohort; syndemics.