All major classes of antiretroviral therapy (ART) have been described to be associated with elevations in serum hepatic enzymes.⁵ As HIV-infected patients live longer, they develop long term manifestations of chronic HIV infection and treatment complication.⁶ The severity of ART may range from the absence of symptoms to liver decompensation and the outcome ranges from spontaneous resolution to liver failure and death.⁷

In the resource poor setting, Alanine aminotransferase (ALT) and Aspartate aminotransferase (AST) is an ideal marker of hepatocellular injury.⁸ Studies have revealed that 14–20% of adults on ART had elevated serum liver enzymes as a marker of hepatocellular injury.⁹ Chronic hepatitis B and C infections are the most well-established risk factors for liver enzyme elevations.^6,10 There is a lack of information from the region on the extent of ART related hepatotoxicity associated with or without hepatitis C virus. The purpose of this study was to determine hepatotoxicity by using serum alanine aminotransferase levels as markers in HIV-infected patients receiving ART in association with a very important risk factor i.e. hepatitis C co-infection and also compare with HCV naïve or those without HCV infection.

MATERIAL AND METHOD

Data: A prospective followup of HIV positive cases attending ART Centre of JNIMS Hospital, Porompat, Imphal, Manipur was done among those who were screened for HCV infection and found positive and identical controls who were HCV negative for each HCV positive case, from 1^st January 2011 to 31^st December 2015. During the period all HCV co-infected cases who were started on ART were followed up every 3 months up to 6 months. Control group of HIV cases on ART but without HCV infection were similarly assessed at 3 months interval up to 6 months. During the study period, there were 110 cases of HCV co-infection and equal number of HCV negative HIV infected cases were included in the control group.

METHOD

All the cases after Pre-ART enrolment were worked up for CD4 count, HBsAg, HCV Ab, routine blood count, chest radiograph, renal and liver functions. Based on the CD4 levels, anti-retroviral therapy (ART) was started and CD4 count repeated at 6 months. Since the study area was in resource poor setting, only Alanine aminotransferase (ALT) level was followed up at 3 months and 6 months after initiation of ART.

ERS system as prescribed by National AIDS Control Organization (NACO) was used for detecting HIV infection. Antibody test (ELISA) for Hepatitis C Virus (HCVAb) was done for screening HCV infection. Alanine aminotransferase (ALT) was determined by autoanalyser (Dry Chemistry method). CD4+ count was done using FACS counter. Normal value for ALT (SGPT) at 37°C: 0–40 IU/L was taken for both Women and Men. Commonly used grading system developed by the Acquired Immune Deficiency Syndrome (AIDS) Clinical Trials Group (CTG) was utilised to analyze the toxicity levels of liver enzymes.¹¹

Toxicity of Degree 0: The level of toxicity which is considered as normal in which its value is <1.25 × normal value of ALT in serum.

Toxicity of Degree 1: The level of toxicity which is considered as weak in which its value is 1.26 − 2.5 × normal value of ALT in serum.

Toxicity of Degree 2: The level of toxicity which is considered as moderate in which its value is 2.6 − 5 × normal value of ALT in serum.

Toxicity of Degree 3: The level of toxicity which is considered as severe in which its value is 5.1 − 10 × normal value of ALT in serum.

Toxicity of Degree 4: The level of toxicity which is considered as severe in which its value is >10 × normal value of ALT in serum.

Ethical Considerations

The present study had clearance from ethical committee of Jawaharlal Nehru Institute of Medical Sciences, Imphal as this study was not going to involve any intervention that could have produced adverse reactions even though the study was a prospective study. All the treatments were done according to protocol based NACO guidelines for initiation of ART. Emphasis to maintain confidentiality was strictly followed as per guideline given by the ethic committee.

Statistical Analysis

All the statistical analysis was done by calculating mean and standard deviation for variables that were normally distributed; the median and averages were used to calculate the variables which are not distributed uniformly. To calculate proportions, t-test, Chi-square statistics were used and a p-value less than 0.05 was considered statistically significant. We utilised percentage to interpret suitable data. All the statistical analysis was done using SPSS Version 16 software.

RESULTS

There were differences in the baseline ALT levels of the HCV positive HIV cases and HCV negative HIV patients who were taken as controls. However, we have chosen the most identical baseline characteristics as the control group.

At 3 months followup, there were improvements in ALT levels of both cases and controls as evident from reduction in number of patients who had moderate-to-severe hepatotoxicity (Grade 2 and Grade 3). In HCV positive HIV positive group, the reduction was 1 out of 10 patients which was 10% and in HCV negative HIV positive group the reduction was 1 out of 8 patients who had ALT levels at moderate-to-severe hepatotoxicity, the reduction in this group was 12.5% [Table-1] [Table-2].

At 6 months, the improvement in ALT levels of both HCV positive and HCV negative groups of HIV patients after initiation of ART were remarkable. HCV positive HIV patients, whose baseline ALT levels were in the moderate-to-severe hepatotoxicity (Grade 2 and 3), reduced to 7 from 10 patients, which is about 30% reduction. Patients who were levelled with moderate-to-severe hepatotoxicity (Grade 2 and 3) before initiation of ART among HCV negative HIV positive group were reduced to 6 from 8 patients, after 6 months of ART initiation. This reduction in ALT level in the control group was about 25%.

There were 81 patients who had CD4 count less than 200/cu.mm among the HCV positive HIV patients at the time of initiation of ART, and at 6 months after initiation of ART the number of patients having CD4 count less than 200/cu.mm were reduced to 13 patients and majority of the patients i.e. 68 of them had shown improvement in CD4 count above 200/cu.mm, which was approximately 84% [Table-3] [Table-4].

Among the HCV negative HIV positive patients, there were 91 patients with CD4 count less than 200/cu.mm at the time of initiation of ART, and at 6 months after initiation of ART 82 patients had improved to CD4 count above 200/cu.mm, which was about 90%, a remarkable improvement in CD4 count was recorded.