Women living with both HIV and hepatitis C virus (HCV) may face a substantially greater risk of developing severe liver disease than men with the same coinfection, according to a large Canadian study published in the journal AIDS.

Researchers analyzed data from 65,151 people with hepatitis C who were followed between 1999 and 2018 to examine how biological sex and HIV infection jointly influence the risk of liver complications, including cirrhosis, liver decompensation, and liver cancer.

The study included more than 22,000 women and 42,000 men. During follow-up, 460 women and 1,678 men were diagnosed with HIV in addition to hepatitis C.

The researchers found that women with both HIV and hepatitis C had a 44% higher risk of developing cirrhosis than women infected with hepatitis C alone. They were also more than 2.5 times more likely to experience liver decompensation—a serious stage of liver failure in which the organ can no longer perform its normal functions.

By comparison, men with hepatitis C but without HIV had higher overall rates of cirrhosis, liver failure, and liver cancer than women with hepatitis C alone, consistent with previous research suggesting that women may benefit from the protective effects of estrogen and are more likely to clear the hepatitis C virus naturally or after antiviral treatment.

However, HIV coinfection significantly altered these sex-related differences. Statistical analysis showed that HIV had a stronger negative impact on the risk of cirrhosis and liver decompensation in women than in men. In contrast, the effect of HIV on the risk of hepatocellular carcinoma, the most common form of liver cancer, did not differ significantly between the sexes.

The researchers suggest that both biological and social factors may contribute to these findings. Women living with HIV are known to have a higher risk of liver toxicity and metabolic disturbances associated with antiretroviral therapy, which may worsen liver damage. In addition, women often face greater barriers to HIV care, including stigma, discrimination, childcare responsibilities, and limited access to transportation, all of which can interfere with timely treatment.

The authors conclude that women with HIV and hepatitis C may require closer monitoring and earlier interventions to reduce the risk of severe liver complications.