UK cohort reports sexual HCV reinfection in at least 5% HIV-positive gay men following sustained response to treatment

HIV Treat Bull - 2008 March-April;9(3/4):

Rachel Jones form Chelsea and Westminster Hospital presented an analysis of failed treatment of HCV in HIV-positive gay men. Describing the characteristics of individuals with a second episode of HCV viraemia following SVR post-treatment of HCV, using molecular phylogenic analysis to determine whether viraemia was due to treatment relapse or secondary infection.

Patients were identified from the databases of Royal Free Hospital and C+W from 2002-2008. SVR was defined as undetectable HCV PCR on at least two measurements, at least six months apart.

Notes review looked for evidence of risk behaviour, including STIs and HIV characteristics, and then compared paired RNA from the first and subsequent episodes of hepatitis C viraemia.

211 individuals were identified with acute HCV, 16 of whom had a second episode - all detected following a peak in ALT (median peak 413, range 49-2727 I/U).

All were HIV+ gay men with no documented IDU. Mean duration of HIV 4 years (range 2-17) and mean age 38 (range 26-51). Mean CD4 476 cells/mm³ (range 195-834). At second episode of viraemia patients were slightly older with a similar CD4 count. The mean duration of SVR was 28 months.

All but two individuals had at least one documented STI during the period of SVR: syphilis (10, predominantly secondary), NSU (2), gonorrhoea (6, 3 urethral and 3 rectal), herpes (3, 1 new case and 2 recurrent). This incidence may have been underestimated as STI treatment in the UK is frequently accessed at a different centre to HIV care.

Only 8/16 had paired samples, all genotype 1. 6/8 had very divergent samples and even the 2/8 that were closely related were separated by a temporal difference of four and five years indicating this was unlikely to be a relapse so late and more likely to reinfection from a common source.

In summary, supported by evidence of STI, the researchers suggested that in this small but significant cohort, reinfection rather than relapse explained the new infected in at least 6 cases, and probably in all eight cases.

In addition to highlighting the importance of stronger health prevention messages, the researchers suggested that identifying patients who had perhaps cleared HCV spontaneously and generated protection against future infection could help identify immune correlates that might help with prognosis of this group of patients.

Treatment responses were all reported as being as effective with second treatment as the initial HCV treatment. However, two of these patients have since been reinfected a third time.

comment

A recent presentation from a European cohort containing these cases at the recent AASLD meeting in Boston showed an international spread of a few HCV-strains in patients experiencing an acute hepatitis C in Germany, France and UK after high risk sexual engagements.

Some reviewers suggest that this supports the idea that HCV is not an increasing STI in the wider gay community, but is limited to a HIV-positive men who serosort to eliminate the risk of HIV transmission. Risk factor reported in previous studies included group sex, some recreational drug use, not using condoms and longer and more physical activity.

Others have suggested that HCV is not being picked up outside of HIV-positive cohorts because no-one is looking for it. Acute HCV in HIV-positive men is generally only detected due to routine liver enzyme monitoring.

A research letter in the 12 March issue of AIDS reported case reports of two HIV-positive gay men who had been reinfected (superinfected) with a second HCV strain following sexual exposure.

References
1. Jones R et al. Hepatitis C viraemia following sustained virological response to pegylated interferon and ribavarin in HIV+ men who have sex with men-re-infection or late relapse? Oral abstract 61LB.
http://www.retroconference.org/2008/Abstracts/33444.htm
This oral presentation is available to view online from the conference website (Monday 4 February).
2. Ghosn J et al. Sexually transmitted hepatitis C virus superinfection in HIV/hepatitis C virus co-infected men who have sex with men. AIDS:Volume 22(5)12 March 2008p 658-661

2008-03-10
IB080903-19

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