Hepatitis: Limited Data, Lots of Unanswered Questions

Hopkins HIV Report 2006 Sep; 18(5):11

Kelly Gebo, M.D., M.P.H.
Johns Hopkins

The lone oral session on hepatitis coinfection at IAS was called the “Hidden Epidemic.” Given the location of the session and the relative paucity of presentations on hepatitis, some thought that hepatitis was overlooked by the conference organizers. There were several studies of note, however.

Prevalence of Hepatitis Co-infection

Dahoma and colleagues estimated the prevalence of HIV, HCV, and HBV in a study of patients using illicit drugs in Zanzibar, Tanzania in 2005 [Int Conf AIDS. 2006 Aug 13-18;16:Abstract No. WEAX0104]. Of the patients studied, 95% were male, and 93% were urban residents. In this study, they found that the risk behaviors of injection drug users (IDUs) in Zanzibar are concerning: 46% of IDUs share needles and 10% of performed “flashblood,” a technique used to obtain drug for those who can not afford it, in which a person who has money injects drug, then withdraws 2-3 cc of blood into the used syringe, which the next person then injects. Not surprisingly, the prevalence of HIV was high: 26% among IDUs vs. 5% among non IDUs. Of note, HIV prevalence was 17% in those who performed flashblood. In addition, 15% of patients had hepatitis C infection, with a greater prevalence in women than men (22% vs. 15%). Chamie and colleagues in San Francisco evaluated occult (seronegative) HCV co-infection among HIV-infected patients followed in several large HIV cohorts [Int Conf AIDS. 2006 Aug 13-18;16:Abstract No. WEPE0046]. They found that the prevalence of HCV, as determined by HCV RNA, was between 1.3 and 3.9% of HCV antibody-negative, HIV-infected patients. Factors associated with increased risk of seronegative HCV infection included history of injection drug use, increased ALT, and CD4 counts less than 200 cells/mm³.

Treatment

Kruk and colleagues evaluated the success of treatment of acute HCV in a small study in Russia [Int Conf AIDS. 2006 Aug 13-18;16:Abstract No. WEAX0102]. They treated patients with acute HCV infection, seroconversion and positive qualitative HCV RNA of less than 6 months, with pegylated interferon (PEG IFN) alpha 2b (1.5 mcg/kg/week) and oral ribavirin 800 mg daily for 24 weeks. In an intention to treat analysis, the treatment response rates were 94%, 94% and 75% at 12, 24, and 48 weeks. As expected, response rates were lower in those with genotypes 1 and 4 compared to those with genotypes 2 or 3 (Table 1).

Overall, this suggests that treatment of acute hepatitis C is of benefit, especially in those with genotypes 2 and 3. However, even in those with genotypes 1 or 4, the response rates were impressive, emphasizing the importance of diagnosing and treating hepatitis C in the acute phase.

In a sub-analysis of the APRICOT data, Sasadeusz and coworkers presented a study on the effect of baseline fibrosis on the safety and efficacy of PEG IFN alpha 2a (180 mcg/week) plus ribavirin 800 mg daily in HIV/HCV co-infected patients [Int Conf AIDS. 2006 Aug 13-18;16:Abstract No. WEPE0040]. They stratified their analysis on treatment response by baseline fibrosis score F0/1, F2, F3/4 and F5/6. Overall treatment response rates were lower in patients with advanced fibrosis (Table 2). Adverse event rates were high in all categories; however, dose modification was required in more patients with advanced fibrosis than in those with no or minimal fibrosis.

Solid Organ Transplantation

Roland and colleagues studied HIV-infected transplant recipients in San Francisco, following 18 with kidney transplants and 11 with liver transplants for 3 years [Int Conf AIDS. 2006 Aug 13-18;16:Abstract No. WEPE0052]. The rejection rates for kidneys were 52, 64 and 73% at 1, 2, and 3 years of follow-up, respectively. Ten percent of liver transplant recipients experienced rejection at years 1 and 3. There was no progression of HBV in HBV/HIV co-infected patients; however 67% of HCV co-infected patients had evidence of progression of liver disease on biopsy despite treatment with IFN and ribavirin. This suggests that liver transplantation may not be a panacea for patients with HIV-HCV co-infection with end-stage liver disease.

In summary, there were a few important hepatitis studies presented at IAS, emphasizing the importance addressing the high risk behaviors of many drug users, the need for education on risks of HIV and HCV transmission in those most at risk, the effectiveness of therapy for acute HCV infection, the importance of looking for seronegative HCV infection in immunosuppressed patients or those at high risk, and the potential limits of liver transplantation in HCV/HIV co-infected patients.

2006-09-10
HHR-2006-09-04

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