- Category: HCV Prevention
- Published on Tuesday, 19 April 2016 00:00
- Written by Michael Carter
There is a very high incidence of hepatitis C virus (HCV) reinfection among HIV-positive men who have sex with men (MSM) in western Europe, according to research presented at the European Association for the Study of the Liver's International Liver Congress (EASL 2016) this week in Barcelona. Investigators found that a quarter of HIV-positive gay men who cleared an initial HCV infection were reinfected within 3 years. The researchers believe that current prevention strategies are failing, and called for intensive monitoring of people who have apparently cleared HCV infection.
There are ongoing hepatitis C epidemics among HIV-positive men who have sex with men in many industrialized countries. There is convincing evidence of sexual transmission of HCV, with unprotected anal sex, fisting and re-use of injecting equipment identified as high-risk activities. A recent meta-analysis suggested that prevalence of HCV coinfection among HIV-positive MSM is between 5% and 6%. Hepatitis C can be cured with therapy, and spontaneous clearance of acute infection has also been documented.
Research conducted in Amsterdam and London has found a high incidence of HCV reinfection after successful treatment or spontaneous clearance. There are several reasons why it is important to establish a clearer understanding of the incidence of reinfection and its risk factors, including prevention and screening strategies. Moreover, reinfection could affect the cost-benefit analysis of expensive, but highly effective new direct-acting antiviral therapies.
Investigators from the U.K., Germany, Austria, and France therefore designed a study to estimate the incidence of HCV reinfection among HIV-positive MSM who cleared the virus either after treatment or spontaneously.
The study population consisted of 606 men with a confirmed cure or spontaneous clearance. Patients who received therapy were considered cured if they had a negative HCV PCR test 12 weeks after the completion of therapy SVR12); spontaneous clearance was defined as a negative HCV PCR result 24 weeks after the first negative PCR in the absence of treatment.
Data were collected on age, date of HCV diagnosis, HCV genotype, HCV and HIV viral load, use of antiretroviral therapy (ART), CD4 count, and liver function (maximum ALT). Data were also requested on IL28B gene status associated with favorable outcomes, but response was poor. Reinfection was defined as a positive HCV RNA PCR test after confirmed cure or spontaneous clearance.
Over 3 years of follow-up, 149 patients (24.6%) were reinfected with HCV. The median time to reinfection was 1.8 years. The median age at the time of reinfection was 41 years. Most individuals -- 91 of 111 patients with available data -- had an undetectable HIV viral load and a median CD4 cell count of 533 cells/mm3 at the time of HCV reinfection.
Spontaneous clearance was observed in 15% of patients after reinfection. 113 people received antiviral treatment, of whom 87 were cured.
A second reinfection was recorded in 29 patients, 4 patients were reinfected 3 times, and a single individual had 4 reinfections. Just over a quarter of patients (29%) spontaneously cleared their second reinfection, and a third experienced spontaneous clearance of their third reinfection.
Overall incidence of reinfection was 7.6 per 100 person-years. Incidence of second reinfection was even higher, at 19.9 per 100 person years. The incidence of reinfection was markedly higher in Paris (21.8 per 100 person-years) and Vienna (16.8 per 100 person-years) than in London (7 per 100 person-years) and at German centers (5-8 per 100 person-years), but the amount of patient follow-up available for analysis makes it difficult to draw firm conclusions.
Spontaneous clearance of the initial infection was associated with a significant reduction in the risk of reinfection (HR 0.55), and also the chances of spontaneous clearance if reinfected (OR 12.7).
The investigators concluded that there is a substantial risk of HCV reinfection for HIV-positive men who have sex with men. They believe their results show the failure of current prevention interventions and underline the need for new strategies. The researchers also suggested that their findings have implications for the monitoring of HIV/HCV coinfected MSM and called for HCV PCR testing to be performed every 3 to 6 months after HCV infection and every 3 months after reinfection.
TC Martin, R Ingiliz, A Rodger, et al. HCV reinfection incidence and outcomes among HIV-infected MSM in Western Europe. EASL International Liver Congress 2016. Barcelona, April 13-17, 2016. Abstract PS006.