Coinfection

AZT (Retrovir) Ups Anemia Risk in HIV-HCV Coinfected Patients, But Rate Remains Low

Since the advent of effective antiretroviral therapy has reduced the rate of death due to opportunistic illnesses and other AIDS-related causes, liver disease has emerged as a major cause of death among HIV positive people. HIV, in turn, has also influenced rates of death among patients with chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infection, according to a study published in the February 2008 Journal of Hepatology.

In this analysis, Patrick Marcellin and colleagues estimated mortality related to HCV and HBV infection in France. A random sample of 999 death certificates was obtained from among all 65,000 French death certificates in 2001 that listed HBV, HCV, hepatitis, liver disease, possible complication of cirrhosis, bacterial infection, HIV, or transplantation as causes of death. Physicians who reported these deaths were sent a questionnaire to identify how many deaths were related to HBV or HCV infection. Death rates were then estimated according to national population census data.


Results

• The estimated annual number of deaths associated with HCV was 3618 (6.1 deaths per 100,000 inhabitants).

• The estimated annual number of deaths associated with HBV was 1507 (2.5 per 100,000 inhabitants).

• The estimated number of deaths attributable to HCV was 2646 (4.5 per 100,000 inhabitants).

• The estimated number of deaths attributable to HBV was 1327 (2.2 per 100,000 inhabitants).

• In the HCV infected group, 95% had cirrhosis and 33% had hepatocellular carcinoma (HCC).

• In the HBV infected group, the rates were similar: 93% and 35%, respectively.

• 11% percent of these deaths occurred in patients with HIV coinfection.

• Deaths related to hepatitis B or C occurred at an earlier age in patients with a history of excessive alcohol consumption. 

"In France, 4000-5000 deaths related to HCV and HBV infection occurred in 2001," the researchers concluded. "Alcohol consumption and HIV infection were important co-factors."

They added that, "These data emphasize the need for ongoing, efficient public health programs that include screening, management, and counseling for HCV- and HBV-infected individuals."

02/29/08

Reference

P Marcellin, F Pequignot, E Delarocque-Astagneau, and others. Mortality related to chronic hepatitis B and chronic hepatitis C in France: Evidence for the role of HIV coinfection and alcohol consumption. Journal of Hepatology 48(2): 200-207. February 2008.

CROI 2008: Rapid Liver Fibrosis Progression in HIV Positive Men with Acute HCV Infection

In recent years there have been reports of several outbreaks of apparently sexually transmitted acute hepatitis C among mostly HIV positive men who have sex with men (MSM) in European cities and Australia. These cases are notable because the patients were known to already be infected with HIV when they acquired HCV (typically HCV is acquired first).

Several studies have shown that HIV-HCV coinfected individuals with chronic hepatitis C tend to experience more rapid liver fibrosis progression. But little is known about the effect of HIV on liver disease in people with acute HCV infection.

At the 2007 Conference on Retroviruses and Opportunistic Infections (CROI) last February, Daniel Fierer and colleagues from Mt. Sinai School of Medicine in New York City presented early data from a prospective study of HIV positive MSM with acute HCV infection, defined as the first 6 months after HCV infection. The researchers considered a combination of 3 criteria as indicators of acute hepatitis C: recent seroconversion to HCV antibody positive status, marked elevations in serum alanine aminotransferase (ALT) level, and wide fluctuations in HCV viral load.

Study participants underwent liver biopsy within 4 months of the first-noted ALT elevation. Fibrosis was staged using the Scheuer system, on a scale of 0 to 4. Fibrosis progression rate (FPR) was calculated by dividing the fibrosis stage by the interval between the dates of the recent ALT elevation and the biopsy.

As previously reported, among the first 5 enrolled patients, 4 already had moderate portal fibrosis during acute hepatitis C. At this year’s CROI, taking place this week in Boston, the researchers presented a poster describing further data from more study participants.

Results

  • Of the 11 patients who underwent liver biopsy, 9 did so within 4.5 months of detection of ALT elevation, and 2 within 16 months.
  • Despite the short duration of HCV infection, 9 of the 11 (82%) had stage 2 fibrosis and 1 had stage 1 fibrosis.
  • The mean FPR in these 11 patients was 4.5 (± 3.3) units per year.
  • No causes of liver damage other than acute HCV infection were identified.
  • In the analysis of risk factors for HCV acquisition, only 4 patients reported even a single episode of intravenous drug use.
  • However, non-injection drug use and high-risk sexual behavior were common.
  • 7 reported club drug (including methamphetamine) use and 10 reported unprotected anal intercourse with multiple partners.

Based on these findings, the researchers concluded, “Acute HCV infection of MSM with underlying HIV infection resulted in early and rapid progression of liver fibrosis, with FPR rates far in excess of other settings of HCV infection.”

“Many of these HIV-infected men with acute HCV used non-injection drugs and had unprotected sex with multiple partners,” they continued. “Some appear to have become HCV-infected via sexual activity.”

The investigators recommended that, “More intensive prevention and screening strategies for acute HCV in MSM are needed,” and “further research is needed to identify the disease processes leading to this highly accelerated liver injury.”

Mt Sinai School of Medicine, New York, NY.

2/5/08

Reference

D Fierer, A Uriel, D Carriero, and others. An Emerging Syndrome of Rapid Liver Fibrosis in HIV-infected Men with Acute HCV Infection. 15th Conference on Retroviruses and Opportunistic Infections. Boston, MA. February 3-6, 2008. Abstract 1050.

CROI 2007: Does Pre-existing HIV Infection Lead to Accelerated Liver Fibrosis in People with Acute Hepatitis C?

Multiple outbreaks of acute hepatitis C virus (HCV) infection have recently been reported in cities in the UK and Europe among HIV positive men who have sex with men (MSM). These outbreaks are notable because these patients were already infected with HIV when they acquired HCV. More typically, individuals with both HIV and HCV infection acquired HCV first, since it is easier to transmit (e.g., through shared use of injection drug equipment).

Although much is known about the course of liver disease in HCV-infected patients who later acquire HIV, little is known about the course of liver damage in HIV-infected patients who later acquire HCV.

Researchers at Mount Sinai School of Medicine in New York City conducted a prospective study of HIV-infected MSM with acute HCV infection, including examination of liver histology. At the 14th Conference on Retroviruses and Opportunistic Infections last month in Los Angeles, they reported data from the first 5 consecutively-enrolled patients.

The patients underwent serological testing for hepatitis A virus (HAV) antibodies; hepatitis B virus (HBV) antigens, antibodies, and HBV DNA; and HCV antibodies, HCV RNA, and HCV genotype. They also received liver biopsies within 4 months of the first-noted ALT elevation.

Acute hepatitis C was defined as the first 6 months of HCV infection. Because no single test result provides a definitive diagnosis of acute HCV infection, the researchers considered 3 factors in combination:

  • Recent seroconversion to HCV antibody positive status;
  • Marked elevations in serum ALT level;
  • Wide fluctuations in HCV viral load.

The latter 2 factors are considered hallmarks of acute HCV infection and are uncommon during chronic infection.

All patients were MSM in their 40s who had:

  • Recent seroconversion to anti-HCV antibody positive status; in 3 cases, this occurred within a year after a previous negative test, defining a narrow time window in which the new HCV infection could have occurred;
  • Rapid changes in ALT levels, with elevations greater than 10 times the upper limit of normal (ULN), consistent with acute hepatitis;
  • Wide HCV viral load fluctuations, in 4 cases exceeding 1.5 log10 IU/mL.

Results

  • Liver biopsies showed moderate portal fibrosis (stage 2 of 4; Scheuer system) in 3 of 4 patients, as well as acute HCV.
  • 1 patient had central hyalin sclerosis.
  • All patients denied heavy alcohol use and 1 had never received HAART.
  • No cause of chronic liver disease common to all patients could be identified to explain the degree of fibrosis.
  • All had negative evaluations for active HAV or HBV infection.
  • No evidence for other etiologies of new hepatitis was found.
  • All patients had recent histories of unprotected receptive anal intercourse, some with many partners.
  • 3 acknowledged a single recent episode of injection drug use, but without clear recollection of sharing injection equipment.
  • 1 shared paraphernalia for snorting drugs.
  • All denied any other known risk factors for HCV infection.

The researchers concluded that 4 of 5 HIV-infected MSM had moderately advanced portal fibrosis during the acute phase of HCV infection. No other etiologies were found to explain the presence of moderate liver fibrosis in this population, suggesting that pre-existing HIV infection results in accelerated fibrosis progression in patients with acute hepatitis C.

The investigators noted that, “These cases suggest that HIV-infected patients presenting with acute HCV infection may already have significant liver disease, and that liver biopsy should be considered in theses patients.”

They added that further research is needed to define the prevalence and understand the pathogenesis of rapid liver fibrosis in this population.

3/16/07

Reference

D Fierer, A Uriel, D Carriero, and others. Portal Fibrosis During Acute HCV Infection of HIV-infected Men. 14th Conference on Retroviruses and Opportunistic Infections. Los Angeles, February 25-28, 2007. Abstract 889 (poster).

Accelerated Liver Disease Progression in HIV-HCV Coinfected Patients May Be Due to Increased Liver Inflammation

Although results have not been not entirely consistent, several studies have shown that HIV-HCV coinfected patients tend to experience more rapid liver disease progression than HIV negative people with hepatitis C alone. A study reported in the January 11, 2008 issue of AIDS suggests a possible mechanism underlying accelerated liver disease progression in coinfected individuals.

 

Read more:

CROI 2007: HCV May Be Sexually Transmitted in HIV Negative as Well as HIV Positive Men

In recent years, outbreaks of apparently sexually transmitted hepatitis C virus (HCV) infection have been reported in London and Brighton in the UK and in a few European cities. In almost all cases, these acute HCV infections have occurred in HIV positive gay and bisexual men.

Read more:

Does Pre-existing HIV Infection Lead to Accelerated Liver Fibrosis in People with Acute Hepatitis C?

Multiple outbreaks of acute hepatitis C virus (HCV) infection have recently been reported in cities in the UK and Europe among HIV positive men who have sex with men (MSM). These outbreaks are notable because these patients were already infected with HIV when they acquired HCV. More typically, individuals with both HIV and HCV infection acquired HCV first, since it is easier to transmit (e.g., through shared use of injection drug equipment).

Although much is known about the course of liver disease in HCV-infected patients who later acquire HIV, little is known about the course of liver damage in HIV-infected patients who later acquire HCV.

Researchers at Mount Sinai School of Medicine in New York City conducted a prospective study of HIV-infected MSM with acute HCV infection, including examination of liver histology. At the 14th Conference on Retroviruses and Opportunistic Infections last month in Los Angeles,they reported data from the first 5 consecutively-enrolled patients.

The patients underwent serological testing for hepatitis A virus (HAV) antibodies; hepatitis B virus (HBV) antigens, antibodies, and HBV DNA; and HCV antibodies, HCV RNA, and HCV genotype. They also received liver biopsies within 4 months of the first-noted ALT elevation.

Acute hepatitis C was defined as the first 6 months of HCV infection. Because no single test result provides a definitive diagnosis of acute HCV infection, the researchers considered 3 factors in combination:

  • Recent seroconversion to HCV antibody positive status;
  • Marked elevations in serum ALT level;
  • Wide fluctuations in HCV viral load.

The latter 2 factors are considered hallmarks of acute HCV infection and are uncommon during chronic infection.

All patients were MSM in their 40s who had:

  • Recent seroconversion to anti-HCV antibody positive status; in 3 cases, this occurred within a year after a previous negative test, defining a narrow time window in which the new HCV infection could have occurred;
  • Rapid changes in ALT levels, with elevations greater than 10 times the upper limit of normal (ULN), consistent with acute hepatitis;
  • Wide HCV viral load fluctuations, in 4 cases exceeding 1.5 log10 IU/mL.

Results

  • Liver biopsies showed moderate portal fibrosis (stage 2 of 4; Scheuer system) in 3 of 4 patients [SHOULD THIS BE 4 OF 5?], as well as acute HCV.
  • 1 patient had central hyalin sclerosis.
  • All patients denied heavy alcohol use and 1 had never received HAART.
  • No cause of chronic liver disease common to all patients could be identified to explain the degree of fibrosis.
  • All had negative evaluations for active HAV or HBV infection.
  • No evidence for other etiologies of new hepatitis was found.
  • All patients had recent histories of unprotected receptive anal intercourse, some with many partners;
  • 3 acknowledged a single recent episode of injection drug use, but without clear recollection of sharing injection equipment.
  • 1 shared paraphernalia for snorting drugs;
  • All denied any other known risk factors for HCV infection.

Conclusions

The researchers concluded that 4 of 5 HIV-infected MSM had moderately advanced portal fibrosis during the acute phase of HCV infection. No other etiologies were found to explain the presence of moderate liver fibrosis in this population, suggesting that pre-existing HIV infection results in accelerated fibrosis progression in patients with acute hepatitis C.

The investigators noted that, “These cases suggest that HIV-infected patients presenting with acute HCV infection may already have significant liver disease, and that liver biopsy should be considered in theses patients."

They added that further research is needed to define the prevalence and understand the pathogenesis of rapid liver fibrosis in this population.

 

Patient 1

Patient 2

Patient 3

Patient 4

Age (years)

40

47

40

47

Duration HIV diagnosis

4 years

13 years

17 years

11 months

CD4 count (cells/mm3)*

720

303

241

697

HIV viral load (log10 copies/mL)*

<1.7

5.2

2.9

<1.7

Antiretroviral therapy history

3 years;
no ddI/d4T

never

17 years;
past ddI/d4T

11 months;
no ddI/d4T

Peak ALT (U/mL)

1164

1620

567

1880

HCV viral load fluctuation

1.1 log in 2 weeks

2 log in 12 weeks

1.7 log in 4 weeks

2.8 log in 2 weeks

HCV seroconversion (months)

4

27

34

11

HCV genotype

1a

1a

1b

1a

Pathological diagnosis

stage 2 fibrosis

stage 2 fibrosis

stage 2 fibrosis

central hyalin sclerosis

 

 

 

Link to full study abstract and PDF of poster

03/16/07

Reference

D Fierer, A Uriel, D Carriero, and others. Portal Fibrosis During Acute HCV Infection of HIV-infected Men. 14th Conference on Retroviruses and Opportunistic Infections. Los Angeles, February 25-28, 2007. Abstract 889 (poster).