Discussion
According
to the investigators, immunosuppression increases the progression of fibrosis
in HCV-infected patients. "The magnitude of the acceleration is relatively
modest if immunosuppression occurs after the chronic phase of HCV infection has
been established," they wrote.
The
authors pointed out that prior study results have indicated that the fibrosis
progression rate (FPR) of patients with chronic HCV monoinfection is 0.11 unts
per year and that the FPR of patients with chronic HIV-HCV coinfection is <2-fold
greater, at 0.15 units per year.
"The
majority of HIV-HCV coinfected injection drug users (IDUs) are not expected to
develop cirrhosis (stage 4 fibrosis) for 20 years or more," wrote the researchers.
In contrast, they noted, "Patients who acquire HCV infection when they already
have defects in cellular immunity are reported to progress to cirrhosis, end-stage
liver disease, and death in as few as 3 years.
They
continued, "This dire outcome has been observed in transplant recipients,
patients with hematological disorders and immunodeficiencies, and patients with
preexisting HIV infection."
Among
the 11 consecutive HIV-infected MSM in the study who underwent liver biopsy during
the early periods of HCV infection, nine (82%) had stage 2 fibrosis. In contrast,
biopsy specimens from immunocompetent patients obtained during the early periods
of HCV infection contained no or minimal fibrosis [1].
"[Therefore]
the FPR of the HIV-infected MSM with newly acquired HCV infection in our study
was far higher than that of immunocompetent patients with acute HCV infection,"
wrote the authors.
"Our
findings of moderately advanced fibrosis during the initial period of HCV infection
are consistent with the rapid clinical progression to end-stage liver disease
reported in previous studies of individuals who acquired HCV infection while already
infected with HIV or who acquired HIV and HCV infection simultaneously."
In
their conclusion, the researchers stated that their study indicates that high-risk
sexual practices and non injection-drug use may play a role in the transmission
of HCV to HIV-infected MSM.
In
addition, they wrote, "Our findings also demonstrate that HIV-infected men
with acute HCV infection have moderately advanced liver disease. The FPR of this
population is 5 times greater than that for people who are not immunocompromised
at the time when they become HCV infected. Our findings are of particular importance
with regard to the recent outbreaks of acute HCV infection in HIV-infected MSM
in Europe and the United States" [2].
The
authors observed that regular screening of MSM for HCV antibodies "is not
currently recommended by U.S. or international HIV care guidelines, and ALT elevations
during acute HCV infection are relatively transient and therefore could be easily
missed during routine clinical care." They maintained that many (if not most)
cases of acute HCV infection "are not diagnosed, even in areas in which the
outbreaks have been recognized."
In
closing, the study authors urge caregivers to initiate more intensive screening
of HIV-infected MSM, "given the grave implications of missing the diagnosis
of acute HCV infection in these patients."
Divisions
of Infectious Diseases and Liver Diseases, Department of Medicine, and Department
of Pathology, Mount Sinai School of Medicine, New York, NY.
8/05/08
Reference
DS
Fierer, AJ Uriel, DC Carriero, and others. Liver fibrosis during an outbreak of
acute hepatitis C virus infection in HIV-infected men: a prospective cohort study
(brief report). Journal of Infectious Diseases. July 15, 2008 [Epub ahead of print].
(Abstract)
Other citations
1.
SM Kamal, Turner B, Q He, and others.. Progression of fibrosis in hepatitis C
with and without schistosomiasis: correlation with serum markers of fibrosis.
Hepatology 43: 771-779. 2006.
2.
M Danta, D Brown, S Bhagani, and others.. Recent epidemic of acute hepatitis C
virus in HIV-positive men who have sex with men linked to high-risk sexual behaviours.
AIDS 21: 983-991. 2007.
