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HIV and Coverage of the
46th Annual Meeting of the European
Association for the Study of the Liver

March 30 - April 3, 2011, Berlin, Germany

HIV/HCV Coinfection among HIV Positive Gay Men

SUMMARY: Researchers at EASL presented further data on outbreaks of sexually transmitted HCV among HIV positive men who have sex with men. Sustained response rates are high when interferon-based therapy is started during acute infection, but re-infection after treatment is common in this population.

By Liz Highleyman

Starting around 2000 clinicians began reporting outbreaks of apparently sexually transmitted hepatitis C virus (HCV) infection among HIV positive gay and bisexual men in the U.K., followed by large cities in Europe, Australia, and North America. HIV/HCV coinfected people tend to experience more rapid liver disease progression and do not respond as well to interferon-based therapy, but treatment is more effective if started during acute HCV infection.

Three posters presented at the European Association for the Study of the Liver's International Liver Congress (EASL 2011) this month in Berlin looked at sexually transmitted HCV in men with HIV.

HCV Incidence in CASACDE

Investigators with the CASCADE Collaboration characterized the hepatitis C epidemic among HIV positive men who have sex with men (MSM) from 1990 through 2007. Recent phylogenetic analyses suggest that the spread of HCV in this population started around 1996, they noted as background.

The researchers estimated HCV incidence among HIV positive MSM in 12 cohorts in the U.K., Europe, and Canada participating in the CASCADE study. They accounted for the fact that HCV data collection started in different years in the various cohorts.

Of 4724 MSM in the participating cohorts, 3014 men with an available HCV test result were included in the analysis. Of these, 124 men (4%) had only positive HCV test results, 2798 (93%) had only negative results, and 92 (3%) had both.

In 1990 HCV incidence ranged from 0.9 to 2.2 cases per 1000 person-years (PY), depending on the method of analysis used. HCV incidence crept up through 1995, when it was estimated at between 5.5 and 8.1 per 1000 PY. From 2002 onwards, new HCV infections increased more substantially, reaching estimated incidence rates ranging from 16.8 to 30.0 cases per 1000 PY in 2005 and 23.4 to 51.1 cases per 1000 PY in 2007.

"Our data support phylodynamic findings that HCV incidence had already increased among HIV-infected MSM from the mid-1990s," the researchers concluded. "However, the main expansion of the HCV epidemic started after 2002."

"Raising awareness, routine testing, and HCV treatment are needed to minimize further spread of HCV among HIV-infected MSM," they recommended.

Treating Acute HCV

In a related study, P. Ingiliz and colleagues performed a retrospective analysis of more than 300 HIV positive men in northern Germany who were diagnosed with acute HCV infection between 2001 and 2008. The researchers compared untreated patients vs those who received interferon-based therapy.

Most study participants (93%) reported male-male sex as a risk factor for HCV infection; only 3 people (1%) reported injection drug use. The median age at HCV diagnosis was 40 years (range 20-69 years). A majority (70%) had HCV genotype 1 while 18% had genotype 4, which is uncommon in Europe outside MSM sexual transmission clusters. The men had well-controlled HIV overall; the median duration of HIV infection was 5.5 years, median HIV viral load was 110 copies/mL, and median CD4 cell count was 461 cells/mm3.

About three-quarters of participants received hepatitis C therapy, with a median treatment duration of 33 weeks. Just over half of patients who completed treatment and follow-up achieved sustained virological response (SVR). Men who achieved SVR were treated significantly longer than non-responders (41 weeks vs 27 weeks). About one-quarter of the untreated participants spontaneously cleared HCV.

"Our findings confirm that acute hepatitis C in HIV-infected patients affects mainly MSM who acquire HCV sexually," the researchers concluded. "In this real-life setting from urban regions in northern Germany, treatment rates appear to be high."

HCV Reinfection

Finally, J. Sasadeusz and colleagues from the U.K. and Australia looked at rates of apparently sexually transmitted HCV re-infection among HIV positive MSM after interferon-based therapy.

Using a clinical database, the researchers identified new cases of acute HCV infection that occurred between March 2003 and December 2007. They looked at spontaneous HCV clearance, treatment response, and re-infection rates. Re-infection was defined as detectable HCV RNA following treatment-induced SVR or 2 consecutive undetectable tests at least 3 months apart following spontaneous clearance.

A total of 61 people -- all men -- met the case definition for acute HCV infection; 97% reported male-male sex as a risk factor. Here too, about 73% had HCV genotype 1 and 20% had genotype 4.

Within this group, 9 men (15%) experience spontaneous HCV clearance and 40 were treated with pegylated interferon plus weight-based ribavirin. The SVR rate was high at 80%.

Of the 41 men with either spontaneous clearance or SVR, 39% subsequently experienced re-infection (including 1 man who was re-infected twice). HCV re-infection occurred a median 46 months (range 20-66 months) after initial infection, and all had male-male sex as their reported risk factor. Only 1 re-infected patient experienced spontaneous HCV clearance, 9 underwent treatment again, and 33% achieved SVR.

Based on these findings, the researchers concluded, "HCV infection remains high in HIV positive MSM individuals."

"There is no immunity conferred by prior infection," they added. "There is a need to alter high-risk behaviors leading to re-infection."

These results are in accordance with those of another recent analysis reported at this year's Retrovirus conference (CROI 2011), which found that 25% of HIV positive men treated for acute hepatitis C in Amsterdam became re-infected within about 1 year.

Investigator affiliations:

Abstract 1053: Cluster Infectious Diseases, Health Service Amsterdam; Department of Internal Medicine, Center for Immunity and Infection Amsterdam (CINIMA), Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands; Instituto de Salud Carlos III, Madrid, Spain; Basel Institute for Clinical Epidemiology & Biostatistics, University Hospital Basel, Basel, Switzerland; INSERM U897, University Victor Ségalen, Bordeaux, France; Instituto Superiore di Sanitá, Rome, Italy; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Robert Koch Institute, Berlin, Germany; Oslo University Hospital, Ulleval, Norway; MRC Clinical Trials Unit, London, UK; Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands.

Abstract 243: Medical Center for Infectious Diseases, Infectious Diseases, Vivantes Auguste-Viktoria Klinikum, Berlin, Germany; Medical Center for Infectious Diseases, Hamburg, Germany;MVZ City Ost, Praxiszentrum-Kaiserdamm Dres. Jörg Gölz Arend Moll, Praxis Hintsche-Klausen, Praxis Tumstrasse, Praxis Koeppe/Kreckel, Berlin, Germany; Center for Interdisciplinary Medicine, Muenster, Germany; Aerzteforum Seestrasse, Berlin, Germany.

Abstract 1057: Alfred Hospital, Melbourne, Victoria, Australia; Infection and Population Health, University College London, UK; Infectious Diseases/HIV Medicine, Royal Free Hospital, London, UK.



J van der Helm, M Prins, J del Amo, et al (CASCADE Collaboration). The hepatitis C epidemic among HIV-positive men who have sex with men: incidence estimates from 1990 to 2007. 46th Annual Meeting of the European Association for the Study of the Liver (EASL 2011). Berlin. March 30-April 3. Abstract 1053.

P Ingiliz, M Obemeier, L Weitner, et al. Acute hepatitis C in persons infected with the human immunodeficiency virus (HIV): the "real-life setting" proves the concept. 46th Annual Meeting of the European Association for the Study of the Liver (EASL 2011). Berlin. March 30-April 3. Abstract 243.

J Sasadeusz, A Rodger, T Fernandez, and S Bhagani. High rates of sexually transmitted HCV re-infection in HIV positive men who have sex with men: prevention is the key. 46th Annual Meeting of the European Association for the Study of the Liver (EASL 2011). Berlin. March 30-April 3. Abstract 1057.
























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