Coinfection

Alarming Rate of Hepatitis C Re-infection among HIV+ Gay Men

One-third of HIV positive men who have sex with men (MSM) who were treated for acute hepatitis C virus (HCV) infection in Amsterdam became re-infected within 2 years, indicating a need for improved prevention efforts, according to a recent report.

Femke Lambers from the Amsterdam Public Health Service and colleagues with the MOSAIC (MSM Observational Study of Acute Infection with Hepatitis C) study group assessed the incidence of re-infection among HIV positive gay and bisexual who cleared HCV following treatment of acute primary (first case) hepatitis C. They presented their findings at the 18th Conference on Retroviruses and Opportunistic Infection (CROI 2011) and in the August 19, 2011, advance online edition of AIDS.

Starting around the year 2000, clinicians began reporting cases of apparently sexually transmitted acute HCV infection among HIV positive gay and bisexual men, first in the U.K. and then in major cities in Europe, Australia, and the U.S.

Overall, HIV positive people are more likely to develop chronic HCV infection (that is, they are less likely to clear spontaneously without treatment), experience more rapid liver disease progression, and do not respond as well to interferon-based therapy as people with HCV alone; treatment is considerably more effective, however, if started during acute infection. Unlike many diseases, HCV infection does not confer immunity and people can become infected multiple times.

The researchers analyzed 56 HIV positive MSM at 2 large HIV outpatient clinics in Amsterdam who were previously diagnosed with presumed sexually transmitted acute HCV infection, were treated between 2003 and 2011, and had undetectable HCV RNA at the end of therapy.

HCV re-infection was defined as detectable HCV viral load with a switch in HCV genotype or clade, indicating new infection rather than potential late post-treatment relapse. This method would not count men who were infected a second time with the same type of HCV, thus possibly underestimating the re-infection rate.

Results

• From 2006 through 2009, 5 of the 56 participants experienced presumed HCV relapse and were not included in further analysis.
• 11 of the remaining 51 participants were found to be re-infected with a different type of HCV during a median follow-up period of 1.3 years.
• The median time until re-infection was 8.4 months.
• The incidence of HCV re-infection in this group was 15.2 per 100 person-years.
• The cumulative incidence of re-infection was 33% within 2 years.
• Most men switched from HCV genotype 4 to genotype 1.
• 3 men were re-infected with the same genotype but a different clade.
• CD4 counts did not differ between participants with and without HCV re-infection, and all re-infected patients on antiretroviral therapy had undetectable HIV viral load.
• Among 21 men with available data on behavior, those who were re-infected were significantly more likely to report non-injection recreational drug use, but no statistically significant differences in sexual activity were observed in this small population.
• 4 re-infected men were treated a second time: 2 achieved sustained virologic response (SVR), 1 relapsed, and 1 was still undergoing follow-up at the time of the report.

"An alarmingly high incidence of HCV re-infection was found in this group," the study authors concluded. "This high re-infection rate indicates that current prevention measures should be discussed, frequent HCV RNA testing should be continued after successful treatment and in case of possible relapse, clade typing should be performed to exclude re-infection."

Given the lack of association between CD4 T-cell count and re-infection, they recommended that more research is needed of the relationship between HIV infection and acquisition of HCV.

Most importantly, they elaborated in their discussion, "these findings stress the importance of repeated risk counseling for HCV transmission, which should be provided not only before and during treatment but also after its completion."

Investigator affiliations: Department of Research, Cluster infectious diseases, Public Health Service of Amsterdam, Netherlands; Department of Internal Medicine, Division of Infectious Diseases, Tropical Medicine and AIDS, CINIMA, Academic Medical Center, Amsterdam, Netherlands; Department of Medical Microbiology, Section of Clinical Virology, Academic Medical Center, Amsterdam, Netherlands; Department of Microbiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands; Department of Internal Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands.

8/23/11

Reference

FAE Lambers, M Prins, X Thomas, et al on behalf of the MOSAIC (MSM Observational Study of Acute Infection with hepatitis C) study group. Alarming incidence of hepatitis C virus (HCV) reinfection after treatment of sexually acquired acute HCV infection in HIV-infected men having sex with men in Amsterdam. AIDS (abstract). August 19, 2011 (Epub ahead of print).