Epidemic of Sexually Transmitted HCV in HIV-Infected Men Reported in New York

Megan Brooks

November 07, 2009

November 7, 2009 (Boston, Massachusetts) — New York City–based researchers are reporting an epidemic in the city of sexually transmitted acute hepatitis C virus (HCV) infection, leading to rapid progression of liver fibrosis in HIV-infected men who have sex with men (MSM).

Daniel S. Fierer, MD, from Mount Sinai School of Medicine in New York City, principal investigator on the study, reported his team's observations here this week in an oral presentation at the Liver Meeting 2009, the 60th annual meeting of the American Association for the Study of Liver Diseases.

"This epidemic represents a new clinical syndrome for HCV infection that turns much of our knowledge on its ear — a new risk group becoming infected through a previously rare route of transmission, resulting in unprecedented progression of liver fibrosis," Dr. Fierer said in a statement from the conference.

Enrolled in the ongoing study are 51 HIV-infected MSM, median age 40 years, with 53 episodes of acute HCV infection, defined as newly identified HCV antibody with either new elevation of alanine aminotransferase (ALT) levels, greater than 1 log fluctuation in HCV viral load, or high clinical suspicion.

In an analysis of 21 HCV-infected patients matched with uninfected control patients, the only factors significantly associated with increased risk for HCV were unprotected receptive anal intercourse with (P =.04) or without (P =.03) ejaculation, unprotected receptive oral sex with ejaculation (P =.03), use of sex toys (P =.03), "sex while high" (P =.01), and marijuana use (P =.04). Current or prior injection drug use was not associated with HCV infection.

Antiviral treatment was "highly successful" when initiated in the acute phase (within 6 months of diagnosis) but may be considerably less successful when delayed, Dr. Fierer and colleagues reported. Of 16 patients with genotype 1 acute HCV infection who completed peginterferon and ribavirin and were evaluated for sustained virologic response, 12 (75%) had the response. Of the 4 patients who failed therapy, 3 started treatment more than 6 months after diagnosis.

What's "particularly concerning," Dr. Fierer said during his oral presentation, is that 23 (77%) of 30 patients who underwent liver biopsy during the acute phase of HCV infection (median, 4.4 months after first ALT elevation) already showed moderate fibrosis; 21 had stage 2 fibrosis, and 2 had stage 3 fibrosis.

"This is a very worrisome outcome," Dr. Fierer told Medscape Gastroenterology after his presentation.

Session moderator Edmund J. Bini, MD, from the Veteran's Affairs New York Harbor Healthcare System, New York City, who was not involved in the study, said more research is needed. "It will be important to try to figure out whether the fibrosis in these patients really does represent very rapid fibrosis progression."

"We don't really completely understand the natural history of liver histology and acute HCV infection in HIV-positive patients," Dr. Bini added. "To think that everybody is going to be cirrhotic in a year if they are already stage 2 or stage 3, I think we should be concerned about that, but I also think it is still an understudied area, and it may be that some of the fibrosis is going to get reabsorbed."

However, on the basis of their findings, Dr. Fierer's team recommends ALT testing "every 3 months and HCV antibody testing every 6 to 12 months for all HIV-infected MSM. Promotion of safe sex is also warranted."

The study did not receive commercial support. Dr. Fierer and Dr. Bini have disclosed no relevant financial relationships.

The Liver Meeting 2009: American Association for the Study of Liver Diseases 60th Annual Meeting: Abstract 82. Presented November 1, 2009.


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