Hepatitis C Virus Reinfection Incidence and Treatment Outcome Among HIV-Positive MSM

Thomas C.S. Martin; Natasha K. Martin; Matthew Hickman; Peter Vickerman; Emma E. Page; Rhiannon Everett; Brian G. Gazzard; Mark Nelson

Disclosures

AIDS. 2013;27(16):2551-2557. 

In This Article

Abstract and Introduction

Abstract

Objective: Liver disease secondary to hepatitis C virus (HCV) infection in the context of HIV infection is one of the leading non-AIDS causes of death. Sexual transmission of HCV infection among HIV-positive MSM appears to be leading to increased reports of acute HCV infection. Reinfection after successful treatment or spontaneous clearance is reported among HIV-positive MSM but the scale of reinfection is unknown. We calculate and compare HCV reinfection rates among HIV-positive MSM after spontaneous clearance and successful medical treatment of infection.

Design: Retrospective analysis of HIV-positive MSM with sexually acquired HCV who subsequently spontaneously cleared or underwent successful HCV treatment between 2004 and 2012.

Results: Among 191 individuals infected with HCV, 44 were reinfected over 562 person-years (py) of follow-up with an overall reinfection rate of 7.8/100 py [95% confidence interval (CI) 5.8–10.5]. Eight individuals were subsequently reinfected a second time at a rate of 15.5/100 py (95% CI 7.7–31.0). Combining all reinfections, 20% resulted in spontaneous clearance and treatment sustained viral response rates were 73% (16/22) for genotypes one and four and 100% (2/2) for genotypes two and three. Among 145 individuals with a documented primary infection, the reinfection rate was 8.0 per 100 py (95% CI 5.7–11.3) overall, 9.6/100 py (95% CI 6.6–14.1) among those successfully treated and 4.2/100 py (95% CI 1.7–10.0) among those who spontaneously cleared. The secondary reinfection rate was 23.2/100 py (95% CI 11.6–46.4).

Conclusion: Despite efforts at reducing risk behaviour, HIV-positive MSM who clear HCV infection remain at high risk of reinfection. This emphasizes the need for increased sexual education, surveillance and preventive intervention work.

Introduction

Following the introduction of effective antiretroviral therapy (ART), liver disease has become the leading non-AIDS cause of death among HIV-positive individuals in the resource rich world.[1] The majority of liver disease in HIV-positive patients is caused by coinfection with the hepatitis C virus (HCV).[1–3] Coinfection with HIV and HCV is associated with accelerated liver fibrosis and shorter time to progression to cirrhosis and hepatic decompensation when compared with those with HCV monoinfection.[4–8]

Over the past decade, an epidemic of sexually transmitted HCV among HIV-positive MSM in Europe, the USA and Australia has been reported.[9–17] Phylogenetic analyses of circulating HCV strains in European countries suggest sexual transmission occurring since the mid-1990s.[10,18] The incidence of HCV infection among HIV-positive MSM is increasing with recent reports of rates as high as 2–5 per 100 person-years (py).[18–21] Identified risk factors for transmission include ulcerating genital infections, unprotected anal intercourse and high-risk sexual activity such as toy use, group sex, fisting and recreational drug use.[9,17,21–23]

Reinfection with HCV following either treatment or spontaneous clearance has been demonstrated in animal models, people who inject drugs (PWID) and, more recently, HIV-positive MSM.[24–27] Among PWID, weak evidence exists to suggest that individuals who spontaneously clear HCV monoinfection are at lower risk of developing chronic reinfections. This lower risk may in part be explained by the development of partial immunity leading to a higher probability of spontaneous clearance of reinfection. However, study results are highly heterogeneous and conflicting results may in part be explained by variable testing intervals during follow-up.[24,28] One retrospective study in the Netherlands revealed an alarmingly high HCV reinfection rate of 15.2 per 100 py among HIV-positive MSM who had previously been treated for acute HCV infection.[29] No studies to date have investigated the rate of reinfection among HIV-positive MSM in the United Kingdom, and whether there are differing reinfection rates among those who spontaneously clear their infections and those who are successfully treated.

We, therefore, calculated and compared the HCV reinfection rate among individuals who had either been treated for acute or chronic HCV infection, or who had spontaneously cleared their HCV infection within a cohort of over 8000 HIV-infected individuals attending clinic at Chelsea and Westminster Hospital in London, United Kingdom.

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