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Hepatitis C Virus (HCV) and HIV Coinfection
A Review of Data Presented at the 12th World AIDS Conference

Gordon Nary

September 1998

More than 40 posters and oral presentations featured at the 12th World AIDS Conference directly or indirectly addressed the burgeoning epidemic of HIV/HCV coinfection. Following are a few findings of particular interest:


Risk Factors and Transmission

HCV approaches saturation in injection drug users (IDUs) and is associated with duration of injection drug use, female gender, and incarceration, were some of the findings reported by David Michael Patrick, MD, and his colleagues from the British Columbia Center for Disease Control Society, Vancouver. The authors reported on a study of 1080 IDUs during a documented outbreak of HIV infection to determine predictors of HCV prevalence and progression in the IDU cohort. The authors recommend that continued emphasis be placed on harm reduction in prison, protection of women, and primary prevention of injection drug use as critical risk reduction strategies [abstract 13296].

Prisons throughout the world are now beginning to face the challenges and consequences of an epidemic of hepatitis C which may have always been there, but not diagnosed. Joachim Nelles of the Psychiatric University of Bern, reported on the extent of hepatitis B and C in Hindelbank prison for women which may prove to be similar in prisons in many countries. HIV-prevalence was reported at 3.2 percent, hepatitis B at 33 percent, and hepatitis C at 25 percent, figures that, as the author points out, are comparable to other international studies of the incidence of blood-borne viruses in prisons. The data also reinforce previous studies that indicate the prevalence of these diseases in prison is several times higher than in the outside community. What may have rattled the generally stoic Swiss was that the Hindelbank prevalence rate was sixty times higher than estimated in the whole of Swiss society. Nelles's study pointed out that while prisoners' knowledge of risks for HIV infection and appropriate protection against such infection was good, their knowledge of hepatitis B and C was poor, and that more efforts are needed to raise prisoners' awareness of the risk factors of hepatitis. One wonders, however, if the prison inmates were using their HIV knowledge to reduce the risk of HIV infection in prison, why were not the same precautions adequate for other bloodborne diseases such as hepatitis B and C? At least in Hindelbank prison, HIV-prevention messages are dispensed with sterile syringes [abstract 60493].

Non-injecting heroin users may have a low risk of HIV infection but a potential high risk of transitioning to injecting and, thus, are at high risk of HCV infection. This was one of the conclusions in a paper by Alan Neagius, PhD, and colleagues from the National Development and Research Institutes, New York, who analyzed data from 268 non-injecting heroin users (NIUs) in an ongoing prospective cohort study who were recruited in outpatient settings in New York City during 1996-97. The authors also concluded that NIUs are at risk of acquiring HBV through sexual transmission. They recommend that advocacy of non-injecting heroin use as a harm reduction approach needs to incorporate methods to reduce possible adverse outcomes, including transitions to injecting and non-parenteral infection with HBV and possibly HCV [abstract 13382].

There was one report at the Geneva conference that provided data on what may prove to be an important harm-reduction strategy against HIV coinfection among HCV-positive injection drug users. Barbara Broers of the AIDS Unit Hopital Cantonal and her colleagues from Geneva reported on the incidence and prevalence rates of HIV, HBV, and HCV infection in a cohort of 700 drug users on methadone maintenance treatment between 1988 and 1995.

According to the authors, the incidence rates for HIV and HBV which, reflected in-treatment risk behavior, were low (0.6 percent and 2.1 percent per person year of follow-up). For HCV the rate remained higher (4.2 percent). The authors conclude that their data, which show a spectacular decrease in HIV infection, suggest that the drug users have changed their HIV risk-taking behaviors in response to HIV risk prevention campaigns [abstract 60440].

The low risk of sexual transmission of HCV was reported by Marise O. Fonseca from the Instituto de Saúde-Ses and colleagues from Sao Paulo. They reported on the first HCV prevalence study in a Brazillian cohort of men who have sex with men. The cohort consisted of HIV-positive men between ages 18 and 59 who are non-injection-drug users. A total of 631 men volunteered for the study which checked their HCV serology and found seven (1.12 percent) to be HCV-positive with no new HCV seroconversions during a three-year follow-up [abstract 60753].


Coinfection and disease progression

HCV-l is associated with faster progression to AIDS and death in hemophiliac patients concluded Angelos Hatzakis, MD, of Athens University Medical School, Athens, and colleagues at Laikon General Hospital, Athens, and the National Cancer Institute, Maryland. The researchers studied 152 hemophilic patients from the US and 129 from Greece with known HIV seroconversion dates who were genotyped by RT-PCR [abstract 13306].

HCV coinfection has negative consequences on HIV-coinfected patients. Margaret Hoffman-Terry, MD, and colleagues at Lehigh Valley Hospital, Allentown, reported their retrospective study which matched 50 HCV/HIV-coinfected patients with 50 HIV-positive patients who were HCV-negative. The patients were matched by age, sex, ethnicity, and antiretroviral regimens. Trends in HIV viral loads and CD4 counts along with liver function tests (LFTs) were examined. The researchers concluded that unlike previous studies on hemophiliacs, their patient population had higher LFTs with a trend toward decreasing CD4 counts and increasing HIV viral loads than the HCV-negative patients [abstract 22255].

HAART may contribute to more rapid HCV infection of coinfected patients. Gilles Pialoux, MD, and colleagues from Broussais, Pasteur, Necker, and Laennec Hospitals in Paris, measured HCV and HIV RNA levels (Roche assays) on ten patients selected from a cohort of 120 HIV/HCV coinfected patients when rapidly evolving HCV infection was suspected in the ten because of an unexplained elevation of alanine aminotransferase (ALT). The mean ALT were 57 ± 20 before HAART compared to 137 ± 52 after. The authors concluded that dramatic improvement in the immune status under HAART may enhance the occurrence of severe HCV infection in coinfected patients [abstract 22243].


Treatment

HAART has no long-term beneficial effect on HCV viremia. Olivier Rutschmann, MD, Bernard Hirschel, MD, and their colleagues of the University Hospital in the host city of the 12th World AIDS Conference, reported a prospective study of 20 HIV/HCV-coinfected patients who were on highly active anti-retroviral therapy (HAART) including reverse transcriptase inhibitors (RTIs) in combination with indinavir, ritonavir, and ritonavir/saquinavir. HCV and HIV RNA levels were determined by Roche Amplicor, before initiation of HAART, six weeks later, and every three to four months thereafter. No significant change in ALT and AST levels was observed during the long-term follow-up [abstract 22238].

An undetectable viral load does not influence HCV replication in HIV/HCV coinfection. Michelle Bentata-Pessayre, MD, and colleagues from Avicenne Hospital, Bobigny (France) screened HBV and HCV serologies in 381 HIV-positive patients during the period 1995-1997. The complexities of the study design and outcome are detailed in the abstract. The data collected and analyzed led the authors to conclude that in HIV infection, HCV coinfection is common in injection drug users in which there is also a high rate of HBV infection, but in which only HCV is replicated. Under antiretroviral therapy with or without protease inhibitors, ALT levels are higher and HCV replication is not modified. An undetectable viral load does not influence HCV replication. The authors speculated that if more of the patients had been eligible for alpha interferon therapy, this might have affected the outcome [abstract 60806].


Side Effects of HBV/HCV Coinfection

Chronic active hepatitis (CAH) and cirrhosis are the most relevant complications of long-term HIV survivors with HBV/HCV coinfection. Francesca Moretti, MD, and colleagues from Milan analyzed the prevalence of HBV/HCV coinfection in 46 patients with HIV disease classified as long-term-non-progressers (LTNPs). The authors predict that CAH and cirrhosis will continue to be observed in more LTNPs as antiretroviral therapies continue to prolong survival in HIV/HCV coinfected patients. Moretti and colleagues recommend that studies are needed to analyze the natural history of CAH and cirrhosis, the incidence of HIV infection, and the effects of interferon therapy in long-term survivors with HIV infection with various degrees of immune deterioration [abstract 60675].

Gordon Nary is editor of the Journal




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