Since October 2002, 38 gay men attending the Royal Free Hospital's HIV clinic, who were already chronically infected with HIV, have been identified as newly infected with HCV. Only six of the men (15 percent) were diagnosed due to symptoms related to acute HCV infection. A further 12 men (30 percent) had their HCV infection detected during routine sexually transmitted infection (STI) screening. The majority (55 percent) were diagnosed after their routine liver function tests indicated that further investigation was warranted. All HCV infections were confirmed by positive HCV RNA (viral load) testing.
The average age of the coinfected men was 30.5 years, median CD4 count was 514 cells/mm3 (range 207-943 cells/mm3), and 18 (48 percent) were on antiretroviral therapy at the time of diagnosis. Twenty of the men (52 percent) had also been diagnosed with another STI in the prior six months, adding weight to the assumption that the mode of transmission was sexual, since no other traditional risk factors have been found.
The majority (58 percent) were infected with genotype 1, which is more difficult to clear once the infection becomes established compared with genotypes 2 and 3; however there are few data on the success rate of treating acute genotype 1 HCV coinfection.
All of the men were offered treatment with pegylated interferon (PegIFN) and ribavirin -- the "gold standard" of chronic HCV treatment -- after 12 weeks of persistently testing HCV viral load positive. Seventeen men agreed to start treatment, 13 of whom were infected with genotype 1, three with genotype 3, and one with genotype 4. Their median HCV viral load was 5.86 log 10 at baseline.
Since the men were diagnosed at different times, the length of follow-up reported at Cardiff ranged from 12 to 48 weeks.
Of the remaining 21 men who did not take anti-HCV therapy, nine were reported as having spontaneously cleared their HCV infection. This is a much higher number than expected -- around 10 percent of all infections spontaneously clear in patients not coinfected with HIV -- although it is possible that reappearance of HCV viral load may occur at some point in the future.
The Royal Free Hospital researchers reported a 30 percent withdrawal rate, reflecting the difficulty of tolerating interferon therapy due to its major side effect: severe depression.
These results correspond closely to the results reported at last year's BHIVA conference by Mark Nelson and colleagues from the Chelsea & Westminster Hospital. Although the on-treatment success rate at the Royal Free Hospital appears to be around 70 percent -- much higher than even the recently reported APRICOT results of 40 percent in coinfected people with chronic HCV infection -- less than half of the men offered treatment took it; of those, 30 percent were unable to tolerate its side effects for the long term.
However, considering that the majority of those who achieved treatment success were infected with genotype 1 -- of whom only 29 percent achieved success in APRICOT -- the researchers suggest that treatment of HCV-coinfected patients with PegIFN and ribavirin during the acute stage of infection has a favorable response rate. At the moment, the BHIVA Guidelines for Treatment and Management of HIV and Hepatitis C Coinfection recommend only that physicians consider using PegIFN with or without ribavirin, with standard interferon suggested as first choice (Table 1).
Editor's Note: Reprinted with permission from www.aidsmap.com.
Back to the July 2004 issue of IAPAC Monthly.