Viral hepatitis and HIV coinfection

Oral fluid and hepatitis A, B and C: a literature review

BACKGROUND AND AIMS

Viral hepatitis is a significant global health problem that, depending upon the virus, affects individuals of the developing and/or developed world. In recent years, there has been renewed interest in whether oral fluids can be considered as a source of viral hepatitis transmission and whether oral fluid, in particular, whole saliva, may be a useful source for viral detection as part of the diagnosis and monitoring of viral hepatitis. The aim of this article was to review current data concerning the possible carriage of the hepatitis A, B and C viruses within saliva and gingival crevicular fluid. Such knowledge will indicate if (i) oral fluid is a possible source of infection and (ii) whether oral fluid can be used for diagnosis and monitoring of viral hepatitis.

DATA AND SOURCES

A literature search was conducted using PubMed (Medline), EMBASE/Excerpta medica, the Cochrane database and Scopus. The results were limited to published material after 2000. Relevant material was evaluated and reviewed.

CONCLUSION

There is some evidence that hepatitis viruses A, B and C are present in oral fluids, particularly whole saliva and gingival crevicular fluid and may thus be possible sources of viral detection in clinical diagnosis and monitoring. However, the data are inconsistent and warrant the need for well-planned longitudinal studies to explore the precise frequency of oral carriage of such viruses and to determine the virological and host factors that may influence the oral presence of hepatitis A, B and C viruses.

[Treatment of hepatitis C virus in HIV-positive patients]

Hepatitis C virus (HCV)-HIV coinfection currently occurs in more than 30% of HIV-positive patients in Spain. Nowadays, the treatment of choice for chronic hepatitis due to HCV infection in HIV-positive patients is pegylated interferon plus ribavirin. This combination achieves an overall cure rate of 50%, which is somewhat lower than those obtained in patients with HCV monoinfection. Adverse effects are frequent, leading to treatment withdrawal in 10-20% of patients. Importantly, there are three new features of hepatitis C in patients with HIV: (1) the recent development of epidemic outbreaks of acute hepatitis due to HCV infection in HIV-positive men caused by homosexual activity, (2) pharmacogenetic markers in the form of genetic polymorphisms near the IL28B gene related to response to HCV treatment as well as spontaneous eradication of HCV after acute infection, and (3) new antiviral molecules have allowed triple combination treatments to be designed and the preliminary results of clinical trials reporting high response rates are highly promising.

Lamivudine-resistant HBV infection in HIV-positive patients receiving antiretroviral therapy in a public routine clinic in Cameroon

BACKGROUND

In Africa, most HIV-HBV-coinfected patients on antiretroviral therapy (ART) receive an anti-HBV lamivudine monotherapy that has been shown in northern countries to lead to frequent emergence of drug resistance. We assessed the HBV prevalence and the rate and pattern of lamivudine-resistant HBV mutations in Cameroonian HIV-infected, ART-treated patients.

METHODS

A cross-sectional survey was performed in 2006-2007 at the HIV/AIDS outpatient clinic of the Central Hospital in Yaoundé, Cameroon. Plasma samples were tested as appropriate for hepatitis B surface antigens, antibodies to hepatitis B core, HBV DNA, genotypes and lamivudine-resistant polymerase mutations.

RESULTS

Of 552 adult patients (71% women, median age 38 years), 290 had received lamivudine-based ART for 12 months and 262 for 24 months. No patient had received tenofovir. The prevalence of hepatitis B surface antigen was 9.8%. Overall, 26% of seropositive patients had an HBV DNA level >40 IU/ml. Genotypes A and E were identified. Polymerase resistance mutations were detected in 14% and 60% of patients at months 12 and 24, respectively.

CONCLUSIONS

This study supports both WHO recommendations of screening for HBV before initiation of ART and of using ART containing tenofovir and either lamivudine or emtricitabine in HIV-HBV-coinfected patients in Africa.

Felt and enacted stigma among HIV/HCV-coinfected adults: the impact of stigma layering

The realization that many persons with HIV/AIDS are subjected to multiple layers of stigmatization because they belong to socially deviant and disenfranchised groups (e.g., injection drug users, racial/ethnic and sexual minorities) accounts for an increasing interest in the phenomenon of stigma layering. The stigma associated with hepatitis C virus (HCV) has also been conceptualized as layered. However, researchers have overlooked the fact that HCV adds a layer to the HIV stigma and vice versa. Qualitative interviews with 132 HIV/HCV-coinfected patients were analyzed to explore how they experience the two layers of stigma. Most participants hierarchically ordered the stigmas associated with each disease and regarded HIV as the more stigmatizing of the two. A small number perceived HIV and HCV as equally stigmatizing. The impact of the hierarchical and nonhierarchical ordering of the two stigmas on coinfected patients' felt and enacted stigmatization is explored and implications for interventions are discussed.

Hepatocellular carcinoma in HIV-infected patients: check early, treat hard

PURPOSE

Hepatocellular carcinoma (HCC) is an increasing cause of mortality in HIV-infected patients in the highly active antiretroviral therapy (HAART) era. The aims of this study were to describe HCC tumor characteristics and different therapeutic approaches, to evaluate patient survival time from HCC diagnosis, and to identify clinical prognostic predictors in patients with and without HIV infection.

PATIENTS AND METHODS

A multicenter observational retrospective comparison of 104 HIV-infected patients and 484 uninfected patients was performed in four Italian centers. HCC was staged according to the Barcelona Clinic Liver Cancer (BCLC) criteria.

RESULTS

Tumor characteristics of patients with and without HIV were significantly different for age, Eastern Cooperative Oncology Group performance status (PS) score ≤1, and etiology of chronic liver disease. Despite the similar potentially curative option rate and better BCLC stage at diagnosis, the median survival time was significantly shorter in HIV(+) patients. HIV(+) patients were less frequently retreated at relapse. Independent predictors of survival were: BCLC stage, potentially effective HCC therapy, tumor dimension ≤3 cm, HCC diagnosis under a screening program, HCC recurrence, and portal vein thrombosis. Restricting the analysis to HIV(+) patients only, all positive prognostic factors were confirmed together with HAART exposure.

CONCLUSION

This study confirms a significantly shorter survival time in HIV(+) HCC patients. The less aggressive retreatment at recurrence approach does not balance the benefit of younger age and better BCLC stage and PS score of HIV(+) patients. Thus, considering the prognosis of HIV(+) HCC patients, effective screening techniques, programs, and specific management guidelines are urgently needed.

Is statin therapy safe in patients with HIV/hepatitis C coinfection?

Statins are effective therapy for hypercholesterolemia and are commonly indicated in patients with HIV and hepatitis C virus infections. Unfortunately, in patients coinfected with these viruses, the safety of statins has not been conclusively evaluated. We retrospectively evaluated five coinfected patients in our outpatient clinic who received statin therapy. Although the sample size was small, we found that statins were safe in this population and recommend that further evaluation with a prospective controlled trial be undertaken to definitively answer this safety issue.

Correlates of spontaneous clearance of hepatitis C virus in a Danish human immunodeficiency virus type 1 cohort

BACKGROUND

Around a quarter of individuals infected with hepatitis C virus (HCV) are spontaneously able to clear the virus. Correlates of spontaneous HCV clearance are not well established and the aim of this study was to characterize factors associated with spontaneous HCV clearance in a human immunodeficiency virus (HIV)-co-infected cohort.

METHODS

We analyzed 327 anti-HCV-positive HIV-1-infected patients using multivariate logistic regression. HCV clearance was defined as the presence of anti-HCV with undetectable HCV RNA from at least 2 measurements more than 6 months apart.

RESULTS

We included 327 HIV-1-infected individuals, predominantly of Caucasian race; 112 (34%) were females, 258 (79%) were injecting drug users (IDU), 25 (8%) were men who have sex with men (MSM), and 20 (6%) were hepatitis B surface antigen (HBsAg)-positive. Seventy-six (23%; 95% confidence interval (CI) 18-28) had cleared their HCV infection and 251 (77%; 95% CI 72-82) had a chronic infection. The clearance rate in HBsAg-positive individuals was 65%. Being female, HBsAg-positive, or belonging to HIV exposure groups IDU and MSM predicted higher HCV clearance rates (adjusted odds ratio (aOR) 1.8, 95% CI 1-3.2; aOR 7.6, 95% CI 2.7-21; aOR 5.2, 1.2-23.5; and aOR 10.2, 95% CI 1.8-58, respectively). Race, acquired immunodeficiency syndrome (AIDS), and antiretroviral therapy were not associated with HCV clearance.

CONCLUSIONS

The HCV clearance rate in this HIV-1 cohort was 23%. MSM and IDUs may have higher clearance rates due to their repeated exposure to low-dose HCV, leading to immune memory. Our data suggest an interaction of hepatitis B virus and HCV that influences the outcome of acute HCV infection.

Hepatitis C virus subtypes circulating among intravenous drug users in Lisbon, Portugal

Hepatitis C virus (HCV) infects 2-3% of the world population and intravenous drug consumption is the leading cause of transmission in industrialized countries. The unavailability of data on the molecular epidemiology of HCV infection in Portugal prompted the study of HCV subtypes circulating among intravenous drug users residing in the Lisbon metropolitan area and sampled about 10 years apart (1998-2000 and 2008-2009). Partial coding sequences for E1 and/or NS5B were obtained from 124 individuals with HCV viremia, both mono-infected and co-infected with HIV. Phylogenetic analysis showed that, for both time periods, the most prevalent subtypes were 1a and 3a, found, altogether, in 64.9% and 71.6% of the individuals, respectively for the first and the second sampling periods. However, genotype 4 viruses (subtypes 4a and 4d), introduced later, as inferred by comparison of intra-subtype genetic distances, were also relatively frequent even one decade ago (24.6%). This HCV subtype profile for Portuguese intravenous drug users is in agreement with those described for other southern European countries when in association with drug consumption. With the exception of subtype 1b, phylogenetic trees did not show clustering of the Portuguese sequences, but rather phylogenetic mixing of HCV sequences from different geographic origins, as described previously in other Western countries and suggestive of a large international transmission network. Consistent with the low recombination rates reported for HCV, only one sample revealed discordant subtypes for the two regions analyzed (4d in E1 and 4a in NS5B), representing a potential new recombinant that deserves further analysis.

Safety and efficacy of raltegravir in patients with HIV-1 and hepatitis B and/or C virus coinfection

OBJECTIVE

The aim was to examine the long-term safety and efficacy of raltegravir in patients with HIV-1 and hepatitis B virus (HBV) and/or hepatitis C virus (HCV) coinfection in three double-blind, randomized, controlled Phase III studies.

METHODS

In STARTMRK, treatment-naïve patients received raltegravir 400 mg twice a day (bid) or efavirenz 600 mg at bedtime, both with tenofovir/emtricitabine. In BENCHMRK-1 and -2, highly treatment-experienced patients with multi-drug resistant virus and prior treatment failure received raltegravir 400 mg bid or placebo, both with optimized background therapy. Patients with chronic HBV and/or HCV coinfection were enrolled if baseline liver function tests were ≤5 times the upper limit of normal. HBV infection was defined as HBV surface antigen positivity for all studies; HCV infection was defined as HCV RNA positivity for STARTMRK and HCV antibody positivity for BENCHMRK.

RESULTS

Hepatitis coinfection was present in 6% (34 of 563) of treatment-naïve patients (4% HBV only, 2% HCV only and 0.2% HBV+HCV) and 16% (114 of 699) of treatment-experienced patients (6% HBV only, 9% HCV only and 1% HBV+HCV). The incidence of drug-related adverse events was similar in raltegravir recipients with and without hepatitis coinfection in both STARTMRK (50 vs. 47%) and BENCHMRK (34 vs. 38.5%). Grade 2-4 liver enzyme elevations were more frequent in coinfected vs. monoinfected patients, but were not different between the raltegravir and control groups. At week 96, the proportion of raltegravir recipients with HIV RNA <50 HIV-1 RNA copies/mL was similar between coinfected and monoinfected patients (93 vs. 90% in STARTMRK; 63 vs. 61% in BENCHMRK).

CONCLUSION

Raltegravir was generally well tolerated and efficacious up to 96 weeks in HIV-infected patients with HBV/HCV coinfection.

Short Communication: Hepatitis B Virus Harboring Nucleotide Deletions in the Basal Core Promoter in HBe-Positive HIV-Coinfected Patients Under Lamivudine Therapy

The presence of HBV genomes with deletions at the basal core promoter (BCP) is associated with more aggressive liver disease. This 3-year longitudinal analysis of two HIV-HBV-coinfected patients allowed identification of three deletions with dissimilar abundance and permanence into the HBV quasispecies composition. These deletions may contribute to HBV pathogenesis in HIV-coinfected individuals.

Hepatitis B and C infection and liver disease trends among human immunodeficiency virus-infected individuals

AIM: To examine trends in and correlates of liver disease and viral hepatitis in an human immunodeficiency virus (HIV)-infected cohort.

METHODS: The multi-site adult/adolescent spectrum of HIV-related diseases (ASD) followed 29 490 HIV-infected individuals receiving medical care in 11 U.S. metropolitan areas for an average of 2.4 years, and a total of 69 487 person-years, between 1998 and 2004. ASD collected data on the presentation, treatment, and outcomes of HIV, including liver disease, hepatitis screening, and hepatitis diagnoses.

RESULTS: Incident liver disease, chronic hepatitis B virus (HBV), and hepatitis C virus (HCV) were diagnosed in 0.9, 1.8, and 4.7 per 100 person-years. HBV and HCV screening increased from fewer than 20% to over 60% during this period of observation (P < 0.001). Deaths occurred in 57% of those diagnosed with liver disease relative to 15% overall (P < 0.001). Overall 10% of deaths occurred among individuals with a diagnosis of liver disease. Despite care guidelines promoting screening and vaccination for HBV and screening for HCV, screening and vaccination were not universally conducted or, if conducted, not documented.

CONCLUSION: Due to high rates of incident liver disease, viral hepatitis screening, vaccination, and treatment among HIV-infected individuals should be a priority.

Fibrosis in chronic viral hepatitis

In the last years, several studies have been performed with the aim to evaluate the real impact of antiviral treatments on fibrosis progression in patients with chronic viral hepatitis. The main goal of therapy in patients with chronic hepatitis B is viral suppression. This outcome leads to an important improvement in both hepatic inflammation and fibrosis and reduces the HCC occurrence. An histological improvement has been largely demonstrated in patient treated with oral nucleoside and nucleotide analogs achieving the rate of 72% with entecavir and tenofovir. Similarly, in patients with chronic hepatitis C, sustained virologic response to interferon therapy is associated with regression of fibrosis and lower liver decompensation and HCC occurrence. In the next future further studies will assess the real impact of the new directly anti-viral agents on liver necroinflammation and fibrosis in chronic hepatitis C.

No evidence of XMRV or related retroviruses in a London HIV-1-positive patient cohort

Background

Several studies have implicated a recently discovered gammaretrovirus, XMRV (Xenotropic murine leukaemia virus-related virus), in chronic fatigue syndrome and prostate cancer, though whether as causative agent or opportunistic infection is unclear. It has also been suggested that the virus can be found circulating amongst the general population. The discovery has been controversial, with conflicting results from attempts to reproduce the original studies.

Methodology/Principal Findings

We extracted peripheral blood DNA from a cohort of 540 HIV-1-positive patients (approximately 20% of whom have never been on anti-retroviral treatment) and determined the presence of XMRV and related viruses using TaqMan PCR. While we were able to amplify as few as 5 copies of positive control DNA, we did not find any positive samples in the patient cohort.

Conclusions/Significance

In view of these negative findings in this highly susceptible group, we conclude that it is unlikely that XMRV or related viruses are circulating at a significant level, if at all, in HIV-1-positive patients in London or in the general population.

HIV/HCV co-infection: pathogenesis, clinical complications, treatment, and new therapeutic technologies

World-wide, hepatitis C virus (HCV) accounts for approximately 130 million chronic infections, with an overall 3% prevalence. Four to 5 million persons are co-infected with HIV. It is well established that HIV has a negative impact on the natural history of HCV, including a higher rate of viral persistence, increased viral load, and more rapid progression to fibrosis, end-stage liver disease, and death. Whether HCV has a negative impact on HIV disease progression continues to be debated. However, following the introduction of effective combination antiretroviral therapy, the survival of coinfected individuals has significantly improved and HCV-associated diseases have emerged as the most important co-morbidities. In this review, we summarize the newest studies regarding the pathogenesis of HIV/HCV coinfection, including effects of coinfection on HIV disease progression, HCV-associated liver disease, the immune system, kidney and cardiovascular disease, and neurologic status; and effectiveness of current anti-HIV and HCV therapies and proposed new treatment strategies.

Liver transplantation for hepatocellular carcinoma: the impact of human immunodeficiency virus infection

Liver transplantation (LT) has become an accepted therapy for end-stage liver disease in human immunodeficiency virus-positive (HIV+) patients, but the specific results of LT for hepatocellular carcinoma (HCC) are unknown. Between 2003 and 2008, 21 HIV+ patients and 65 HIV- patients with HCC were listed for LT at a single institution. Patient characteristics and pathological features were analyzed. Univariate analysis for overall survival (OS) and recurrence-free survival (RFS) after LT was applied to identify the impact of HIV infection. HIV+ patients were younger than HIV- patients [median age: 48 (range = 41-63 years) versus 57 years (range = 37-72 years), P < 0.001] and had a higher alpha-fetoprotein (AFP) level [median AFP level: 16 (range = 3-7154 μg/L] versus 13 μg/L (range = 1-552 μg/L), P = 0.04]. There was a trend toward a higher dropout rate among HIV+ patients (5/21, 23%) versus HIV- patients (7/65, 10%, P = 0.08). Sixteen HIV+ patients and 58 HIV- patients underwent transplantation after median waiting times of 3.5 (range = 0.5-26 months) and 2.0 months (range = 0.5-24 months, P = 0.18), respectively. No significant difference was observed in the pathological features of HCC. With median follow-up times of 27 (range = 5-74 months) and 36 months (range = 3-82 months, P = 0.40), OS after LT at 1 and 3 years reached 81% and 74% in HIV+ patients and 93% and 85% in HIV- patients, respectively (P = 0.08). RFS rates at 1 and 3 years were 69% and 69% in HIV+ patients and 89% and 84% in HIV- patients, respectively (P = 0.09). In univariate analysis, HIV status did not emerge as a prognostic factor for OS or RFS.

CONCLUSION

Because of a higher dropout rate among HIV+ patients, HIV infection impaired the results of LT for HCC on an intent-to-treat basis but had no significant impact on OS and RFS after LT.

Comparison of HIV-, HBV-, HCV- and co-infection prevalence between Chinese and Burmese intravenous drug users of the China-Myanmar border region

Background

Co-infection with HIV and HCV and/or HBV is highly prevalent in intravenous drug users (IDUs). Because of the proximity to the “Golden Triangle”, HIV prevalence among the IDUs is very high in the China-Myanmar border region. However, there are few studies about co-infection with HIV and HCV and/or HBV, especially in the region that belongs to Myanmar.

Methods

721 IDUs, including 403 Chinese and 318 Burmese, were investigated for their HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) serological status. Statistical analysis was performed to evaluate the differences of the epidemic situation between the Chinese IDUs and the Burmese IDUs.

Results

Among the Chinese IDUs and the Burmese IDUs, HCV infection was the most prevalent (69.0% vs 48.1%, P<0.001), followed by HBV (51.6% vs 43.1%, P<0.05) and HIV (33.7% vs 27.0%, P>0.05). Besides, there were more HIV-HBV co-infected IDUs (20.1% vs 11.3%, P<0.005), and HIV-HCV co-infected IDUs (31.8% vs 23.9%, P<0.05) in China than in Myanmar, as well as HIV-HBV-HCV triple infection (19.1% vs 10.4%, P<0.005).

Conclusion

Co-infection with HIV and HCV and/or HBV is highly prevalent among the IDUs in the China-Myanmar border region. The HIV epidemic appears to be in a downward trend, compared with previous reports. However, all infections were more prevalent among the Chinese IDUs than among the Burmese.

A case of palpable purpura and nephropathy: Occam's Razor or Hickam's Dictum

Vasculitis causing palpable purpura, nephropathy, and hematologic abnormalities is a well-known entity. However, sometimes, vasculitis may not be the primary cause but is part of a systemic disease. Literature suggests that infections like HIV can induce nephropathy and antineutrophilic cytoplasmic antibody-positive vasculitis, which is different from the well-known entity of "antineutrophilic cytoplasmic antibody-associated vasculitis." We present a 46-year-old female patient with a history of intravenous drug abuse who reported with a rash, swelling, and palpable purpura of the lower extremities. Peripheral smear showed no evidence of disseminated intravascular coagulation or thrombotic thrombocytopenic purpura; metabolic profile showed acute kidney injury. She was found to be HIV- and hepatitis C-positive. Immunologic workup was positive for both MPO and PR3 antineutrophilic cytoplasmic antibodies and negative for cryoglobulins; complement levels were low. Skin biopsy showed leukocytoclastic vasculitis but kidney biopsy was negative for any immunologic involvement; it showed only glomerulosclerosis. Thus, it was thought that nephropathy and vasculitis, in this case, are two distinct pathologic processes, both induced by infection (HIV and/or hepatitis C). The patient responded to low-dose steroid therapy. She was later started on the definitive therapy, the highly active antiretroviral therapy regimen. This case illustrates the fact that low-dose steroids can still be a good alternative in acute situations in patients at risk from immunosuppression.

Liver disease in the HIV-infected individual

Since the advent of effective antiretroviral therapy (ART) for human immunodeficiency virus-1 (HIV), there has been a substantial decrease in deaths related to acquired immunodeficiency syndrome (AIDS). However, in the ART era, liver disease is now the most common non-AIDS-related cause of death among HIV-infected patients, accounting for 14%-18% of all deaths in this population and almost half of deaths among hospitalized HIV-infected patients. Just as the burden of non-AIDS morbidity and mortality has changed in the ART era, the types of liver disease the clinician is likely to encounter among these patients have changed as well. This review will discuss the causes of liver disease in the HIV-infected population in the ART era, including chronic hepatitis C virus, chronic hepatitis B virus, medication-related hepatotoxicity, alcohol abuse, nonalcoholic fatty liver disease, and AIDS-related liver diseases.

Advances in hepatobiliary pathology: update for 2010

Recent publications on hepatology and hepatic pathology provide a wealth of new information on wideranging topics. Morphologic aspects of liver disease associated with hepatitis B and C viruses, autoimmune hepatitis, and HIV infection were addressed, as was the prevalent problem of nonalcoholic fatty liver disease. Advances in diagnosis and pathogenesis of primary biliary cirrhosis, primary sclerosing cholangitis, and the increasingly complex spectrum of IgG4 hepatobiliary diseases were also reported. The histologic and immunohistochemical features of the rare "calcifying nested stromal-epithelial tumor" of the liver were described in a 9-case series. For benign and malignant liver tumors, immunohistochemistry plays a major diagnostic role, and several recent studies demonstrate the value of immunostains in distinguishing between liver-cell adenoma and focal nodular hyperplasia.

Hepatitis C/HIV co-infection is associated with higher mortality in hospitalized patients with hepatitis C or HIV

Up to 10% of all patients with Hepatitis C virus (HCV) infection are co-infected with human immunodeficiency virus (HIV); 25-30% of HIV patients are co-infected with HCV. The aim of this study was to examine the association of HCV/HIV co-infection with outcomes of hospitalized patients compared to those with HCV or HIV monoinfection. Using the 2006 Nationwide Inpatient Sample, patients with HCV or HIV monoinfection or HCV/HIV co-infection were identified using ICD-9-CM codes. We compared liver-related and infection-related admission between the three groups of patients. Multivariate logistic regression was performed to identify independent predictors of in-hospital mortality. A total of 474,843 discharges with HCV monoinfection, 206,758 with HIV monoinfection and 56,304 with HCV/HIV co-infection were included. Liver-related admissions were more common in co-infected patients (15.4%) compared to those with HIV monoinfection (3.3%, P < 0.001). Primary infectious hospitalizations were more common in HIV monoinfection (33.9%) compared to co-infected patients (26%, P < 0.001). HCV/HIV co-infection was associated with higher mortality compared to HCV monoinfection (OR 1.41, 95% CI 1.20-1.65) but not when compared to monoinfected-HIV patients. HCV-associated cirrhosis or complications thereof conferred four times greater mortality risk in patients with HIV (OR 3.96, 95% CI 3.29-4.79). The rate of hospitalization for HCV/HIV co-infected patients (23.5%) was significantly higher than those with HCV (14.8%) or HIV (19.9%) (P < 0.001). HCV/HIV co-infection is associated with significantly higher rates of hospitalization and is a risk factor for in-hospital mortality compared to patients with isolated HCV.

Care of hepatitis C virus infection in human immunodeficiency virus-infected patients: modifications in three consecutive large surveys between 2004 and 2009

BACKGROUND & AIMS

To analyze the care of HCV infection in HIV-HCV coinfected patients and its progression between 2004 and 2009.

METHODS

Three hundred eighty HIV-HCV coinfected patients were prospectively included from November 22 to 29, 2004 (2004 survey), 416 patients from April 3 to 10, 2006 (2006 survey), and 419 patients from June 15 to 22, 2009 (2009 survey).

RESULTS

The rate of liver biopsy decreased (14% vs. 38% vs. 56%), while the use of non-invasive liver damage tests increased (47% vs. 24% vs. ND) in the 2009, 2006, and 2004 surveys, respectively. The rate of patients that had never been treated for HCV infection progressively decreased in the 2009, 2006, and 2004 surveys (37%, 42%, and 54%). The main reasons for HCV non-treatment changed as HCV treatment was deemed less questionable and the lack of liver biopsy became a very rare reason (6%, 18%, and 34%). Among patients treated for HCV infection, the rate of sustained virological response increased (49%, 29%, and 29%). The main factors independently associated with HCV treatment were a liver fibrosis score > or =F2 (odds ratio=3.5; 95% CI 2.1-5.7), a liver biopsy activity grade > or =A2 (2.7; 1.4-5.3), a CD4 cell count > or =350 ml (2.7; 1.6-4.4), European origin (2.1; 1.3-3.4), daily alcohol consumption<30 g (2.1; 1.2-3.8), and male gender (2.0; 1.2-3.3).

CONCLUSION

Compared to the 2004 and 2006 surveys, the 2009 coinfected patients had liver damage assessment more frequently, more patients had received HCV treatment and more patients had achieved a sustained virological response.

Suppressive and pro-inflammatory roles for IL-4 in the pathogenesis of experimental drug-induced liver injury: a review

IMPORTANCE OF THE FIELD

Idiosyncratic drug reactions resulting in drug-induced liver injury (DILI) account for approximately 13% of acute liver failure cases in the US. Idiosyncratic drug reactions are the third most common cause of liver transplantation, exceeded only by acetaminophen and indeterminate causes. Clinical evidence suggests that idiosyncratic DILI is triggered by drug hapten-altered self proteins resulting in hepatocellular injury. An example of this type of DILI is hepatitis that develops in susceptible individuals following administration of halogenated volatile anesthetics, dihydralazine, carbamazepine or diclofenac.

AREAS COVERED IN THIS REVIEW

In this review, we describe research in animal models that supports a critical role for suppressive and pro-inflammatory roles for IL-4 in the pathogenesis of immune-mediated DILI.

WHAT THE READER WILL GAIN

The reader will gain insights into the roles of IL-4 in the development of experimental DILI. The reader will gain tools to assist in the translation of these findings to those in patients with immune-mediated DILI, as well as other inflammatory diseases of the liver. The reader will then be made aware of gaps in knowledge in the pathogenesis of DILI where research could result in significant advances in the care of these complicated patients.

TAKE HOME MESSAGE

In experimental immune-mediated DILI, IL-4 suppresses regulatory responses to CYP2E1 autoantigens but induces pro-inflammatory responses to drug haptens.

Hepatitis B infection and association with other sexually transmitted infections among men who have sex with men in Peru

To assess the epidemiology of hepatitis B virus (HBV) infection among men who have sex with men (MSM) in Peru, we evaluated the prevalence and associated risk factors for HBV serologic markers among participants of a HIV sentinel surveillance conducted in 2002-2003. The standardized prevalences for total antibodies to hepatitis B core antigen (anti-HBc) and hepatitis B surface antigen (HBsAg) were 20.2% and 2.8%, respectively. Individuals with human immunodeficiency virus (HIV-1) infection had significantly higher anti-HBc (44.3% versus 19.3%) and HBsAg (9.5% versus 2.3%) prevalences than uninfected men. Increasing age (adjusted odds ratio [AOR] = 1.06), versatile sexual role (AOR = 1.59), sex in exchange for money/gifts (AOR = 1.58), syphilis (AOR = 1.74), HIV-1 infection (AOR = 1.64), and herpes simplex virus type 2 (HSV-2, AOR = 2.77) infection were independently associated with anti-HBc positivity, whereas only HIV-1 infection (AOR = 3.51) and generalized lymph node enlargement (AOR = 3.72) were associated with HBsAg positivity. Pre-existing HBV infection is very common among Peruvian MSM and was correlated with sexual risk factors. MSM in Peru constitute a target population for further HBV preventive and treatment interventions.

Prevalence of hepatitis B and hepatitis C virus infections in France in 2004: social factors are important predictors after adjusting for known risk factors

To monitor the prevalence of hepatitis B and hepatitis C a cross-sectional survey was conducted in 2004 among French metropolitan residents. A complex sampling design was used to enroll 14,416 adult participants aged 18-80 years. Data collected included demographic and social characteristics and risk factors. Sera were tested for anti-HCV, HCV-RNA, anti-HBc and HBsAg. Data were analyzed with SUDAAN software to provide weighted estimates for the French metropolitan resident population. The overall anti-HCV prevalence was 0.84% (95% CI: 0.65-1.10). Among anti-HCV positive individuals, 57.4% (95% CI: 43.2-70.5) knew their status. Factors associated independently with positive anti-HCV were drug use (intravenous and nasal), blood transfusion before 1992, a history of tattoos, low socioeconomic status, being born in a country where anti-HCV prevalence >2.5%, and age >29 years. The overall anti-HBc prevalence was 7.3% (95%: 6.5-8.2). Independent risk factors for anti-HBc were intravenous drug use, being a man who has sex with men, low socioeconomic status, a stay in a psychiatric facility or facility for the mentally disabled, <12 years of education, being born in a country where HBsAg prevalence >2%, age >29 and male sex. The HCV RNA and HBsAg prevalence were 0.53% (95% CI: 0.40-0.70) and 0.65% (95% CI: 0.45-0.93), respectively. Among HBsAg positive individuals, 44.8% (95% CI: 22.8-69.1) knew their status. Anti-HCV prevalence was close to the 1990s estimates whereas HBsAg prevalence estimate was greater than expected. Screening of hepatitis B and C should be strengthened and should account for social vulnerability.

Seroepidemiology of viral hepatitis, HIV and herpes simplex type 2 in the household population aged 21-64 years in Puerto Rico

BACKGROUND

Viral hepatitis and sexually transmitted infections (STIs) are key public health problems that pose an enormous risk for disease transmission in the general population. This study estimated, for the first time, prevalence estimates of serologic markers of HCV, HBV, HAV, HIV and HSV-2 in the adult population of Puerto Rico and assessed variations across sociodemographic and behavioral characteristics.

METHODS

A seroepidemiologic survey was employed using a stratified cluster probability sample of households in Puerto Rico. Participants completed a face-to-face interview, a self-administered questionnaire using an ACASI system, and provided blood specimens for antibody testing. Prevalence estimates of viral hepatitis, HIV and HSV-2 were estimated using a logistic regression model weighting for the probability of participation in each household block and the inverse of the probability of selection according to geographic strata, households' blocks, and sex distribution.

RESULTS

A total of 1,654 adults participated in the study. Seroprevalence estimates for HCV (2.3%, 95% CI: 1.3%-4.2%), HBV (3.1%, 95% CI: 2.0%-4.7%), and HSV-2 (22.3%, 95% CI: 18.5%-26.7%) in Puerto Rico are roughly in agreement with estimates obtained in the US population; however, HAV (41.3%, 95% CI: 36.9%-45.8%) and HIV (1.1%, 95% CI: 0.5%-2.3%) seroprevalence estimates in Puerto Rico were higher. The proportion of individuals that were unaware of their serostatus was as follows: 80% for HCV, 98.3% for HBV, 96.4% for HAV, 36.4% for HIV, and 97.8% for HSV-2. Post-stratification estimates of seroprevalence varied significantly by demographic and risk related characteristics.

CONCLUSION

This data underscore the disproportionate impact of some viral infections across selected population subgroups in Puerto Rico. A concerted island-wide effort is needed to strengthen viral hepatitis and STIs prevention and control strategies, support surveillance to monitor chronic infections, and ensure appropriate counseling, testing, and medical management of infected persons. Integration of HCV, HBV, and HSV-2 counseling into HIV existing prevention services and outreach through social networks might represent a valuable approach to reach high-risk individuals.

Prevalence and incidence of HCV infection among Vietnam heroin users with recent onset of injection

HCV infection continues to spread at an alarming rate among IDU populations. The available evidence suggests that HCV is acquired relatively quickly following onset of injection. However, there are few prospective studies of HCV acquisition, particularly among IDU populations in resource-poor settings. A sample of young male heroin injectors with recent onset of injection (<4 years) was recruited in Hanoi, Vietnam for a prospective assessment of the early course of injection (n = 179). Both behavioral and biological assessments (including detailed retrospective assessment of injection initiation) were conducted at baseline and repeated at 6-month intervals for a period of 16 months. Variables associated with HCV infection (p value < 0.05) in bivariate analyses were considered for inclusion in logistic regression models to identify risk factors independently associated with HCV infection. HCV incidence was calculated by using the incidence density approach and was expressed in terms of person-years of observation. The baseline of prevalence of HCV was 46%. HCV significantly increased in relation to time since first injection, from 30% in subjects with </=10 months of injection risk to 70% in subjects with >/=30 months injection risk (p value = 0.0005). In multivariate logistic regression analysis, increasing age, incarceration in a drug detention facility (OR = 2.54; 95%CI 1.05, 6.15), and time since first injection remained significantly associated with HCV infection. Use of injection as primary mode of administration (OR = 2.56; 95%CI 0.98, 6.69) achieved marginal significance. After 16 months of follow-up, the incidence rate of HCV was 23.35 per 100 person-years and the mean time between first injection and first positive HCV test was 1.2 years. HCV is acquired much more rapidly among new injector populations than previously recognized, demonstrating the need for early behavioral intervention among new heroin-user populations. Particularly critical are interventions that target new heroin user populations, including interventions that improve understanding of viral transmission dynamics, that promote alternative strategies for drug sharing, and that delay initiation of injection.

MELD score is an important predictor of pretransplantation mortality in HIV-infected liver transplant candidates

BACKGROUND & AIMS

Human immunodeficiency virus (HIV) infection accelerates liver disease progression in patients with hepatitis C virus (HCV) and could shorten survival of those awaiting liver transplants. The Model for End-Stage Liver Disease (MELD) score predicts mortality in HIV-negative transplant candidates, but its reliability has not been established in HIV-positive candidates.

METHODS

We evaluated predictors of pretransplantation mortality in HIV-positive liver transplant candidates enrolled in the Solid Organ Transplantation in HIV: Multi-Site Study (HIVTR) matched 1:5 by age, sex, race, and HCV infection with HIV-negative controls from the United Network for Organ Sharing.

RESULTS

Of 167 HIVTR candidates, 24 died (14.4%); this mortality rate was similar to that of controls (88/792, 11.1%, P = .30) with no significant difference in causes of mortality. A significantly lower proportion of HIVTR candidates (34.7%) underwent liver transplantation, compared with controls (47.6%, P = .003). In the combined cohort, baseline MELD score predicted pretransplantation mortality (hazard ratio [HR], 1.27; P < .0001), whereas HIV infection did not (HR, 1.69; P = .20). After controlling for pretransplantation CD4(+) cell count and HIV RNA levels, the only significant predictor of mortality in the HIV-infected subjects was pretransplantation MELD score (HR, 1.2; P < .0001).

CONCLUSIONS

Pretransplantation mortality characteristics are similar between HIV-positive and HIV-negative candidates. Although lower CD4(+) cell counts and detectable levels of HIV RNA might be associated with a higher rate of pretransplantation mortality, baseline MELD score was the only significant independent predictor of pretransplantation mortality in HIV-infected liver transplant candidates.

Telbivudine in the treatment of chronic hepatitis B: experience in HIV type-1-infected patients naive for antiretroviral therapy

BACKGROUND

Telbivudine is a potent inhibitor of hepatitis B virus (HBV) replication without anti-HIV type-1 (HIV-1) activity demonstrated in vitro; however, very few clinical data on HIV-1-infected patients are available at present. Because it represents a therapeutic option in HIV-1-HBV-coinfected patients who do not require antiretroviral therapy, we strictly monitored three HIV-1-HBV-coinfected patients treated with telbivudine monotherapy for chronic hepatitis B.

METHODS

We performed molecular analysis of HBV DNA and of HIV-1 reverse transcriptase and protease RNA and DNA sequences in three HIV-1-HBV-coinfected patients treated with telbivudine monotherapy.

RESULTS

Despite a transient and deep reduction of HIV-1 RNA, observed in two of the three patients studied, no genotypic resistance mutations were detected on both HIV-1 and HBV viruses.

CONCLUSIONS

Telbivudine therapy for 24 weeks showed a potent anti-HBV activity in HIV-1-positive, hepatitis B e antigen-positive patients with high HBV viraemia. No direct anti-HIV-1 activity of telbivudine was demonstrated and no genotypic resistance mutations to anti-HIV-1 drugs was found; however, the transient but deep reduction of HIV RNA, after telbivudine introduction, deserves further investigation and a strict monitoring of HIV-1 viraemia in HIV-1-infected patients on treatment with this drug.

Hepatitis B precore/core promoter mutations in isolates from HBV-monoinfected and HBV-HIV coinfected patients: a 3-yr prospective study

BACKGROUND

The course of chronic HBV infection is modified by HIV-coexistence.

OBJECTIVE

To analyze the role of HBV genomic heterogeneity in basal core promoter (BCP) and precore (Pc) genomic regions.

STUDY DESIGN

In a 3-yr prospective study, 39 HBV infected patients (20 monoinfected and 19 HIV-coinfected) were included. Eighty-two HBV isolates were studied at quasispecies level in the BCP/Pc genomic region. Clinical records obtained include data on lamivudine therapy and resistance mutations, HBV and HIV-viral load.

RESULTS

HBV isolates were predominantly ascribed to genotype (Gt) A2 among HBV-monoinfected and HIV-coinfected patients. BCP mutations in isolates from monoinfected patients were significantly more frequent than in those from coinfected ones, irrespective of the HBe expression pattern (p<0.0001). Regardless of the HIV-coexistence, the Pc mutation at G1896A only barely appeared among clone-derived sequences of GtF1 isolates, mainly from HBe(-) HBV-monoinfected patients.

CONCLUSIONS

HBV isolates characterized from HIV-coinfected patients seem to be more prone to exhibit a wild type genomic pattern at BCP regulatory region with respect to those from HBV-monoinfected ones. Besides, mutations at Pc region might be genotype-dependent in their frequency but not on HIV co-presence related.

Chronic Hepatitis B Infection: Principles of Therapy

Chronic hepatitis B is a global health concern in many resource-limited settings due to perinatal or pediatric hepatitis B virus transmission. In the United States, pediatric infection has been virtually eliminated due to maternal screening during pregnancy and the availability of an effective vaccine. However, young adults remain an at-risk group for hepatitis B virus infection due to sexual transmission and injection drug use. The frequency of progression from acute hepatitis B virus infection to chronic hepatitis B infection depends on multiple factors, including host immune function and age at time of hepatitis B virus infection. Fortunately, there are 7 currently approved therapies for chronic hepatitis B infection, and several emerging therapies that show promise. Despite the availability of these agents, many clinical questions still surround chronic hepatitis B therapy including when to start therapy, which agent is ideal for first and second line therapy, the appropriate duration of therapy, and the role of combination antiviral therapy. This review focuses on agents available for chronic hepatitis B management, including pharmacology, safety and efficacy data, monitoring parameters, and the role for each in chronic hepatitis B therapy in adult patients.

High rates of active hepatitis B and C co-infections in HIV-1 infected Cameroonian adults initiating antiretroviral therapy

OBJECTIVES

To investigate the presence of hepatitis B virus (HBV) DNA and hepatitis C virus (HCV) RNA in HIV-infected patients initiating antiretroviral therapy in Cameroon.

METHODS

Baseline blood samples from 169 patients were tested retrospectively for hepatitis B surface antigens (HBsAg), anti-hepatitis B core (anti-HBc), anti-HCV and - if HBsAg or anti-HCV result was positive or indeterminate - for HBV DNA or HCV RNA, respectively, using the Cobas Ampliprep/Cobas TaqMan quantitative assay (Roche Diagnostics GmbH, Mannheim, Germany).

RESULTS

HBV DNA was detected in 14 of the 18 patients with positive or indeterminate HBsAg results [8.3% of the total study population, 95% confidence interval (CI) 4.6-13.5]. The median HBV viral load was 2.47 x 10(7) IU/mL [interquartile range (IQR) 3680-1.59 x 10(8); range 270 to >2.2 x 10(8)]. Twenty-one patients (12.4%, 95% CI 7.9-18.4) were found with HCV RNA (all with positive HCV serology). The median HCV viral load was 928 000 IU/mL (IQR 178 400-2.06 x 10(6); range 640-5.5 x 10(6)). No patient was co-infected with HBV and HCV. In multivariate analysis, HCV co-infection was associated with greater age [>or=45 years vs. <45 years, odds ratio (OR) 11.89, 95% CI 3.49-40.55, P<0.001] and abnormal serum alanine aminotransferase level [>or=1.25 x upper limit of normal (ULN) vs. <1.25 x ULN, OR 7.81, 95% CI 1.54-39.66, P=0.01]; HBV co-infection was associated with abnormal serum aspartate aminotransferase level (OR 4.33, 95% CI 1.32-14.17, P=0.02).

CONCLUSIONS

These high rates of active HBV and HCV co-infections in HIV-positive Cameroonian patients requiring antiretroviral therapy underline the need to promote: (i) screening for HBV and HCV before treatment initiation; (ii) accessibility to tenofovir (especially in HBV-endemic African countries); and (iii) accessibility to treatment for HBV and HCV infections.

Current HIV type 1 molecular epidemiology profile and identification of unique recombinant forms in Jakarta, Indonesia

HIV infection is a major problem in Indonesia. The number of people living with HIV has been increasing from year to year, especially among injecting drug users (IDUs). Since there were only limited data about molecular epidemiology profiles of HIV/AIDS in Indonesia, a cross-sectional study involving 208 HIV-1-seropositive individuals was conducted in 2007 in Jakarta. The majority of participants were 16-30 years of age (64.9%) and 74.5% were male. The most frequent risk factor was injecting drug use (IDU) (45.7%) followed by heterosexual transmission (34.1%). Phylogenetic analysis of gag (p17 and p6) and env C2V3 regions showed 200 (96.2%) of 208 DNA samples were CRF01_AE and only 3 (1.4%) were subtype B. Five samples (2.4%) indicated discordant subtypes between the three aforementioned regions: three of them showed unique CRF01_AE/B recombination patterns in 2.3-kbp nucleotide sequences (from p17 to part of RT), including one sample showing similarity to CRF33_01B, reported previously in Malaysia. This study shows the current predominant subtype is CRF01_AE in every risk group, with a decreasing number of pure subtype B, and the first identification of CRF01_AE/B recombinant forms among HIV-1-seropositive Indonesians.

HIV, hepatitis C virus, and hepatitis B virus co-infections among injecting drug users in Tehran, Iran

OBJECTIVES

To assess the prevalence of HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) infections and co-infections among injecting drug users (IDUs) in Tehran.

METHODS

A sample of 899 IDUs (861 male and 38 female) was recruited in Tehran from treatment and harm reduction facilities and from drug user hangouts in public areas in equal proportions. ELISA testing for HIV, HCV antibody (HCV-Ab), hepatitis B surface antigen (HBsAg), and hepatitis B core antibody (HBcAb) was carried out. Positive HIV tests were rechecked by Western blot.

RESULTS

The prevalence of HIV was 10.7%, HCV infection was 34.5%, and past or current HBV infection was 50.7%. Infection with all three viruses was seen in 6.5% (95% confidence interval 4.9-8.2) of participants. HIV/HCV, HIV/HBV, and HBV/HCV co-infections were seen in 8.7%, 7.8%, and 21.0% of participants, respectively. The rate of HCV infection among HIV-positive cases was significantly higher than in HIV-negative IDUs (80.6% vs. 28.7%, p<0.0001). There was no significant association between these infections and co-infections with gender and source of sampling.

CONCLUSION

In general, co-infection with these three blood-borne viruses is common among IDUs. Since co-infection increases the morbidity and mortality of all infections, the observed level of co-infection in the high number of IDUs in Iran necessitates a serious comprehensive response.

Seroprevalence of HIV/HBV coinfection in Malian blood donors

OBJECTIVES

A cross-sectional study was conducted to assess the prevalence of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and their coinfection among blood donors at the National Blood Transfusion Center in Bamako, Mali, from November 2001 to July 2002.

METHODS

Enzyme-linked immunosorbent assay techniques with reagents from Bio-Rad (France) were used to test the blood samples.

RESULTS

11,592 blood donors were tested for HIV and HBV surface antigens. The prevalence of HIV was 4.5% and the prevalence of HBV was 14.9%. The HIV/HBV coinfection rate was only 1.13% in this population.

CONCLUSION

The coinfection rate was unexpectedly low in this blood donor population where monoinfection with HIV or HBV prevalence was high.

Reduction of CCR5 with low-dose rapamycin enhances the antiviral activity of vicriviroc against both sensitive and drug-resistant HIV-1

Vicriviroc (VCV) is a chemokine (C-C motif) receptor 5 (CCR5) antagonist with potent anti-HIV activity that currently is being evaluated in phase III clinical trials. In the present study, donor CCR5 density (CCR5 receptors/CD4 lymphocytes) inversely correlated with VCV antiviral activity (Spearman's correlation test; r = 0.746, P = 0.0034). Low doses of the transplant drug rapamycin (RAPA) reduced CCR5 density and enhanced VCV antiviral activity. In drug interaction studies, the RAPA/VCV combination had considerable antiviral synergy (combination indexes of 0.1-0.04) in both multicycle and single-cycle infection of lymphocytes. The synergy between RAPA and VCV translated into dose reduction indexes of 8- to 41-fold reductions for RAPA and 19- to 658-fold reductions for VCV. RAPA enhanced VCV antiviral activity against both B and non-B clade isolates, potently suppressing clade G viruses with reported reduced sensitivities to VCV and to the licensed CCR5 antagonist maraviroc. Importantly, RAPA reduction of CCR5 density in lymphocytes sensitized VCV-resistant strains to VCV, inhibiting virus production by approximately 90%. We further demonstrated the role of CCR5 density on VCV activity against resistant virus in donor lymphocytes and in cell lines expressing varying CCR5 densities. Together, these results suggest that low doses of RAPA may increase the durability of VCV-containing regimens in patients by enhancing VCV viral suppression, by allowing the use of lower doses of VCV with reduced potential for toxicity, and by controlling emerging VCV-resistant variants.

Hepatitis E virus as a newly identified cause of acute viral hepatitis during human immunodeficiency virus infection

The recent description of chronic hepatitis E in organ transplant recipients deserves increased awareness in the context of hepatitis E virus (HEV) infection in immunocompromised individuals. Reported here is what is apparently the first PCR-documented case of acute hepatitis E in a human immunodeficiency virus (HIV)-1-infected patient. The CD4(+) T-lymphocyte count was 246/mm(3). The IgM anti-HEV antibody and HEV RNA tests results from serum were positive. Hepatitis was benign, and chronic HEV infection was ruled out. The HEV genotype was 3f. The patient did not report recent travel abroad. HEV should be tested in HIV-infected individuals presenting with acute hepatitis. HEV RNA detection is useful in diagnosing HEV infection and in monitoring recovery.