Altered natural history of hepatitis B in homosexual males--a reflection of altered immune responsiveness?

The treatment effect of alpha interferon in chronic hepatitis B is independent of pre-treatment variables. Results based on individual patient data from 10 clinical controlled trials. European Concerted Action on Viral Hepatitis (Eurohep)

Alpha interferon induces HBeAg seroconversion in about one third of treated patients and has become an established treatment of chronic hepatitis B. A number of smaller studies have suggested that response to treatment is more likely to occur in patients with higher levels of transaminases, with recent (adult) onset, a history of acute hepatitis, low levels of HBV DNA and in heterosexual males. The aim of this European co-operative study was to estimate the effect of alpha interferon more accurately and to evaluate the influence of host pre-treatment variables on the effect of interferon. Individual data were collected from 751 patients from 10 controlled clinical trials on alpha interferon (lymphoblastoid or recombinant) treatment for chronic hepatitis B. Alpha interferon was administered to 496 patients, while 255 were untreated controls. Individual patient data were analysed by survival analysis (log rank test and Cox regression analysis), stratified by trial, with the disappearance of HBeAg as the major endpoint. The results showed that the HBeAg disappearance rate with or without interferon treatment was higher in patients with high aminotransferase levels, with a history of acute hepatitis and in male heterosexual patients disregarding HIV status. If HIV-positive patients were excluded, the effect of sexual orientation was not significant. Therapy with alpha interferon increased the a priori HBeAg disappearance rate by a factor of 1.76; the relative treatment effect of alpha interferon was independent of the tested pretreatment host variables, but dependent on the total (intended) interferon dose (low dose < or = 200 MU/m2 increased HBeAg disappearance by a factor 1.37; medium/high dose > or = 200 MU/m2 increased HBeAg disappearance by a factor 2.05). In conclusion, this meta-analysis suggests that the effect of alpha interferon is less than previously assumed and independent of pretreatment host variables tested. It confirms the higher therapeutic benefit of a total dose exceeding 200 MU/m2 and of selection of patients based on disease activity and immune reactivity. Although all patient seem to have the same relative benefit, the absolute benefit of alpha interferon treatment seems to be greatest in patients with high transaminase levels and with a history of acute hepatitis.

Correlation of hepatitis B surface antigen clearance with the route of hepatitis B virus infection

We studied 563 consecutive adults with acute hepatitis B hospitalized from May 1981 to May 1983 and their habitual heterosexual partners. Radio-immunoassays for the detection of serological markers of hepatitis A virus (HAV) and hepatitis B virus (HBV) and enzyme-immunoassay for the detection of IgM antibody to hepatitis B core antigen (IgM anti-HBc) were used. Of the 563 patients, 503 (89.7%) were hepatitis B surface antigen (HBsAg) positive and 60 (10.7%) were HBsAg negative on admission. Absence of HBsAg on admission was observed significantly more frequently in patients infected possibly by the heterosexual route than in the remaining patients (23.3% versus 6.6%; P less than 0.001). This finding was independent of sex. These data show that the route of HBV infection rather than the sex appears to have a more important role in the rapid clearance of HBsAg.

Molecular characterization of a new variant of hepatitis B virus in a persistently infected homosexual man

Based on the diversity of nucleotide sequences of cloned hepatitis B virus DNA genomes, we have predicted possible replication of genetic variants of human hepatitis B virus. This prediction is exemplified by studies of a chronic carrier of HBsAg/adw2, who lacked anti-HBc but carried exceedingly high levels of hepatitis B virus DNA in serum. Molecular characterization of a number of clones revealed a restriction map that deviated significantly from the typical pattern of the adw2 subtype, especially around the EcoRI site commonly used as a reference point. Mutations appearing consistently in the precore and core regions included (a) mutation in the precore region resulting in a termination codon after the initiation codon, (b) mutation of the core initiation codon and (c) an inframe insert of 36 nucleotides in the precore region with a new initiation site for the core protein. The 36-nucleotide insertion resulted in a new core protein with 12 extra amino acids at its amino-terminal end. A few scattered point mutations were clustered in the amino-terminal half of the core gene. Although the core protein of this hepatitis B virus variant carried immunologically detectable HBcAg, the absence of a humoral immune response to HBcAg could have been caused by previous infection with human immunodeficiency virus. This naturally occurring human hepatitis B virus variant replicated efficiently without expressing the precore region, confirming previous observations made of the artificial mutants of duck hepatitis B virus.

Influence of hepatitis delta virus superinfection on the clearance of hepatitis B virus (HBV) markers in HBV carriers in Japan

To elucidate the influence of hepatitis delta virus (HDV) superinfection on the clearance of hepatitis B virus (HBV) associated antigens in HBV carriers, we examined for antibody to hepatitis delta antigen (anti-HD) serial sera collected from 1,029 HBV carriers in Kure, Japan. Of the 242 HBV carriers with hepatitis B e antigen (HBeAg), 28 became seropositive for anti-HD, of whom 18 (64.3%) cleared HBeAg; 214 did not become seropositive for anti-HD, of whom 70 (32.7%) cleared HBeAg. Thus, HBeAg clearance was observed in a significantly higher proportion of HDV-superinfected carriers as compared with carriers without HDV infection (P less than 0.005). In the 56 HBV carriers who cleared hepatitis B surface antigen (HBsAg), anti-HD was detected in three cases with increased serum alanine aminotransferase activity preceding HBsAg clearance. The duration of anti-HD seropositive state was less than 5 years, and the titer of anti-HD was relatively low in every case. These data suggest that the HDV infection rate in Japan is higher than previously reported, that HDV superinfection can be one of the factors that induce the HBeAg clearance and HBsAg clearance in HBV carriers, and also that the most likely outcome of HDV superinfection in HBV carriers in Japan may be acute self-limited infection.

Randomised controlled trial of lymphoblastoid interferon for chronic active hepatitis B

Thirty male patients (27 homosexual) with biopsy proven chronic active hepatitis B were randomised to receive lymphoblastoid interferon (Wellferon) or no treatment. All patients were HBeAg positive and had continuing viral replication. Patients receiving treatment were given a single daily intramuscular injection of interferon for 28 days at a starting dose of 2.5 MU/m2 increasing to a maximum of 7.5 MU/m2/day. Transient side effects of malaise and influenza like symptoms occurred in all patients and resolved rapidly after treatment. Hepatitis B viral replication was suppressed during interferon treatment in all patients but the effect was limited to the period of therapy. After one year there was no appreciable difference in viral markers between the two groups of patients and this treatment schedule appears less effective than the thrice weekly, three month regimes recently reported from other centres.

Delta-infection and suppression of hepatitis B virus replication in chronic HBsAg carriers

The presence of hepatitis B virus DNA and anti-delta was examined in a longitudinal study of 24 patients known to be delta-infected during the course from acute to chronic hepatitis B virus infection. Fifteen patients (63%) were hepatitis B virus DNA positive in the first serum sample. Eleven of 14 patients, who cleared hepatitis B virus DNA, did so following or at the same time as onset of delta-infection. Duration of hepatitis B virus DNA positivity in these 11 patients was shorter than in 11 anti-delta-negative controls matched according to duration of preceding hepatitis B virus DNA positivity, but the difference was not statistically significant. Considering only patients positive for IgM anti-delta in the last serum sample (eight patients), a statistically significant shorter duration of hepatitis B virus DNA positivity was found in delta-infected patients than in the controls (p less than 0.02). The study indicates that the delta-agent may have the capacity to inhibit hepatitis B virus replication and that a chronic delta-infection may lead to a termination of the period of active viral replication.

The influence of HTLV-III infection on the natural history of hepatitis B virus infection in male homosexual HBsAg carriers

The presence of antibodies to HTLV-III and markers of active hepatitis B virus replication was examined in a longitudinal study of 33 consecutive male homosexual HBsAg carriers. The mean follow-up time was 37 months (range = 4 to 109 months). All patients were initially hepatitis B virus DNA-positive and HBeAg positive. Antibodies to HTLV-III were detectable in eight patients while they were positive for both of these markers. One of them cleared hepatitis B virus DNA and seroconverted from HBeAg to anti-HBe. This corresponds to an annual clearance/seroconversion rate of 4% (95% confidence limits = 0 to 15%). In two patients, antibodies to HTLV-III appeared after clearance of hepatitis B virus DNA and HBeAg, and in one of them, hepatitis B virus DNA reappeared. Among the 25 patients negative for HTLV-III antibodies, the annual hepatitis B virus DNA clearance rate was 20% and HBeAg to anti-HBe seroconversion rate was 11% (95% confidence limits = 11 to 31% and 4 to 20% respectively). The observed hepatitis B virus DNA clearance rates in the two groups were significantly different (p less than 0.05). Disease activity, as determined by transaminase levels, was significantly lower in HTLV-III-infected individuals as compared to individuals without HTLV-III infection (p less than 0.05). Infection with HTLV-III may extend the period of active viral replication or even reactivate hepatitis B virus replication and seems to diminish inflammatory disease activity in chronic HBsAg carriers.

Long term follow up of chronic hepatitis B virus infection in intravenous drug abusers and homosexual men

Long term follow up of 16 homosexual men and 78 intravenous drug abusers who were chronic carriers of hepatitis B surface antigen (HBsAg) showed fundamental differences between the two groups. Viral replication, expressed by the presence of hepatitis B e antigen, lasted for four years or more in 10 out of 14 (71%) of the homosexual men whereas it was not present in 43 out of 73 (59%) of the drug addicts within one year. This shows a difference in the immunological response between homosexual HBsAg carriers and addicts that is not related to infection with human T cell lymphotropic virus type III. Severe histological damage such as chronic aggressive hepatitis, cirrhosis, or primary liver cancer was found in more than half of the homosexual men who underwent biopsy examinations. In drug addicts chronic persistent hepatitis was a regular finding in the absence of markers of delta infection, but in those addicts infected with the delta agent the degree of liver damage was comparable with that found in homosexual men.

Randomised controlled trial of lymphoblastoid interferon for chronic active hepatitis B

Thirty male patients (28 homosexual or bisexual) with biopsy proven chronic active hepatitis B were randomised to receive lymphoblastoid interferon (Wellferon) or no treatment. All patients were HBeAg-positive and had continuing viral replication. Interferon was given as a single daily i.m. injection for 28 days at a starting dose of 2.5 megaunits/m2 increasing to a maximum of 7.5 megaunits/m2/day. Transient side-effects occurred in all patients. Hepatitis B viral replication was suppressed during interferon treatment in all patients but the effect was limited to the period of therapy. After 1 year there was no appreciable difference in viral markers between the two groups of patients and this treatment schedule appears less effective than the thrice weekly, 3-month regimes reported from other centres.

Influence of sexual preference and chronic hepatitis B virus infection on T lymphocyte subsets, natural killer activity, and suppressor cell activity

To determine whether abnormalities of cell-mediated immunity are associated with chronic hepatitis B virus infection or with homosexuality, we studied 15 homo- and 11 heterosexual men with chronic hepatitis B virus infection, as well as 11 homo- and 16 heterosexual apparently healthy men. T lymphocyte subsets, natural killer activity, and suppressor cell activity were determined. Homosexual men had significantly lower peripheral blood T4/T8 ratios resulting from a significant increase in T8-positive (suppressor/cytotoxic) cells, and they also had lower natural killer activity. These effects of homosexuality were independent of chronic hepatitis B virus infection, which caused no significant changes independent of homosexuality, and they were not caused by infection with human immunodeficiency virus (formerly HTLV-III/LAV). Suppressor cell function was unaltered in this study. We conclude that studies of cellular immunity in hepatitis B virus infection must take male sexual preference into account.