[Acute outbreak of hepatitis C in human immunodeficiency virus-infected patients]

Acute hepatitis due to the hepatitisC virus: Where are the transmission occurring?

OBJECTIVE

To know the transmission patterns of the acute infection by the hepatitisC virus at a time when we are close to its elimination.

PATIENTS AND METHODS

A prospective descriptive clinical-epidemiological study of cases of acute HCV infection diagnosed between 2016 and 2020 was carried out in a reference hospital in the island of Gran Canaria.

RESULTS

Twenty-two cases of acute HCV were diagnosed (10 primary infections and 12 reinfections). There was an increase in the incidence from 0.6 in 2016 and 2017 to 2.3 cases per 100,000 inhabitants in 2020. The median age was 46years. From these, 77.3% were men and 68.2% were HIV-positive. According to the risk factors, 54.5% had high-risk sexual practices, 83.3% were men who had sex with men (70% with a concomitant STI), 31.8% were drug users, 9.1% were women with neuropsychiatric disorders, and one woman (4.5%) had a previous surgical intervention. There were thirteen patients (40.9%) who presented symptoms and eleven out of the thirteen patients who were asymptomatic were HIV-positive.

CONCLUSIONS

An increase in incidence was observed in the last years of the study and the main route of infection was high-risk sexual practice, mainly in men who have sex with men and who are HIV positive. Cases related to unsafe sex in other non-HIV groups are probably under-diagnosed. Microelimination strategies may not be sufficient to diagnose these cases, so in order to achieve elimination of the HCV the best strategy would be a population-based screening.

Impact of Sexualized Substance Use and Other Risk Practices on HCV Microelimination in gbMSM Living with HIV: Urgent Need for Targeted Strategies. Results of a Retrospective Cohort Study

INTRODUCTION

The objective of the present study is to describe the incidence of recently acquired hepatitis C (RAHCV) in a large cohort of people living with HIV (PLWHIV) and sexualized drug use and other related risk behaviours.

METHODS

Observational study including all PLWHIV with a RAHCV episode between June 2005 and December 2019 at the Hospital Clinic of Barcelona, Spain. Incidence of RAHCV was determined per person calendar year (py) in those patients who were HCV RNA negative. Data were collected on high-risk sexual practices for HCV transmission focused on gay, bisexual and other men having sex with men (gbMSM).

RESULTS

A total of 340 RAHCV were diagnosed in 290 PLWHIV; 274 (94%) of them were gbMSM and developed 324 RAHCV, mainly since 2010 (90%). Overall incidence rate (IR) of RAHCV in gbMSM was 0.10 py (95% CI 0.09-0.11), with a 40% decreased observed since 2017 (IR 0.06, 95% CI 0.03-0.09 in 2019). Sixty reinfections were detected in 50 gbMSM (n = 244, 20%). The overall reinfection IR was 0.17 per py (95% CI 0.12-0.23) and the proportion of reinfection among total RAHCV increased to 47% cases in 2019, mainly in patients engaged in sexualized substance use (76%), unprotected anal intercourse (94%), sex partying (80%), fisting (43%), slamming (14%) and 60% of concomitant sexually transmitted infections (STIs).

CONCLUSIONS

Despite RAHCV incidence decline in our cohort since 2017, HCV reinfection increased. High sexualized substance use and other risk behaviours are described in this context, indicating the need for public health tailored strategies to reduce this transmission and achieve HCV microelimination in gbMSM living with HIV.

Hepatitis C virus: Testing rate and attrition at linkage to specialized care, Catalonia, Spain 2011-2016

Hepatitis C virus (HCV) screening through primary care providers (PCP) might increase linkage to specialized care. This study aimed to calculate HCV testing rate and prevalence of anti-HCV according to socio-demographic factors in primary care in Catalonia, Spain, from 2011 to 2016, and to identify the rate and determinants of attrition at linkage to specialized care. Patient data from 274 primary care centres (3414 PCP) were analysed, including socio-demographic information, morbidity, laboratory tests and treatments (1-Jan-2011 to 31-Dec-2016). Both descriptive and inferential statistics were used to examine HCV testing rate, HCV seroprevalence and rate of attrition at linkage to specialized care. In the study period, there were 839 072 people tested for HCV infection and 21 156 with first-time positive anti-HCV test results. Rate of HCV testing was 143.54/10³ pop (95% CI: 143.26-143.83). Women had higher HCV testing rate (158.65/10³ women [95% CI: 158.24-159.07]), compared to men (128.10/10³ men [95% CI: 127.72-128.49]). The highest HCV testing rate was among people aged 25-34 (284.11/10³ pop [CIs: 283.10-285.12]). The anti-HCV seroprevalence was 3.62/10³ pop (CIs: 3.57-3.67). The highest prevalence was found among men (4.20/10³ men [CIs: 4.12-4.27]), people aged 45-54 (7.19/10³ pop [CIs: 7.01-7.37]), people aged 75-84 (7.26/10³ pop [CIs: 6.99-7.53]), Spanish (3.68/10³ [CIs: 3.61-3.75]), European and Northern Americans (5.64/10³ [CIs: 5.33-5.96]) and Asians (9.78/10³ [CIs: 9.21-10.35]). From those who had a positive anti-HCV result, 49.8% (N = 10 528) were not linked to specialized care. Appropriate clinical care pathways and referral systems need to be established to ensure optimal linkage to specialized care for people newly diagnosed with HCV in primary care.

Efficacy of Elbasvir/Grazoprevir in Early Chronic G1/G4 Hepatitis C infection in HIV/HCV co-infected patients with mild fibrosis

BACKGROUND

Acute hepatitis C virus (AHC) infection is increasingly common among HIV+ men who have sex with men (MSM). Until 2017, the guidelines recommended therapy with pegylated-interferon plus ribavirin with a mild sustained virological response (SVR). This prompted many patients to reject that treatment, at that time, waiting to be treated with better and safer options with new Direct-Acting-Antivirals (DAA).

OBJECTIVES

Assess the efficacy and safety of Elbasvir/Grazoprevir to treat recent chronic hepatitis C infection, genotype 1 or 4, in HIV+ MSM patients.

METHODS

Prospective, open-labeled, two center, pilot study. SVR is analyzed for treatment with Elbasvir/Grazoprevir (8 weeks in GT1b or 12 in GT1a or GT4) in patients with a recent chronic HCV infection, defined as HCV infection lasting less than 4 years and mild liver fibrosis (liver stiffness <8kPa).

RESULTS

Forty-eight patients were included (May 2017-March 2018): 2 GT1b, 24 GT1a and 22 GT4. HCV-RNA>800000UI in 63% and medium liver stiffness 4.9kPa. The SVR was 98%, one patient failed due to poor adherence. 67% of patients had adverse effects, but only 16% treatment related. The most frequent side effects were gastrointestinal (19%), related with the central nervous system (18%), respiratory (16%) and systemic symptoms (15%). During one year of follow-up post-therapy, 4 AHC and 18 patients with sexually transmitted diseases (STD) were diagnosed.

CONCLUSIONS

Treatment with Elbasvir/Grazoprevir in this scenario is highly effective and safe. Patients with risky sexual practices must remain linked to the medical care system to detect new STD and HCV reinfection.

Human Immunodeficiency Virus/Hepatits C Virus Coinfection in Spain: Elimination Is Feasible, but the Burden of Residual Cirrhosis Will Be Significant

Background

We assessed the prevalence of antibodies against hepatitis C virus (HCV-Abs) and active HCV infection in patients infected with human immunodeficiency virus (HIV) in Spain in 2016 and compared the results with those of similar studies performed in 2002, 2009, and 2015.

Methods

The study was performed in 43 centers during October-November 2016. The sample was estimated for an accuracy of 2% and selected by proportional allocation and simple random sampling. During 2016, criteria for therapy based on direct-acting antiviral agents (DAA) were at least significant liver fibrosis, severe extrahepatic manifestations of HCV, and high risk of HCV transmissibility.

Results

The reference population and the sample size were 38904 and 1588 patients, respectively. The prevalence of HCV-Abs in 2002, 2009, 2015, and 2016 was 60.8%, 50.2%, 37.7%, and 34.6%, respectively (P trend <.001, from 2002 to 2015). The prevalence of active HCV in 2002, 2009, 2015, and 2016 was 54.0%, 34.0%, 22.1%, and 11.7%, respectively (P trend <.001). The anti-HCV treatment uptake in 2002, 2009, 2015, and 2016 was 23.0%, 48.0%, 59.3%, and 74.7%, respectively (P trend <.001). In 2016, HCV-related cirrhosis was present in 7.6% of all HIV-infected individuals, 15.0% of patients with active HCV, and 31.5% of patients who cleared HCV after anti-HCV therapy.

Conclusions

Our findings suggest that with universal access to DAA-based therapy and continued efforts in prevention and screening, it will be possible to eliminate active HCV among HIV-infected individuals in Spain in the short term. However, the burden of HCV-related cirrhosis will continue to be significant among HIV-infected individuals.

Evolution of acute hepatitis C virus infection in a large European city: Trends and new patterns

The aims of this study were to describe the evolution of acute hepatitis C virus (HCV) infections since 2004 and to determine its associated factors. Acute HCV infections diagnosed in Barcelona from 2004 to 2015 were included. Incidence ratios (IR) were then estimated for sex and age groups. Cases were grouped between 2004-2005, 2006-2011 and 2012-2015, and their incidence rate ratios (IRR) were calculated. In addition, risk factors for acute HCV infection were identified using multinomial logistic regression for complete, available and multiple imputed data. 204 new HCV cases were identified. Two peaks of higher IR of acute HCV infection in 2005 and 2013 were observed. Men and those aged 35-54 had higher IR. IRR for men was 2.9 times greater than in women (95% confidence intervals (CI): 1.8 ‒ 4.7). Factors related to the period 2012-2015 (versus 2006-2011) were: a) sexual risk factor for transmission versus nosocomial (relative-risk ratio (RRR): 13.0; 95% CI: 2.3 ‒ 72.1), b) higher educated versus lower (RRR: 5.4; 95% CI: 1.6 ‒ 18.7), and c) HIV co-infected versus not HIV-infected (RRR: 53.1; 95% CI: 5.7 ‒ 492.6). This is one of the few studies showing IR and RRRs of acute HCV infections and the first focused on a large city in Spain. Sexual risk for transmission between men, higher educational level and HIV co-infection are important factors for understanding current HCV epidemic. There has been a partial shift in the pattern of the risk factor for transmission from nosocomial to sexual.

Hepatitis C hospitalizations in Spain, 2004-2013: a retrospective epidemiological study

Background

Hepatitis C is an important public health problem about which there is currently scarce epidemiological information. The objective of this study is to describe and analyse the demographic and epidemiological characteristics of hospitalized cases of hepatitis C in the Spanish population between 2004 and 2013.

Methods

The study uses the Hospital Discharge Records Database of the Spanish National Health System. It is a retrospective descriptive epidemiological study. The variables analysed were year of infection, age, sex, diagnostic category, days admitted and co-morbidity.

Results

There have been a total of 351,996 hospitalizations; 225,138 men (64%) and 126,858 women (36%). They are divided between acute hepatitis 8161 (2.3%); chronic hepatitis 325,185 (92.4%) and unspecified hepatitis 18,650 (5.3%). The mean age for men is 53.7 (+/−15.2) and for women 62.3 (+/−17.3). 22.8% also present with an Human immunodeficiency virus (HIV) disease coinfection, and 14.7% with opioid dependencies. The trend is for a gradual increase in cases without statistical significance.

Conclusions

The Hepatitis C cases hospitalized had high levels of chronicity, which entails two distinct patterns of illness in men and women – who are affected in different age ranges.

Stroke in HIV-infected individuals with and without HCV coinfection in Spain in the combination antiretroviral therapy era

The incidence of stroke in human immunodeficiency virus (HIV)–infected individuals has been well analyzed in recent epidemiological studies. However, little is known about the specific contribution of hepatitis C virus (HCV) infection to stroke among HIV-infected individuals. The aims of this study were to analyze trends in the incidence rates of stroke in HIV-infected individuals during the combination antiretroviral (cART) era in Spain and to categorize them by the presence or absence of HCV coinfection. We analyzed hospital discharges with a diagnosis of stroke in Spain according to ICD-9-CM during 1997–2013. The study period was divided into four calendar periods (1997–1999, 2000–2003, 2004–2007, and 2008–2013). Patients were classified according to HCV serology. The number of HIV-infected patients was estimated based on data from the National Centre of Epidemiology. We calculated incidence rates (events per 10,000 patient-years) and in-hospital case fatality rates (CFR). The incidence of hemorrhagic stroke (HS) decreased in HIV-monoinfected patients (15.8 [1997–1999] to 6.5 [2008–2013]; P<0.001) and increased in HIV/HCV-coinfected patients (1.3 [1997–1999] to 5.5 [2008–2013]; P<0.001). The incidence of ischemic stroke (IS) decreased in HIV-monoinfected patients (27.4 [1997–1999] to 21.7 [2008–2013]; P = 0.005) and increased in HIV/HCV-coinfected patients (1.8 [1997–1999] to 11.9 [2008–2013]; P<0.001). The CFR was 3.3 times higher for HS than for IS for the whole study period. The CFR of HS in HIV-monoinfected patients decreased significantly (47.4% [1997–1999] to 30.6% [2008–2013]; P = 0.010) but did not change significantly among HIV/HCV-coinfected patients (41.4% [1997–1999] to 44.7% [2008–2013]; P = 0.784). The CFR of IS in the whole HIV-infected population decreased significantly (14.6% [1997–1999] to 10.9% [2008–2013]; P = 0.034), although no significant differences were found when each group was analyzed separately. In conclusion, after the introduction of cART, HS and IS rates decreased in HIV-monoinfected individuals, but increased steadily in HIV/HCV-coinfected individuals.

Phylogenetic analysis of an epidemic outbreak of acute hepatitis C in HIV-infected patients by ultra-deep pyrosequencing

BACKGROUND

The incidence of acute hepatitis C (AHC) among HIV-infected men who have sex with men (MSM) has increased significantly in the last 10 years. Several studies point to a social and sexual network of HIV-positive MSM that extends internationally.

OBJECTIVES

The aim of our study was to investigate the dynamics of HCV transmission in an outbreak of AHC in HIV-infected MSM in Barcelona by ultra-deep pyrosequencing.

STUDY DESIGN

Between 2008 and 2013, 113 cases of AHC in HIV-infected MSM were diagnosed in the Infectious Diseases Unit, Hospital Clínic, Barcelona. Massive sequencing was performed using the Roche 454 GS Junior platform. To define possible transmission networks, maximum likelihood phylogenetic trees were constructed, and levels of genetic diversity within and among patients were compared.

RESULTS

Among the 70 cases analyzed, we have identified 16 potential clusters of transmission: 8 for genotype 1a (23 cases involved), 1 for genotype 1b (3 cases) and 7 for genotype 4d (27 cases). Although the initial phylogenetic reconstruction suggested a local transmission cluster of HCV gt4d, our approach based on low genetic differentiation did not corroborate it. Indeed, gt4d strains formed 4 independent groups related to patients from other countries.

CONCLUSIONS

Frequent clustering of HIV-positive MSM shows that HCV infection has spread through a local network in Barcelona. This outbreak is related to a large international HCV transmission network among MSM. Public health efforts are needed to reduce HCV transmission among this high-risk group.

No evidence of firstly acquired acute hepatitis C virus infection outbreak among HIV-infected patients from Southern Spain: a multicentric retrospective study from 2000-2014

Background

Acute hepatitis C virus (HCV) infection (AHCVI) outbreaks have been described recently within defined areas worldwide among HIV-infected homosexual men. This study aims to describe the cumulative frequency and incidence of firstly acquired AHCVI in an HIV-infected population in Southern Spain.

Methods

This is a retrospective study conducted at the Infectious Diseases Units of eight hospitals in Andalusia, Southern Spain. Primary AHC was considered as HCV immunoglobulin G antibody seroconversion. The time of infection was considered the moment between the last negative and the first positive HCV antibody determination.

Results

A total of 23 cases of primary AHCVI have been detected from 2000 to 2014. Incidence rates [IR; 95 % confidence interval (CI)] were 0.036 (2.272–0.054) per 100 person-years (py) in the overall population over a follow-up period of 64170 py. Of the 22 (95.7 %) male subjects, 21 (95.5 %) had acquired AHCVI by homosexual contact, the IR (95 % CI) was 0.039 (0.024–0.06) per 100 py in this subpopulation. There was no evidence of an increase of AHCVI IR. The incidence of AHCVI was slightly lower between 2000 and 2004 as compared to 2005–2009 [IR ratio (IRR) of 8.8 (95 % CI: 1.279–378.794; p = 0.01)] but reached a plateau afterwards [IRR between 2010 and 2014 versus 2005–2009: 0.727 (0.286–1.848; p = 0.5)]. The median (Q1-Q3) time between the last negative anti-HCV and the first positive anti-HCV determination was 4.7 (1.9–11.2) months. Peak (Q1-Q3) ALT and total bilirubin values during AHCVI were 496 (291–656) IU/mL and 1.15 (0.9–1.98) mg/dL, respectively.

Conclusions

In contrast to what has been reported from other areas, the incidence of primary AHCVI in the HIV-infected population is stable in Southern Spain and there is no evidence of an epidemic, in spite of the high prevalence of HIV/HCV-coinfection in this area.

Human Immunodeficiency Virus/Hepatitis C Virus Coinfection in Spain: Prevalence and Patient Characteristics

Background.  The purpose of this study was to assess the prevalence of anti-hepatitis C virus (HCV) antibodies (Abs) and active HCV infection in human immunodeficiency virus (HIV)-infected (HIV+) patients in Spain in 2015. This was a cross-sectional study. Methods.  The study was performed in 41 centers in 2015. Sample size was estimated for an accuracy of 2%, the number of patients from each hospital was determined by proportional allocation, and patients were selected using simple random sampling. Results.  The reference population was 35 791 patients, and the sample size was 1867 patients. Hepatitis C virus serostatus was known in 1843 patients (98.7%). Hepatitis C virus-Abs were detected in 695 patients (37.7%), in whom the main route of HIV acquisition was injection drug use (75.4%). Of these 695 patients, 402 had HCV RNA, 170 had had a sustained viral response (SVR) after anti-HCV therapy, and 102 cleared HCV spontaneously. Hepatitis C virus-ribonucleic acid results were unknown in 21 cases. Genotype distribution (known in 367 patients) was 1a in 143 patients (39.0%), 4 in 90 (24.5%) patients, 1b in 69 (18.8%) patients, 3 in 57 (15.5%) patients, 2 in 5 (1.4%) patients, and mixed in 3 (0.8%) patients. Liver cirrhosis was present in 93 patients (23.1%) with active HCV infection and in 39 (22.9%) patients with SVR after anti-HCV therapy. Conclusions.  The prevalence of HCV-Abs and active HCV infection in HIV+ patients in Spain is 37.7% and 22.1%, respectively; these figures are significantly lower than those recorded in 2002 and 2009. The predominant genotypes in patients with active HCV infection were 1a and 4. A high percentage of patients had cirrhosis. Cirrhosis is also common in patients with SVR after anti-HCV therapy.

Prevalence and Risk Factors of HCV/HIV Co-Infection and HCV Genotype Distribution in North-Eastern Poland

BACKGROUND

HIV/HCV co-infection predisposes to accelerated liver damage and increased both liver-related and unrelated morbidity and mortality in patients with HIV infection.

OBJECTIVES

The aim of this study was to evaluate the prevalence of HCV infection, seropositivity, risk factors and genotype distribution among treated HIV positive patients. Furthermore, the occurrence and causes of deaths were analyzed.

PATIENTS AND METHODS

Adult HIV-1 infected patients, with at least one antiHCV result, treated in one of Polish HIV/AIDS reference centers, participated in this cross-sectional study.

RESULTS

Four hundred and fifty seven patients with a median age of 38 years (ranged 23 - 72), and predominantly male (76.6%) were enrolled in the study. Anti-HCV antibodies were detected in 325 individuals (71.1%). HCV RNA was detected in 207 of the 233 patients tested (88%). The HCV genotype analysis (n = 193) demonstrated almost equal distribution with slight genotype 1 domination as 37.3%, mainly 1b, followed by genotypes 3 as 32.1% and 4 as 30.6%. No association was found between HCV genotype and route of HIV acquisition. In univariate analysis, higher HCV seropositivity was related to male sex, intravenous drug use (IDU), mode of HIV transmission, history of drug and alcohol abuse and imprisonment. In multivariate analysis, only being injection drug user (P = 0.0001), imprisonment (P = 0.310) and younger age at the HIV diagnosis per each year (P = 0.025) were identified as risk factors for HCV infection. Sixty three deaths were reported; no association was found between HCV seropositivity and death prevalence.

CONCLUSIONS

HIV/HCV co-infection is an important medical problem in North-Eastern Poland. A history of incarceration and younger age at HIV diagnosis were additional to IDU risk factors for HCV seropositivity in this cohort.