Coinfection with HIV and Hepatitis C Virus in Injection Drug Users and Minority Populations

The Changing Epidemiology of Hepatitis C Virus Acquisition Among HIV-Infected Individuals in Brazil

Identification of mechanisms of hepatitis C virus (HCV) acquisition among HIV-infected people is critical for prevention guidance. The aim of this study was to investigate risk factors for HCV infection and variations in HCV genotype distribution in a cohort of HIV-HCV coinfected patients in Brazil. This was a cross-sectional observational epidemiological study of a cohort of HIV-HCV coinfected individuals seen at a referral center for HIV-infected patients in the city of São Paulo between January and December 2017. The time of HCV acquisition, as determined by chart review, was categorized as before 2000, between 2000 and 2009, and from 2010 onward. HCV genotypes were determined by gene amplification and analysis. Among 3,143 HIV-infected individuals analyzed, 362 (11.5%) were HCV-HIV coinfected. Overall, the reported modes of HCV acquisition were sexual exposure in 172 (47.5%), injection drug use (IDU) in 86 (23.8%), use of inhaled drugs in 67 (18.5%) and blood transfusion in 10 (2.8%) individuals. All individuals who acquired HCV after IDU became infected before 2010. HCV acquisition by sexual contact was reported by 26.4%, 65.9%, and 63.8% of patients before 2000, between 2000 and 2009, and from 2010, respectively. There was an increase (p < .001) in the proportion of cases due to sexual transmission from the period before 2000 (26.4%) to between 2000 and 2009 (65.9%). There was no corresponding increase from 2000 and 2009 to after 2010 (p = .751). HCV genotype 1 was most prevalent at all time periods. The genotype 3 frequency decreased over time (test for trend p < .001), whereas genotype 4, extremely uncommon before 2010, became the second most prevalent genotype from 2010 onward. In HIV-infected individuals in Sao Paulo, Brazil, sexual transmission has replaced IDU as the most frequent mode of HCV acquisition.

[Epidemiology of hepatitis C virus infection in ColombiaEpidemiologia da infecção pelo vírus da hepatite C na Colômbia]

OBJECTIVE

To describe the epidemiology of hepatitis C virus (HCV) infection in Colombia.

METHODS

Critical review of epidemiological studies of HCV infection in Colombia. The PubMed, SciELO, and ScienceDirect databases were searched for original articles and reviews on the subject published from 1989 to 2020. Reports from the National Institute of Health and the High Cost Account of the Ministry of Health and Social Protection were also reviewed.

RESULTS

Data on seroprevalence of HCV antibodies in blood donors range from 1.5% to 0.32%, corresponding to reports at the beginning and end of the study period, respectively. In the population with risk factors, a high prevalence of HCV infection is observed, although with variations over time. With respect to HCV genotypes in Colombia, genotypes 1, 2, 3, and 4 (subtypes 1a, 1b, 2a, and 3a) have been identified.

CONCLUSIONS

In the observation period, a decrease was seen in seroprevalence of HCV infection in blood donors and hemodialysis patients in Colombia, demonstrating the impact of safe blood policies and biosafety measures. Studies in people who inject illicit drugs indicate a high prevalence of infection, with regional differences within the country. HCV genotype 1, subtype 1b, is the most frequent in the different studies carried out in Colombia, and the most recent report of the High Cost Account of the Ministry of Health and Social Protection indicates that genotype 4 is the second most frequent genotype in the country.

British Columbia CARMA-CHIWOS Collaboration (BCC3): protocol for a community-collaborative cohort study examining healthy ageing with and for women living with HIV

INTRODUCTION

Women living with HIV (WLWH) experience accelerated ageing and an increased risk of age-associated diseases earlier in life, compared with women without HIV. This is likely due to a combination of viral factors, gender differences, hormonal imbalance and psychosocial and structural conditions. This interdisciplinary cohort study aims to understand how biological, clinical and sociostructural determinants of health interact to modulate healthy ageing in WLWH.

METHODS AND ANALYSIS

The British Columbia Children and Women: AntiRetroviral therapy and Markers of Aging-Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CARMA-CHIWOS) Collaboration (BCC3) study will enrol WLWH (n=350) and sociodemographically matched HIV-negative women (n=350) living in British Columbia. A subset of BCC3 participants will be past participants of CARMA, n≥1000 women and children living with and without HIV, 2008-2018 and/or CHIWOS, n=1422 WLWH, 2013-2018. Over two study visits, we will collect biological specimens for virus serologies, hormones and biological markers as well as administer a survey capturing demographic and sociostructural-behavioural factors. Sociodemographics, comorbidities, number and type of chronic/latent viral infections and hormonal irregularities will be compared between the two groups. Their association with biological markers and psychostructural and sociostructural factors will be investigated through multivariable regression and structural equation modelling. Retrospective longitudinal analyses will be conducted on data from past CARMA/CHIWOS participants. As BCC3 aims to follow participants as they age, this protocol will focus on the first study visits.

ETHICS AND DISSEMINATION

This study has been approved by the University of British Columbia Children's and Women's Research Ethics Board (H19-00896). Results will be shared in peer-reviewed journals, conferences and at community events as well as at www.hivhearme.ca and @HIV_HEAR_me. WLWH are involved in study design, survey creation, participant recruitment, data collection and knowledge translation. A Community Advisory Board will advise the research team throughout the study.

Accessing Medical Care After a Needlestick Injury: First Responders' Perception of HIV Risk and Attitudes Toward Syringe Service Programs

First responders have an increased risk of occupational exposure to HIV as the result of a needlestick injury (NSI) because of the chaotic prehospital environment in which they provide care. Approximately 2.3 of every 1000 first responders (0.23%) who are exposed to HIV via a NSI risk seroconversion if left untreated. Participants completed a 28-question online survey examining level of concern about HIV, thoughts about injection drug use, number of accidental NSIs, and medical services received after a needlestick. First, all data were analyzed descriptively. Second, a multiple linear regression model was used to explore the level of concern about HIV as a function of the predictor variables. Nearly half of the respondents worked as paramedics (n = 141, 23.5%) or emergency medical technicians (n = 154, 25.7%), followed by 15.5% (n = 93) and 11.3% (n = 62) who indicated their primary first responder affiliation as "firefighter" or "police," respectively. The majority of the study population identified as male (75%, n = 450); 24.8% identified as female (n = 149). Slightly more first responders reported receiving no medical services after a needlestick (9.8%, n = 59) than received an HIV screening (9.5%, n = 57), and only 3.2% (n = 19) of those who experienced a needlestick reported receiving post-exposure prophylaxis. The results suggest that perceived risk of HIV infection via needlestick ultimately influences follow-up medical screening. Greater concern about HIV is significantly associated with HIV screening and willingness to obtain post-exposure prophylaxis. Future research should examine the impact of continued HIV education and policies outlining medical evaluation and other post-exposures procedures.

Neurocognitive Trajectories After 72 Weeks of First-Line Anti-retroviral Therapy in Vietnamese Adults With HIV-HCV Co-infection

Background: Long-term neurocognitive outcomes following first-line suppressive anti-retroviral therapy (ART) remain uncertain for individuals with HIV and hepatitis C (HCV) co-infection. The study examined neurocognitive performance before and after 72 weeks of ART using repeated multivariate analyses and latent trajectory models.

Methods: One hundred and sixty adults with chronic, untreated HIV infection (n = 80 with HCV co-infection and n = 80 HIV mono-infected) and 80 demographically similar healthy controls were recruited from the Hospital for Tropical Diseases in Ho Chi Minh City and the surrounding community, respectively. Neurocognitive measures (adapted for use in Vietnam) and liver enzyme tests were compared across groups at baseline. Repeated multivariate and group-based trajectory analyses (GBTA) examined neurocognitive subgroup profiles of the co-infected individuals after 72 weeks of de novo efavirenz- (n = 41) or raltegravir-based (n = 39) ART.

Results: Baseline analyses revealed worse motor function in HIV-HCV co-infected individuals compared to both comparison groups. Longitudinal analyses revealed improved neurocognitive performance by week 48 for most participants regardless of treatment arm. GBTA identified a subgroup (35% of HIV-HCV sample) with persistent motor impairment despite otherwise successful ART. Higher HIV viral load and lower CD4⁺ T cell count at baseline predicted persistent motor dysfunction. Liver indices and ART regimen did not predict neurocognitive outcomes in HIV-HCV co-infected individuals.

Conclusions: Most HIV-HCV co-infected individuals achieve normative neurocognitive performance after 48 weeks of de novo suppressive ART. However, individuals with more severe HIV disease prior to ART exhibited motor impairment at baseline and 72 weeks after otherwise successful treatment. Interventions aimed at improving motor symptoms at the time of HIV treatment onset may improve long-term clinical outcomes in HIV-HCV co-infected adults.

Neurocognitive Trajectories After 72 Weeks of First-Line Anti-retroviral Therapy in Vietnamese Adults With HIV-HCV Co-infection

Background: Long-term neurocognitive outcomes following first-line suppressive anti-retroviral therapy (ART) remain uncertain for individuals with HIV and hepatitis C (HCV) co-infection. The study examined neurocognitive performance before and after 72 weeks of ART using repeated multivariate analyses and latent trajectory models.

Methods: One hundred and sixty adults with chronic, untreated HIV infection (n = 80 with HCV co-infection and n = 80 HIV mono-infected) and 80 demographically similar healthy controls were recruited from the Hospital for Tropical Diseases in Ho Chi Minh City and the surrounding community, respectively. Neurocognitive measures (adapted for use in Vietnam) and liver enzyme tests were compared across groups at baseline. Repeated multivariate and group-based trajectory analyses (GBTA) examined neurocognitive subgroup profiles of the co-infected individuals after 72 weeks of de novo efavirenz- (n = 41) or raltegravir-based (n = 39) ART.

Results: Baseline analyses revealed worse motor function in HIV-HCV co-infected individuals compared to both comparison groups. Longitudinal analyses revealed improved neurocognitive performance by week 48 for most participants regardless of treatment arm. GBTA identified a subgroup (35% of HIV-HCV sample) with persistent motor impairment despite otherwise successful ART. Higher HIV viral load and lower CD4+ T cell count at baseline predicted persistent motor dysfunction. Liver indices and ART regimen did not predict neurocognitive outcomes in HIV-HCV co-infected individuals.

Conclusions: Most HIV-HCV co-infected individuals achieve normative neurocognitive performance after 48 weeks of de novo suppressive ART. However, individuals with more severe HIV disease prior to ART exhibited motor impairment at baseline and 72 weeks after otherwise successful treatment. Interventions aimed at improving motor symptoms at the time of HIV treatment onset may improve long-term clinical outcomes in HIV-HCV co-infected adults.

Prevalence of HIV/Hepatitis C Virus Co-Infection and Injection Risk Correlations in People Who Inject Drugs in Colombia: A Cross-Sectional Study Using Respondent Driven Sampling

Background: In Colombia, an exponential growth of people who inject drugs (PWID) has been reported over the past decades. The main burden of disease in PWID is attributed to human immunodeficiency virus (HIV) and hepatitis C virus (HCV) and their co-infection is associated with poor prognosis, high morbidity and treatment related implications. Nevertheless, the prevalence of HIV/HCV co-infection in Colombian PWIDs is unknown. Objective: To determine the prevalence, demographic characteristics, and injecting behaviors of HIV/HCV co-infected PWID in Colombia. Methods: This was a cross-sectional study of 1,123 PWID recruited by respondent driven sampling in five Colombian cities between January and June of 2014. Each participant completed a quantitative survey, and blood samples for HIV and HCV antibody testing were obtained. A multinomial logistic regression was used for statistical analysis. Results: Average participant age was 26.3 ± 6.5 years, and the majority was male (86%). HIV or HCV mono-infection prevalence was 27.6%, while co-infection was 3.3%. Compared with PWID with mono-infection, co-infected PWID exhibited higher odds of: injecting ≥4 times daily (OR: 3.5; CI: 1.7-7.2; p < .001), cleaning needles and syringes with water (OR 3.2; CI: 1.6-6.3; p < .001), passing drug mix between syringes (OR: 2.7; CI: 1.3-5.3; p = .04), injecting on illegal indoor shooting galleries (OR: 2.4; CI: 1.0-5.3, p = .02), and getting injected by someone who charges for injecting (OR 2.3; CI: 1.0-5.2; p = .04). Conclusion: Prevalence of HIV/HCV co-infection among PWID in Colombia is lower than that reported in other countries. However, addressing the identified demographic characteristics and injection risk behaviors of co-infected PWID is essential for the implementation of broadly available harm reduction interventions as well as routine HIV/HCV testing and treatment strategies aiming to control the spread of both viruses and their associated morbidity and mortality.

Hepatitis C virus treatment as prevention in an extended network of people who inject drugs in the USA: a modelling study

BACKGROUND

Chronic infections with hepatitis C virus (HCV) and HIV are highly prevalent in the USA and concentrated in people who inject drugs. Treatment as prevention with highly effective new direct-acting antivirals is a prospective HCV elimination strategy. We used network-based modelling to analyse the effect of this strategy in HCV-infected people who inject drugs in a US city.

METHODS

Five graph models were fit using data from 1574 people who inject drugs in Hartford, CT, USA. We used a degree-corrected stochastic block model, based on goodness-of-fit, to model networks of injection drug users. We simulated transmission of HCV and HIV through this network with varying levels of HCV treatment coverage (0%, 3%, 6%, 12%, or 24%) and varying baseline HCV prevalence in people who inject drugs (30%, 60%, 75%, or 85%). We compared the effectiveness of seven treatment-as-prevention strategies on reducing HCV prevalence over 10 years and 20 years versus no treatment. The strategies consisted of treatment assigned to either a randomly chosen individual who injects drugs or to an individual with the highest number of injection partners. Additional strategies explored the effects of treating either none, half, or all of the injection partners of the selected individual, as well as a strategy based on respondent-driven recruitment into treatment.

FINDINGS

Our model estimates show that at the highest baseline HCV prevalence in people who inject drugs (85%), expansion of treatment coverage does not substantially reduce HCV prevalence for any treatment-as-prevention strategy. However, when baseline HCV prevalence is 60% or lower, treating more than 120 (12%) individuals per 1000 people who inject drugs per year would probably eliminate HCV within 10 years. On average, assigning treatment randomly to individuals who inject drugs is better than targeting individuals with the most injection partners. Treatment-as-prevention strategies that treat additional network members are among the best performing strategies and can enhance less effective strategies that target the degree (ie, the highest number of injection partners) within the network.

INTERPRETATION

Successful HCV treatment as prevention should incorporate the baseline HCV prevalence and will achieve the greatest benefit when coverage is sufficiently expanded.

FUNDING

National Institute on Drug Abuse.

Treatment optimization for HIV/HCV co-infected patients

Human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections affect millions of persons around the globe and cause profound morbidity and mortality. A major intersection exists between these two epidemics, with HCV infection being more common in persons with HIV than in the general population, largely due to shared routes of transmission. HCV co-infection increases risk for liver- and non-liver-related morbidity and mortality, making HCV treatment a priority in HIV co-infected persons, but the treatment of HCV in co-infected patients has been daunting for multiple reasons. Until recently, HCV treatment has frequently been deferred due to the low rates of cure, significant adverse effects, burdensome duration of therapy and drug-drug interactions with HIV antiretroviral medications. Untreated HCV has resulted in significant health consequences for the millions of those infected and has led to multiple downstream impacts on our healthcare systems around the world. The development of a remarkable number of new HCV direct-acting agents (DAAs) that are significantly more efficacious and tolerable than the previous interferon-based regimens has transformed this important field of medicine, with the potential to dramatically reduce the burden of infection and improve health outcomes in this population. This review will summarize the epidemiology and clinical impact of HIV/HCV co-infection and current approaches to the treatment of HCV in HIV/HCV co-infected patients.

HCV/HIV coinfection among people who inject drugs and enter opioid substitution treatment in Greece: prevalence and correlates

Background

HCV/HIV coinfection in people who inject drugs is a public health issue, which presents a variety of challenges to healthcare providers. The determinants of HCV/HIV coinfection in this population are nonetheless not well known. The aim of the present study is to identify the factors associated with HCV/HIV coinfection in people who inject drugs and enter drug-related treatment.

Methods

Linked serological and behavioral data were collected from people who entered 38 opioid substitution treatment clinics in central and southern Greece between January and December 2013. Three mutually exclusive groups were defined based on the presence of HCV and HIV antibodies. Group 1 clients had neither infection, Group 2 had HCV but not HIV, and Group 3 had HCV/HIV coinfection. Multinomial logistic regression analyses identified differences between groups according to socio-demographic, drug use and higher-risk behavioral characteristics.

Results

Our study population consisted of 580 people who injected drugs in the past 12 months (79.8 % males, with median age 36 years).79.4 % were HCV and 15.7 % HIV infected. Of those with complete serological data in both HCV and HIV indicators, 20.4 % were uninfected, 64.0 % HCV monoinfected, and 14.9 % HCV/HIV coinfected. HCV infection with or without HIV coinfection was positively associated with living alone or with a spouse/partner without children, prior incarceration, drug injecting histories of ≥10 years, and syringe sharing in the past 12 months, and negatively associated with never having previously been tested for HCV. HCV/HIV coinfection, but not HCV infection alone, was positively associated with residence in urban areas (relative risk ratio [RRR] = 4.8, 95 % confidence interval [CI]: 1.7–13.7, p = 0.004) and averaging >3 injections a day in the past 30 days (RRR = 4.5, 95 % CI: 1.6–12.8, p = 0.005), and negatively associated with using a condom in the last sexual intercourse.

Conclusions

People who inject drugs and live in urban areas and inject frequently have higher risk of coinfection. Findings highlight the need for scaling-up needle and syringe programs in inner city areas and promoting access of this population to screening and treatment, especially in prisons. The protective role of living with parents and children could inform the implementation of indicated interventions.

Hepatic fibrosis and immune phenotype vary by HCV viremia in HCV/HIV co-infected subjects: A Women's interagency HIV study

HCV and HIV independently lead to immune dysregulation. The mechanisms leading to advanced liver disease progression in HCV/HIV coinfected subjects remain unclear.In this cross-sectional study, we assessed the association of HCV viremia, liver fibrosis, and immune response patterns in well-characterized HIV phenotypes: Elite controllers (Elites), HIV controlled (ARTc), and HIV uncontrolled (ARTuc) matched by age and race. Groups were stratified by HCV RNA status. Regulatory T-cell frequencies, T-cell activation (HLADR+CD38+), apoptosis (Caspase-3+), and intracellular cytokines (interferon-γ, IL-2, IL-17) were assessed using multiparametric flow-cytometry. Liver fibrosis was scored by AST to platelet ratio index (APRI).We found liver fibrosis (APRI) was 50% lower in Elites and ARTc compared to ARTuc. Higher liver fibrosis was associated with significantly low CD4+ T cell counts (P < 0.001, coefficient r = -0.463). Immune activation varied by HIV phenotype but was not modified by HCV viremia. HCV viremia was associated with elevated CD8 T-cell Caspase-3 in Elites, ARTuc, and HIV- except ARTc. CD8 T-cell Caspase-3 levels were significantly higher in HCV RNA+ Elites (P = 0.04) and ARTuc (P = 0.001) and HIV- groups (P = 0.02) than ARTc. Importantly, ARTuc HCV RNA+ had significantly higher CD4 T-cell interleukin-17 levels than ARTuc HCV RNA- (P = 0.005).HIV control was associated with lower liver fibrosis in HCV/HIV co-infected women. HCV viremia is associated with an inflammatory CD4 TH-17 phenotype in absence of HIV control and higher frequency of pro-apoptosis CD8 T-cells critical to avert progression of HIV and HCV disease that is attenuated in ART controllers. Elite controllers with HCV viremia are more prone to CD8 T-cell apoptosis than ART controllers, which could have negative consequences over time, highlighting the importance of ART control in HCV/HIV coinfected individuals.

National trends in hospitalization and mortality rates for patients with HIV, HCV, or HIV/HCV coinfection from 1996-2010 in the United States: a cross-sectional study

BACKGROUND

The comparative impact of chronic viral monoinfection versus coinfection on inpatient outcomes and health care utilization is relatively unknown. This study examined trends, inpatient utilization, and hospital outcomes for patients with HIV, HCV, or HIV/HCV coinfection.

METHODS

Data were from the 1996-2010 National Hospital Discharge Surveys. Hospitalizations with primary ICD-9-CM codes for HIV or HCV were included for HIV and HCV monoinfection, respectfully. Coinfection included both HIV and HCV codes. Demographic characteristics, select comorbidities, procedural interventions, average hospital length of stay (LOS), and discharge status were compared by infection status (HIV, HCV, HIV/HCV). Annual disease estimates and survey weights were used to generate hospitalization rates.

RESULTS

~6.6 million hospitalizations occurred in patients with HIV (39%), HCV (56%), or HIV/HCV (5%). The hospitalization rate (hospitalizations per 100 persons with infection) decreased in the HIV group (29.8 in 1996; 5.3 in 2010), decreased in the HIV/HCV group (2.0 in 1996; 1.5 in 2010), yet increased in the HCV group (0.2 in 1996; 0.9 in 2010). Median LOS from 1996 to 2010 (days, interquartile range) decreased in all groups: HIV, 6 (3-10) to 4 (3-8); HCV, 5 (3-9) to 4 (2-6); HIV/HCV, 6 (4-11) to 4 (2-7). Age-adjusted mortality rates decreased for all three groups. The rate of decline was least pronounced for those with HCV monoinfection.

CONCLUSION

Hospitalizations have declined more rapidly for patients with HIV infection (including HIV/HCV coinfection) than for patients with HCV infection. This growing disparity between HIV and HCV underscores the need to allocate more resources to HCV care in hopes that similar large-scale improvements can also be accomplished for patients with HCV.

Injection and non-injection drug use and infectious disease in Baltimore City: differences by race

PURPOSE

The current study examines differences in the prevalence of biologically-confirmed hepatitis C virus (HCV), HIV, and coinfection between Black and White adult cocaine/heroin users across three drug use subgroups identified in previous research (Harrell et al., 2012): non-injection smoking crack/nasal heroin users, heroin injectors, and polydrug injectors.

RESULTS

59% of the 482 participants in the study were male. Significant race differences emerged between drug use subgroup memberships. Non-injection smoking crack/nasal heroin users were predominantly Black (75%), while heroin injectors and polydrug injectors were predominantly White (69% and 72%, respectively). Polydrug injectors accounted for nearly three quarters of the HCV positive diagnoses in Whites. Though HIV disease status, stratified by race, did not differ significantly between drug use subgroups, the non-injection smoking crack/nasal heroin subgroup contained over half of the HIV positive diagnoses in the sample and was predominantly Black. Despite much lower rates of injection, Blacks (8%) had a higher prevalence of coinfection than Whites (3%; X(2) (2)=6.18, p=.015).

CONCLUSIONS

The current findings are consistent with trends in the recent HIV transmission statistics where sexual activity has overtaken injection drug use as a HIV risk factor. The current findings also provide further support to the notion of injection drug use as an exceedingly high-risk behavior for HCV and coinfection, specifically those who are polysubstance injectors.

HIV-, HCV-, and co-infections and associated risk factors among drug users in southwestern China: a township-level ecological study incorporating spatial regression

BACKGROUND

The human immunodeficiency virus (HIV) and hepatitis C virus (HCV) are major public health problems. Many studies have been performed to investigate the association between demographic and behavioral factors and HIV or HCV infection. However, some of the results of these studies have been in conflict.

METHODOLOGY/PRINCIPAL FINDINGS

The data of all entrants in the 11 national methadone clinics in the Yi Autonomous Prefecture from March 2004 to December 2012 were collected from the national database. Several spatial regression models were used to analyze specific community characteristics associated with the prevalence of HIV and HCV infection at the township level. The study enrolled 6,417 adult patients. The prevalence of HIV infection, HCV infection and co-infection was 25.4%, 30.9%, and 11.0%, respectively. Prevalence exhibited stark geographical variations in the area studied. The four regression models showed Yi ethnicity to be associated with both the prevalence of HIV and of HIV/HCV co-infection. The male drug users in some northwestern counties had greater odds of being infected with HIV than female drug users, but the opposite was observed in some eastern counties. The 'being in drug rehabilitation variable was found to be positively associated with prevalence of HCV infection in some southern townships, however, it was found to be negatively associated with it in some northern townships.

CONCLUSIONS/SIGNIFICANCE

The spatial modeling creates better representations of data such that public health interventions must focus on areas with high frequency of HIV/HCV to prevent further transmission of both HIV and HCV.

The geographic distribution patterns of HIV-, HCV- and co-infections among drug users in a national methadone maintenance treatment program in Southwest China

Background

HIV-, HCV- and HIV/HCV co-infections among drug users have become a rapidly emerging global public health problem. In order to constrain the dual epidemics of HIV/AIDS and drug use, China has adopted a methadone maintenance treatment program (MMTP) since 2004. Studies of the geographic heterogeneity of HIV and HCV infections at a local scale are sparse, which has critical implications for future MMTP implementation and health policies covering both HIV and HCV prevention among drug users in China. This study aimed to characterize geographic patterns of HIV and HCV prevalence at the township level among drug users in a Yi Autonomous Prefecture, Southwest of China.

Methods

Data on demographic and clinical characteristics of all clients in the 11 MMTP clinics of the Yi Autonomous Prefecture from March 2004 to December 2012 were collected. A GIS-based geographic analysis involving geographic autocorrelation analysis and geographic scan statistics were employed to identify the geographic distribution pattern of HIV-, HCV- and co-infections among drug users.

Results

A total of 6690 MMTP clients was analyzed. The prevalence of HIV-, HCV- and co-infections were 25.2%, 30.8%, and 10.9% respectively. There were significant global and local geographic autocorrelations for HIV-, HCV-, and co-infection. The Moran’s I was 0.3015, 0.3449, and 0.3155, respectively (P < 0.0001). Both the geographic autocorrelation analysis and the geographic scan statistical analysis showed that HIV-, HCV-, and co-infections in the prefecture exhibited significant geographic clustering at the township level. The geographic distribution pattern of each infection group was different.

Conclusion

HIV-, HCV-, and co-infections among drug users in the Yi Autonomous Prefecture all exhibited substantial geographic heterogeneity at the township level. The geographic distribution patterns of the three groups were different. These findings imply that it may be necessary to inform or invent site-specific intervention strategies to better devote currently limited resource to combat these two viruses.

Recommendations for the management of hepatitis C virus infection among people who inject drugs

In the developed world, the majority of new and existing hepatitis C virus (HCV) infections occur among people who inject drugs (PWID). The burden of HCV-related liver disease in this group is increasing, but treatment uptake among PWID remains low. Among PWID, there are a number of barriers to care that should be considered and systematically addressed, but these barriers should not exclude PWID from HCV treatment. Furthermore, it has been clearly demonstrated that HCV treatment is safe and effective across a broad range of multidisciplinary healthcare settings. Given the burden of HCV-related disease among PWID, strategies to enhance HCV assessment and treatment in this group are urgently needed. These recommendations demonstrate that treatment among PWID is feasible and provides a framework for HCV assessment, management, and treatment. Further research is needed to evaluate strategies to enhance assessment, adherence, and SVR among PWID, particularly as new treatments for HCV infection become available.

[Prevalence of chronic kidney disease among HIV-infected individuals in Japan--a report from two tertiary hospitals]

BACKGROUND

The improved survival of subjects with human immunodeficiency virus (HIV) has been accompanied by an increased prevalence of chronic kidney disease (CKD). Epidemic of CKD among those with HIV has not yet been evaluated in multiple tertiary hospitals in Japan.

METHODS

A cross-sectional study was conducted in 2011 at Tokyo Metropolitan Komagome Hospital (TMKH) and Tokyo Medical University Hospital (TMUH). A total of 1482 HIV-infected subjects (1384 men, 98 female, mean age: 44.2 +/- 11.4 years old) were consecutively enrolled in the study. Random urine and blood samples were collected to study prevalence of CKD. CKD was diagnosed as a decrease in glomerular function and/or proteinuria and classified into 5 stages based on National Kidney Foundation guidelines. The estimated glomerular filtration rate based on serum creatinine was calculated using the 3-variable equation, constructed by the Japanese Society of Nephrology. Proteinuria was defined as > or = 1+ on urine dipstick examination. All electronic medical charts were reviewed to determine comorbidities, including hypertension and diabetes mellitus (DM). The proportion of subjects receiving tenofovir disoproxil fumarate (TDF) was investigated. Risk factors for CKD were determined using multivariate logistic regression analysis.

RESULTS

The mean CD4 cell count was 487 +/- 216/microL and 80.5% had undetectable HIV-RNA level in the combined cohort. Of the 90.2% of subjects taking antiretroviral agents, 61.5% was using TDF. The prevalence of overall CKD and CKD > or = stage 3 was 12.9% and 6.7%, respectively, both of which were nearly 3-fold higher in the TMKH cohort (p < .0001). Mean age and proportional prevalent hypertension and DM were significantly higher in the TKMH cohort than in the TMUH cohort. Multivariate analysis showed significant CKD to be associated with age > or =50 years (odds ratio [OR], 2.81), hypertension (OR, 3.04), and DM (OR, 2.05).

CONCLUSIONS

CKD prevalence was 12.9% among combined cohorts, but differed significantly between them. Differences in age distribution and the proportion of comorbidities, including hypertension and DM, are likely involved.

Impact of HCV treatment and depressive symptoms on adherence to HAART among HIV-HCV-coinfected patients: results from the ANRS-CO13-HEPAVIH cohort

BACKGROUND

The additional burden of HCV infection in HIV-HCV-coinfected individuals may have some consequences on adherence to HAART. Few studies have explored the pattern of correlates of non-adherence to HAART while simultaneously considering the impact of HCV treatment and depressive symptoms on adherence to HAART. We used longitudinal data to assess factors associated with non-adherence to HAART.

METHODS

The French national prospective cohort ANRS-CO13-HEPAVIH is a multicentrer cohort, which recruited 1,175 HIV-HCV-coinfected patients in 17 hospital outpatient units delivering HIV and HCV care in France between October 2006 and June 2008. For this analysis, we selected participants on HAART with self-reported data for adherence to HAART (n=727 patients, 1,190 visits). Data were collected using self-administered questionnaires and medical records. A mixed logistic regression model based on an exchangeable correlation matrix was used to identify factors associated with non-adherence to HAART.

RESULTS

Patients reported non-adherence to HAART in 808 (68%) of the 1,190 visits. Four variables remained associated with non-adherence to HAART after multivariate analysis: hazardous alcohol consumption, cocaine use and depressive symptoms, regardless of whether treatment for depression was being received. Finally, patients being treated for HCV infection were less likely to be non-adherent to HAART.

CONCLUSIONS

Besides the problem of polydrug use, two other dimensions deserve special attention when considering adherence to HAART in HIV-HCV-coinfected patients. Access to HCV treatment should be encouraged as well adequate treatment for depression in this population to improve adherence and response to HAART.

Effect of HIV on liver fibrosis among HCV-infected African Americans

Degree of liver fibrosis largely determines treatment urgency for hepatitis C virus (HCV). This retrospective study examined fibrosis stages and predictive factors in African Americans with HCV monoinfection and human immunodeficiency virus (HIV)/HCV coinfection. Nearly 50% of patients had early-stage fibrosis in the study, despite the long duration of infection in many patients. HIV was associated with the early fibrosis group. These results indicate that a large proportion of patients with HCV infection, including those with HIV, could possibly await more-effective and better-tolerated treatment.

Experiences of Oxford House Residents Living with the Hepatitis C Virus

Hepatitis C virus (HCV) is the most prevalent chronic blood-borne infection in the United States and the leading cause of chronic liver disease. HCV is transmitted through blood-to-blood contact. New infections remain common among IDUs, prisoners, and others likely to be exposed to infected blood. The purpose of this study was to use qualitative methods to gain insight into the experiences of HCV-infected residents, an approach that has proved informative in helping individuals manage similar challenging chronic illnesses. Semi-structured interviews were conducted with four Oxford House female residents living with HCV. The semi-structure qualitative interview consisted of 18 questions which were designed to focus on three broad areas: experiences of contracting and being diagnosed with HCV, ways in which HCV affected their lives, and experiences living in an Oxford House. Overall, participants were not surprised at their diagnosis, but it did impact their mood. Participants had difficulty with social functioning, experienced physical and psychological symptoms, and received a substantial amount of social support from family and Oxford House residents.

The natural history of injecting drug use: a 25-year longitudinal study of a cohort of injecting drug users in inner city Dublin

BACKGROUND

Injecting drug use is associated with increased morbidity and mortality. This is the first longitudinal study of a community-based population of injecting drug users (IDUs) in the Republic of Ireland.

AIM

To establish the natural history of IDUs in a deprived Dublin community.

METHODS

Eighty-two IDUs (heroin) were recruited over the summer months of 1985. The prevalence of drug use in this district electoral area was established in 1985 and followed-up over a 25-year period with two formal interviews in 1995 and 2010.

RESULTS

It is a descriptive study of a cohort of IDUs established in 1985 prior to human immunodeficiency virus (HIV) testing being available. The majority of the cohort recruited included single, unemployed males aged 20 to 29 years, who had served a prison sentence. Fifty-one (63 %) of the cohort had died by 2010, of which 26 were attributed to HIV disease. The mean age of death was 35.9 years of age (standard deviation 4.1 years). Fifty-two (63 %) of the cohort tested positive for HIV and 58 (71 %) for hepatitis B between 1985 and 2010. The median survival time for those with a positive HIV status was 17 years (95 % CI 14.0-20.0) and for those with a positive hepatitis C status, 21 years (95 % CI 15.5-26.5).

CONCLUSIONS

The lifestyle of IDUs, as demonstrated by the experience of this cohort, has hazardous consequences resulting in high levels of morbidity and mortality. A relatively stable picture of HIV associated with IDUs is now emerging in Ireland, as is the case throughout most of the EU. HIV is a more manageable chronic disease, posing challenges for primary care in its treatment of former and existing IDUs who are ageing and now have other chronic diseases.

The cost of HIV disease in Northern Italy: the payer's perspective

BACKGROUND

Healthcare expenditures incurred by the Health Service for HIV-infected patients have not been reported in Italy.

OBJECTIVE

To present health care costs for HIV-infected patients in the Lombardy Region, in 2004-2007, to determine the clinical characteristics of HIV infection associated with costs.

METHODS

Retrospective, observational, budget impact study, based on information collected for the period 2004-2007, including hospitalizations, outpatient services, highly active antiretroviral therapy (HAART) and non-HAART drug utilization. Inclusion criteria includes: confirmed HIV infection, age ≥18 years, resident in Lombardy Region, and followed at the "L. Sacco" Hospital in Milan from 2004 to 2007.

RESULTS

The mean total cost per year to provide healthcare to HIV-positive patients was rather stable (€ 9658.36 in 2004 and € 9745.65 in 2007 (+0.90%)); HAART represented more than 60% of the total cost. We found that hepatitis C virus coinfection was related to higher costs (€ 11,003.45 vs. € 8896.06), as well as CD4 cell count <200 cells/mm (€ 12,681.36 vs. € 9594.11 and € 9450.36 in 200-499 and ≥500 cells/mm, respectively). The mean total cost of HIV health care was higher in patients who initiated antiretroviral treatment before 1997 than in those who started after 1996.

CONCLUSIONS

The mean total cost per year to provide health care to HIV-positive patients was stable during the period 2004-2007, with an increase of HAART percentage impact on the total cost. Several clinical characteristics of HIV-infected patients were significantly associated with cost variation.

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.

All-cause and HIV-related mortality rates among HIV-infected patients after initiating highly active antiretroviral therapy: the impact of Aboriginal ethnicity and injection drug use

BACKGROUND

Aboriginals are over-represented in Canada's HIV epidemic and are commonly infected with HIV via injection drug use (IDU); however, little is known about the impact of Aboriginal ethnicity on mortality after starting highly active antiretroviral therapy (HAART). Therefore, we compared mortality rates between Aboriginal and non-Aboriginal HIV patients and between IDU and non-IDU HIV patients after they initiated HAART.

METHODS

We conducted a retrospective cohort study of antiretroviral-naïve patients starting HAART January 1999-June 2005 (baseline), followed until December 2005. We constructed two Cox proportional hazards models, one to estimate all-cause and one to estimate HIV-related mortality hazard ratios (HRs), considering sex, and baseline age, CD4 cell count, HIV RNA level, calendar year, and HAART regimen as potential confounders.

RESULTS

The 548 study patients were followed for 1,889.8 person-years; 194 (35%) were Aboriginal, 255 (46%) were IDUs. We observed 55 deaths; 47% were HIV-related. In multivariable models, Aboriginals experienced higher all-cause (HR = 1.85, 95% CI = 1.05-3.26, p = 0.034) and HIV-related (HR = 3.47, 95% CI = 1.36-8.83, p = 0.009) mortality rates compared to non-Aboriginals; and, compared to patients with other exposures, IDUs experienced higher all-cause (HR = 2.45, 95% CI = 1.31-4.57, p = 0.005) but similar HIV-related (p = 0.27) mortality rates.

CONCLUSIONS

Compared to non-Aboriginals, Aboriginal HIV patients suffer higher all-cause and HIV-related mortality rates after starting HAART. The strongest and most significant predictor of higher all-cause mortality was IDU. Future research should examine reasons for the observed poorer survival of Aboriginal and IDU HIV patients after initiating HAART to develop interventions to improve the prognosis for these vulnerable populations.

Infectious disease comorbidities adversely affecting substance users with HIV: hepatitis C and tuberculosis

The linkage between drug use, particularly injection drug use, and HIV/AIDS, hepatitis C (HCV), and tuberculosis (TB) has been recognized since the beginning of the HIV pandemic. These comorbid conditions affect drug users worldwide and act synergistically, with resultant adverse biologic, epidemiologic, and clinical consequences. Prevention, care, and treatment of TB and HCV can be successful, and both diseases can be cured. Special clinical challenges among drug users, however, can result in increased morbidity, mortality, and decreased therapeutic success. Among these are limited disease screening, inadequate and insensitive diagnostics, difficult treatment regimens with varying toxicities, and complicated pharmacokinetic and pharmacodynamic drug interactions. These may result in delayed diagnosis, deferred treatment initiation, and low completion rates, with the potential for generation and transmission of drug resistant organisms. Strategies to address these challenges include outreach programs to engage substance abusers in nonmedical settings, such as prisons and the streets, active screening programs for HIV, HCV, and TB, increased and broadened clinician expertise, knowledge and avoidance of drug interactions, attention to infection control, use of isoniazid preventive therapy, and creative strategies to insure medication adherence. All of these require structural changes directed at comprehensive prevention and treatment programs and increased collaboration and integration of needed services for substance abusers.

Treatment options for hepatitis C and the rationale for low response rates in African Americans

Hepatitis C virus (HCV), the leading cause for liver transplantation, is emerging as1 of the infections that pose public health problems in the world since about 170 million people worldwide are infected with this virus. Inequality in addressing racial/ethnic disparities in treatment for hepatitis C is a pressing problem. HCV is more common among African Americans than among other racial groups in the United States. Although African Americans have been shown to have a lower rate of viral clearance and a higher rate of chronic hepatitis C, they may have at the same time a much lower rate of fibrosis progression compared to Caucasians. The purpose of this study is to summarize treatment options available for hepatitis C in African Americans and to describe the different mechanisms thought to be the reasons for the disparate response to treatment in African Americans.

Drug abuse and hepatitis C infection as comorbid features of HIV associated neurocognitive disorder: neurocognitive and neuroimaging features

Substance abuse and co-infection with hepatitis C (HCV) are two highly relevant determinants of neurocognitive and neuroimaging abnormalities associated with HIV. Substance abuse and HCV are common in the HIV population and there is increasing evidence that the CNS is directly compromised by these comorbid conditions via additive or synergistic processes. In this article we review the current literature regarding mechanisms of neuronal injury as well as the neuropsychological and neuroimaging signatures associated with substance abuse and HCV status among HIV patients. We discuss specific methodological challenges and threats to validity associated with studies of HIV and comorbid substance use disorders or HCV and review potential strategies for minimizing their confounding effects. Efforts to understand the interactions between HIV, substance abuse and HCV co-infection will lead to more complete models of neuropathogenesis of HIV and a greater understanding of the variability in neuropsychological expression of HIV Associated Neurocognitive Disorder.

Serum concentrations of ribavirin and pegylated interferon and viral responses in patients infected with HIV and HCV

The hepatitis C virus (HCV) infects a substantial proportion of patients infected with human immunodeficiency virus (HIV). Patients infected with both HCV and HIV respond poorly to anti-HCV treatment with pegylated interferon alpha and ribavirin. But few data are available on the influence of ribavirin and interferon concentrations on treatment outcome for these patients. This study investigated the relationship between the serum pegylated interferon and ribavirin concentrations 3 and 6 months after treatment initiation, and treatment outcome in 35 HCV-HIV coinfected patients. The pegylated interferon and ribavirin concentrations at months 3 and 6 were similar. The pegylated interferon concentrations at 3 months in responders and nonresponders were similar. However, responders tended to have higher ribavirin concentrations (2,322 ng/ml) than nonresponders (1,833 ng/ml; P = 0.08). Responders infected with HCV genotype 1 or 4 had higher ribavirin concentrations (2,672 ng/ml) than did similarly infected nonresponders (1,758 ng/ml; P = 0.04). ROC curve analysis showed that a ribavirin concentration of 2,300 ng/ml was the best threshold for predicting a nonresponse (ROC area = 0.80 +/- 0.12). Thus ribavirin concentrations influence treatment outcome in HIV patients infected with HCV genotype 1 or 4. Monitoring ribavirin concentrations could help adapt ribavirin concentrations and improve the sustained virological response.

Cystatin C and creatinine in an HIV cohort: the nutrition for healthy living study

BACKGROUND

Human immunodeficiency virus (HIV)-infected persons have an increased risk of chronic kidney disease (CKD). Serum creatinine level may underestimate the prevalence of CKD in subjects with decreased lean body mass or liver disease. Level of serum cystatin C, an alternative kidney function marker, is independent of lean body mass.

STUDY DESIGN

Cross-sectional.

SETTING & PARTICIPANTS

250 HIV-infected subjects on highly active antiretroviral therapy in the Nutrition for Healthy Living (NFHL) cohort; 2,628 National Health and Nutrition Examination Survey (NHANES) 2001-2002 subjects.

PREDICTORS & OUTCOMES

Comparison of serum creatinine levels in NFHL to those in NHANES subjects; comparison of CKD in NFHL subjects ascertained using serum creatinine versus cystatin C levels.

MEASUREMENTS

Standardized serum creatinine, serum cystatin C, glomerular filtration rate (GFR) estimated from serum creatinine and cystatin C levels.

RESULTS

Creatinine levels were lower in NFHL than NHANES subjects despite greater rates of hepatitis, diabetes, and drug use (mean difference, -0.18 mg/dL; P < 0.001 adjusted for age, sex, and race). Of NFHL subjects, only 2.4% had a creatinine-based estimated GFR less than 60 mL/min/1.73 m(2), but 15.2% had a cystatin-based estimated GFR less than 60 mL/min/1.73 m(2).

LIMITATIONS

GFR was estimated rather than measured. Other factors in addition to GFR may affect creatinine and cystatin C levels. Measurements of proteinuria were not available.

CONCLUSIONS

Serum creatinine levels may overestimate GFRs in HIV-infected subjects. Kidney disease prevalence may be greater than previously appreciated.

Underlying pathophysiology of HCV infection in HIV-positive drug users

HCV and HIV infections are very common among injection drug users (IDUs). It is well known that 80-90% of HIV-infected IDUs are also infected with HCV. Furthermore, patients with HCV/HIV co-infection are at a higher risk of progressing to end-stage liver disease, namely cirrhosis. Even though there is increasing global awareness of HCV/HIV co-infection and extended therapeutic programs for this infected population, little is known about the HCV/HIV pathophysiology that mediates the rapid progression to hepatic disease. Liver disease caused by HCV/HIV co-infection is characterized by inflammation and cell-death. Recent reports suggest that the HIV and HCV envelope proteins may induce apoptosis and inflammation in hepatocytes via a novel pathway involving collaborative signaling. Moreover, HCV/HIV co-infection may also alter the cytokine production in vivo. Further studies to elucidate the molecular mechanisms of HCV and HIV-mediated pathogenesis will help in the development of therapeutic strategies against HCV/HIV co-infection in these patients.

Awareness of hepatitis C infection among women with and at risk for HIV

BACKGROUND

Treatment guidelines recommend all HIV/HCV-co-infected persons be considered for hepatitis C virus (HCV) treatment, yet obstacles to testing and accessing treatment for HCV continue for women.

OBJECTIVE

To assess awareness of HCV, and describe diagnostic referrals and HCV treatment among women in the Women's Interagency HIV Study (WIHS).

DESIGN

Prospective epidemiologic cohort.

PARTICIPANTS

Of 3,768 HIV-infected and uninfected women in WIHS, 1,166 (31%) were HCV antibody positive.

MEASUREMENTS AND MAIN RESULTS

Awareness of HCV infection and probability of referrals for diagnostic evaluations and treatment using logistic regression. Follow-up HCV information was available for 681 (390 died, 15 withdrew, 80 missed visit) in 2004. Of these 681, 522 (76.7%) reported knowing their HCV diagnosis. Of these, 247 of 522 (47.3%) stated their providers recommended a liver biopsy, whereas 139 of 247 or 56.3% reported having a liver biopsy. A total of 170 of 522 (32.6%) reported being offered treatment and 74.1% (n = 126 of 170) reported receiving HCV treatment. In multivariate regression analyses, African-American race, Hispanic/Latina ethnicity, poverty, and current crack/cocaine/heroin use were negatively associated with treatment referrals, whereas elevated alanine aminotransferase (ALT) was associated with increased likelihood of referral and increased likelihood of treatment.

CONCLUSION

One quarter of women with HCV in this cohort were not aware of their diagnosis. Among those aware of their HCV, 1 in 4 received liver biopsy and treatment for HCV. Both provider and patient education interventions regarding HCV testing and HCV treatment options and guidelines are needed to enhance HCV awareness and participation in HCV evaluation and treatment.

Injecting drug use is associated with HIV risk perception among Mexican Americans in the Rio Grande Valley of South Texas, USA

OBJECTIVES

Injecting drug use (IDU) remains an actual risk variable in human immunodeficiency virus (HIV) infection in most ethnic populations, and the association between actual risk and individual perception of HIV risk varies across studies and samples. This study aimed to examine the relationship between IDU and HIV risk perception among Mexican Americans residing in Rio Grande Valley, South Texas.

STUDY DESIGN

A cross-sectional study of IDU as a predictor of HIV risk perception.

METHODS

Two hundred and seventy-five participants [IDUs 11.9%, non-IDUs 88.1%] were assessed for an association between IDU and individual risk perception for HIV infection, as well as history of drug use and HIV risk perception, using Chi-squared statistic for independence and a logistic regression model for the prevalence odds ratio (POR).

RESULTS

There was no statistically significant difference between IDUs and non-IDUs with respect to the sociodemographic variables, except for income and gender (P<0.05). The results indicated a statistically significant decrease in HIV risk perception among IDUs compared with non-IDUs, after adjustment for age, gender, sexual preference, history of drug use and marital status [POR 0.26, 95% confidence intervals (CI) 0.11-0.65]. Likewise, history of drug use was associated with decreased HIV risk perception (POR 0.44, 95% CI 0.22-0.98).

CONCLUSIONS

These results suggest an inverse correlation between actual risk of HIV infection, such as IDU, and HIV risk perception. Therefore, assessment of HIV risk perception, which is a significant determinant of behaviour change, is essential to reduce the prevalence of HIV infection in the targeted population.

Medical management of HIV-hepatitis C virus coinfection in injection drug users

Several million people inject drugs of abuse and, as a result, are coinfected with human immunodeficiency virus (HIV) and hepatitis C virus (HCV). The treatment of this coinfected drug-abusing population is fraught with many problems such that clinicians and other health care providers have to determine whether patients should be treated first for drug addiction, for HIV/AIDS, or for HCV infection or simultaneously treated. These proceedings present the incidence and prevalence of coinfections with HIV and HCV in high-risk populations and discuss the underlying pathophysiology of coinfections and the problems and strategies of managing the treatment of coinfections among people who also inject illicit drugs. In addition, the expert panel recommended further research to determine the best possible treatment regimens applicable to injection drug users coinfected with HIV and HCV.