Hepatitis C virus viremia in HIV-infected individuals with negative HCV antibody tests

Serologic versus molecular testing for screening for hepatitis C virus infection in patients with hematologic malignancies

Testing for antibody against hepatitis C virus (anti-HCV) is a low-cost diagnostic method worldwide; however, an optimal screening test for HCV in patients with cancer has not been established. We sought to identify an appropriate screening test for HCV infection in patients with hematologic malignancies and/or hematopoietic cell transplants (HCT). Patients in our center were simultaneously screened using serological (anti-HCV) and molecular (HCV RNA) assays (February 2019-November 2019). In total, 214 patients were enrolled in this study. Three patients (1.4%) were positive for anti-HCV, and 2 (0.9%) were positive for HCV RNA. The overall percentage agreement was 99.5% (95% CI: 97.4-99.9). There were no cases of seronegative HCV virus infection. The positive percentage agreement was 66.7% (95% CI: 20.8-93.9), and the negative percentage agreement was 100.0% (95% CI: 98.2-100.0). Cohen kappa coefficient was 0.80 (95% CI: 0.41-1.00, P < .0001). The diagnostic yield of screening for chronic HCV infection in patients with cancer is similar for serologic and molecular testing.

Laboratory Diagnosis and Monitoring of Viral Hepatitis

Many microbes, toxins, autoimmune diseases, and neoplastic diseases may cause liver inflammation; however, 5 viruses whose main pathogenesis is liver disease are referred to as hepatitis A, B, C, D, and E viruses. These viruses cause a significant burden of global illness. With the exception of hepatitis A virus, all may cause chronic infection potentially leading to cirrhosis and hepatocellular carcinoma. Excellent serologic and nucleic acid detection methods are available for determining the precise cause and, in some cases, the duration of infection. Diagnostics are critical for identifying individuals needing treatment and for monitoring the treatment success.

Further characterization of bovine hepacivirus: Antibody response, course of infection, and host tropism

Bovine hepacivirus (BovHepV) is a recently added member to the growing genus Hepacivirus within the family Flaviviridae. Animal hepaciviruses are rarely characterized so far. Apart from norway rat hepacivirus which represents a promising HCV surrogate model, only equine hepaciviruses have been studied to some extent. BovHepV has been initially identified in bovine samples and was shown to establish persistent infections in cattle. However, consequences of those chronic infections, humoral immune response and the possibility of an extended host spectrum have not been explored so far. Therefore, we here investigated (a) the presence of anti-NS3-antibodies and viral RNA in cattle herds in Germany, (b) the course of infection in cattle, and (c) the host tropism including zoonotic potential of bovine hepaciviruses. Our results show that 19.9% of investigated bovine serum samples had antibodies against BovHepV. In 8.2% of investigated samples, viral RNA was detected. Subsequent genetic analysis revealed a novel genetic cluster of BovHepV variants. For 25 selected cattle in a BovHepV positive herd the presence of viral genomic RNA was monitored over one year in two to three months intervals by RT-PCR in order to discriminate acute versus persistent infection. In persistently infected animals, no serum antibodies were detected. Biochemical analyses could not establish a link between BovHepV infection and liver injury. Apart from a single sample of a pig providing a positive reaction in the antibody test, neither BovHepV-specific antibodies nor viral RNA were detected in porcine, equine or human samples implying a strict host specificity of BovHepV.

Prevention of Sexually Transmitted Diseases in HIV-Infected Individuals

Prevention of sexually transmitted infections (STIs) is an important part of the care of the HIV-infected individual. STIs have been associated with increased risk of transmission and acquisition of HIV. Among HIV-infected persons, treatment failures and high recurrence rates of some STIs are more common. Despite the recognized importance of prevention and discussion of sexual health, rates of screening for STIs are suboptimal. Moreover, rates of STIs such as syphilis continue to increase particularly in men who have sex with men (MSM). This review focuses on the most common STIs seen among HIV-infected individuals and recommendations for screening and prevention.

HCV screening in a cohort of HIV infected and uninfected homeless and marginally housed women in San Francisco, California

BACKGROUND

Hepatitis C virus (HCV) screening has taken on new importance as a result of updated guidelines and new curative therapies. Relatively few studies have assessed HCV infection in homeless populations, and a minority include women. We assessed prevalence and correlates of HCV exposure in a cohort of homeless and unstably housed women in San Francisco, and estimated the proportion undiagnosed.

METHODS

A probability sample of 246 women were recruited at free meal programs, homeless shelters, and low-cost single room occupancy hotels in San Francisco; women with HIV were oversampled. At baseline, anti-HCV status was assessed using an enzyme immunoassay, and results compared in both HIV-positive and negative women. Exposures were assessed by self-report. Logistic regression was used to assess factors independently associated th HCV exposure.

RESULTS

Among 246 women 45.9% were anti-HCV positive, of whom 61.1% were HIV coinfected; 27.4% of positives reported no prior screening. Most (72%) women were in the 'baby-boomer' birth cohort; 19% reported recent injection drug use (IDU). Factors independently associated with anti-HCV positivity were: being born in 1965 or earlier (AOR) 3.94; 95%CI: 1.88, 8.26), IDU history (AOR 4.0; 95%CI: 1.68, 9.55), and number of psychiatric diagnoses (AOR 1.16; 95%CI: 1.08, 1.25).

CONCLUSIONS

Results fill an important gap in information regarding HCV among homeless women, and confirm the need for enhanced screening in this population where a high proportion are baby-boomers and have a history of drug use and psychiatric problems. Due to their age and risk profile, there is a high probability that women in this study have been infected for decades, and thus have significant liver disease. The association with mental illness and HCV suggests that in addition increased screening, augmenting mental health care and support may enhance treatment success.

Sexually-transmitted seronegative HCV infection in an HIV-positive post-liver transplant recipient. Case report and review of the literature

We report an HIV-positive patient post liver transplant for non-alcoholic steatohepatitis. Posttransplant liver enzymes became persistently elevated, however HCV antibody was repeatedly negative. Nucleic acid testing subsequently revealed ongoing HCV viremia. Exposure to HCV was on the basis of sexual transmission. The patient was subsequently successfully treated with sofosbuvir/ledipasvir.

Paediatric European Network for Treatment of AIDS (PENTA) guidelines for treatment of paediatric HIV-1 infection 2015: optimizing health in preparation for adult life

The 2015 Paediatric European Network for Treatment of AIDS (PENTA) guidelines provide practical recommendations on the management of HIV‐1 infection in children in Europe and are an update to those published in 2009. Aims of treatment have progressed significantly over the last decade, moving far beyond limitation of short‐term morbidity and mortality to optimizing health status for adult life and minimizing the impact of chronic HIV infection on immune system development and health in general. Additionally, there is a greater need for increased awareness and minimization of long‐term drug toxicity. The main updates to the previous guidelines include: an increase in the number of indications for antiretroviral therapy (ART) at all ages (higher CD4 thresholds for consideration of ART initiation and additional clinical indications), revised guidance on first‐ and second‐line ART recommendations, including more recently available drug classes, expanded guidance on management of coinfections (including tuberculosis, hepatitis B and hepatitis C) and additional emphasis on the needs of adolescents as they approach transition to adult services. There is a new section on the current ART ‘pipeline’ of drug development, a comprehensive summary table of currently recommended ART with dosing recommendations. Differences between PENTA and current US and World Health Organization guidelines are highlighted and explained.

New Hopes for HIV and HCV Coinfection in 2004

An increase in liver-related causes of death in HIV-positive patients who are coinfected with the hepatitis C virus (HCV) has been acknowledged over the last few years, particularly since the mid 1990s, when the natural history of HIV infection started to improve with the use of highly active antiretroviral therapy (HAART). Chronic hepatitis C is very common among HIV-infected patients who were infected through intravenous drugs use or contaminated blood products (e.g., hemophiliacs). The bidirectional interferences between HIV and HCV modify the natural history of both infections. Moreover, interactions between anti-HIV and anti-HCV drugs are of concern, and a lower response to anti-HCV therapy limits its benefit in HIV-coinfected patients. Although a slower HCV RNA decay is seen in coinfected patients after standard therapy is initiated with pegylated interferon plus ribavirin, the stopping rule at week 12 that is recommended for HCV-monoinfected individuals seems to be equally valid in HIV-positive patients. This finding is of great value, because it allows treatment to be offered in the absence of contraindication (e.g., low CD4 count, alcohol abuse, etc.) but discontinued as early as 12 weeks when no chances of cure are predicted, which saves costs and deleterious side effects. HAART therapy seems to temper somehow the negative impact exerted by HIV infection over HCV-related liver fibrosis. Liver transplantation is currently the best option for HIV-infected patients with end-stage liver disease. However, the management of patients on the waiting list and after transplantation carries significant new challenges. New anti-HCV drugs are urgently needed and new strategies with the currently available drugs need to be assessed to reduce the negative impact of hepatitis C in HIV-coinfected individuals.

Hepatitis C virus infection in the human immunodeficiency virus infected patient

Human immunodeficiency virus (HIV) and hepatitis C virus (HCV) share the same transmission routes; therefore, coinfection is frequent. An estimated 5-10 million individuals alone in the western world are infected with both viruses. The majority of people acquire HCV by injection drug use and, to a lesser extent, through blood transfusion and blood products. Recently, there has been an increase in HCV infections among men who have sex with men. In the context of effective antiretroviral treatment, liver-related deaths are now more common than Acquired Immune Deficiency Syndrome-related deaths among HIV-HCV coinfected individuals. Morbidity and mortality rates from chronic HCV infection will increase because the infection incidence peaked in the mid-1980s and because liver disease progresses slowly and is clinically silent to cirrhosis and end-stage-liver disease over a 15-20 year time period for 15%-20% of chronically infected individuals. HCV treatment has rapidly changed with the development of new direct-acting antiviral agents; therefore, cure rates have greatly improved because the new treatment regimens target different parts of the HCV life cycle. In this review, we focus on the epidemiology, diagnosis and the natural course of HCV as well as current and future strategies for HCV therapy in the context of HIV-HCV coinfection in the western world.

Human immunodeficiency virus and hepatitis C virus coinfection in Nepal

OBJECTIVES

The study aimed at finding prevalence, mode of transmission, and pattern of CD4 cell count among hepatitis C virus (HCV) coinfected human immunodeficiency virus (HIV)-positive individuals in Nepal.

METHODS

This was a descriptive cross-sectional study carried out in three Volunteer Counseling and Testing clinics, one from Dharan and two from Kathmandu, Nepal. Three hundred and thirteen individuals were recruited.

RESULTS

Forty-two percent of HIV-infected persons had HCV coinfection. Significant associations with HIV and HCV coinfection were male gender (p <0.001) and injection drug use (IDU) (p <0.001). The mean CD4 cell count was significantly lower in HCV coinfected individuals, compared to those without coinfection, after 1.5 years (p =0.017), 2 years (p =0.0457), 3 years (p =0.011), and 3.5 years (p <0.001) of antiretroviral therapy.

CONCLUSION

HCV coinfection was common in HIV-infected individuals in Nepal and was associated with male gender, IDU, and lower CD4 counts.

Seronegative hepatitis C virus infection

Hepatitis C virus (HCV) is a major cause of liver disease worldwide. The routine diagnostics identifying HCV infection include testing for specific anti-HCV antibodies by enzyme-linked immnunosorbent assay and viral genetic material in serum or plasma. However, a small proportion of patients persistently infected with HCV, in whom anti-HCV are undetectable, constitute a serious diagnostic and possibly epidemiologic problem, as they could facilitate pathogen spread in the population. This type of infection is termed seronegative or serosilent. Seronegative HCV infection is currently of great interest to both scientists and physicians. The review presents epidemiological data concerning the prevalence of seronegative HCV infection in HIV/HCV co-infected individuals, hemodialysis patients, and blood and organ donors. The possible mechanisms behind this atypical course of infection are discussed. Furthermore, the differences between seronegative and occult infections and prolonged seroconversion are explained.

High rate of seronegative HCV infection in HIV-positive patients

Co-infection with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) is a significant global health problem. The two viruses are transmitted with high efficacy via blood-to-blood contact, mainly intravenous drug use (IVDU), whereas HCV is less easily transmitted sexually. Antibody testing is the main screening method for HCV infection, although it may not be the optimal option for HIV infection. The aim of this study was to investigate HCV infection in HIV-positive patients, with and without a detectable anti-HCV antibody response. A total of 187 plasma samples were obtained from HIV-positive patients in Surabaya, Indonesia and examined for anti-HCV [HCV enzyme immunoassay (EIA) 3.0], HCV genotype/subtype [reverse transcription-polymerase chain reaction (RT-PCR) using primers targeting a part of NS5B/5'UTR followed by sequencing] and HCV viral load (quantitative RT-PCR). A total of 119 patients (63.6%) were found to be anti-HCV-positive and, among these, HCV RNA was detected in 73 (61.3%), with HCV-1a as the predominant subtype (31.5%). Of the 68 anti-HCV-negative samples, HCV RNA was detected in 26/68 (38.2%) mostly as the HCV-3a subtype (50%). High HCV viral loads were more common among the HCV-seropositive patients. The HCV-seropositive samples with detected HCV RNA were mostly obtained from HIV-positive patients with parenteral transmission (IVDU) (76.7%); however, the HCV-seronegative samples with detected HCV RNA were mostly from patients who had acquired HCV through heterosexual transmission (61.5%). In conclusion, HIV-positive patients were at high risk of becoming co-infected with HCV and several remained HCV-seronegative. Furthermore, there may exist differences in HCV seropositivity and subtypes between HIV-positive patients who acquired HCV sexually and those who acquired HCV parenterally.

Occult infection with hepatitis C virus: friend or foe?

Hepatitis C virus (HCV) infection is a global pandemic associated with a growing disease burden due to cirrhosis and the consequent morbidity and mortality. Transmission is largely via blood-to-blood contact. Following primary infection, a minority of individuals clear the infection predominantly via cellular immune mechanisms, whereas the majority become chronically infected. Recent data suggest that a third outcome may also be possible, termed 'occult' infection in which subjects who are known, or suspected to have previously been infected with HCV, no longer have viral RNA in their serum at levels detectable by sensitive commercial assays, but do have virus detected by ultra-sensitive techniques. Occult infection has also been detected in peripheral blood mononuclear cells, which may indicate an extra-hepatic reservoir of the virus. Although the clinical significance of occult infection remains unknown, most authors have raised concerns of recrudescent infection. Here we critically review the published literature, suggest further avenues of investigation and propose that occult infection may be beneficial to the host by maintaining immunological memory to protect against reinfection.

Seronegative hepatitis C virus infection in a child infected via mother-to-child transmission

Hepatitis C virus (HCV) infection typically leads to antibody response within weeks after primary infection. Here, we describe the case of a child infected with HCV by mother-to-child transmission who remained persistently seronegative despite the presence of high levels of circulating HCV RNA.

Mortality in hepatitis C virus-infected patients with a diagnosis of AIDS in the era of combination antiretroviral therapy

BACKGROUND

Before the introduction of combination antiretroviral therapy (cART), patients infected with the human immunodeficiency virus (HIV) rarely died of liver disease. In resource-rich countries, cART dramatically increased longevity. As patients survived longer, hepatitis C virus (HCV) infection became a leading cause of death; however, because patients with AIDS continue to have 5-fold greater mortality than non-AIDS patients, it is unclear whether HCV infection increases mortality in them.

METHODS

In this investigation, which is part of the Longitudinal Studies of the Ocular Complications of AIDS, plasma banked at enrollment from 2025 patients with AIDS as defined by the Centers for Disease Control and Prevention were tested for HCV RNA and antibodies.

RESULTS

Three hundred thirty-seven patients had HCV RNA (chronic infection), 91 had HCV antibodies and no HCV RNA (cleared infection), and 1597 had no HCV markers. Median CD4(+) T-cell counts/µL were 200 (chronic), 193 (cleared), and 175 (no markers). There were 558 deaths. At a median follow-up of 6.1 years, patients with chronic HCV had a 50% increased risk of mortality compared with patients with no HCV markers (relative risk [RR], 1.5; 95% confidence interval [CI], 1.2-1.9; P = .001) in an adjusted model that included known risk factors. Mortality was not increased in patients with cleared infection (RR, 0.9; 95% CI, .6-1.5; P = .82). In patients with chronic HCV, 20.4% of deaths were liver related compared with 3.8% in patients without HCV.

CONCLUSIONS

Chronic HCV infection is independently associated with a 50% increase in mortality among patients with a diagnosis of AIDS, despite competing risks. Effective HCV treatment may benefit HIV/HCV-coinfected patients with AIDS.

Clinical variables identify seronegative HCV co-infection in HIV-infected individuals

BACKGROUND

A substantial number of people living with HIV (PLWH) are co-infected with Hepatitis C Virus (HCV) but have a negative screening HCV antibody test (seronegative HCV infection, or SN-HCV).

OBJECTIVE

To identify a concise set of clinical variables that could be used to improve case finding for SN-HCV co-infection among PLWH.

STUDY DESIGN

Two hundred HIV-infected participants of the CHARTER study were selected based on 7 clinical variables associated with HCV infection but were HCV seronegative. Data were analyzed using Fisher's exact tests, receiver-operating characteristic (ROC) curves, and logistic regression.

RESULTS

Twenty-six (13%) participants had detectable HCV RNA. SN-HCV was associated with a history of IDU, elevated ALT and AST, low platelets, black ethnicity, and undetectable HIV RNA in plasma. Each of these clinical variables, except for abnormal AST, remained independently associated with SN-HCV in a multivariate logistic regression analysis. A composite risk score correctly identified SN-HCV with sensitivity up to 85% and specificity up to 88%.

CONCLUSIONS

In a substantial minority of PLWH, seronegative HCV viremia can be predicted by a small number of clinical variables. These findings, after validation in an unselected cohort, could help focus screening in those at highest risk.

Risk Factors and Seroprevalence of Hepatitis C among Patients Hospitalized at Mulago Hospital, Uganda

The emergence of hepatitis C virus (HCV) and its associated sequelae in Africa is a cause for significant concern. Human immunodeficiency virus (HIV) positive patients are at an increased risk of contracting HCV infection due to similar risk factors and modes of transmission. We investigated the seroprevalence of hepatitis C in hospitalized HIV-positive and HIV-negative patients in Mulago Hospital, an academic hospital in Uganda. Blood samples were first tested for HCV antibodies, and positive tests were confirmed with HCV RNA PCR. We enrolled five hundred patients, half HIV-positive and half HIV negative. Overall, 13/500 patients (2.6%) tested positive for HCV antibodies. There was no difference in HCV antibody detection among HIV-positive and HIV-negative patients. Out of all risk factors examined, only an age greater than 50 years was associated with HCV infection. Traditional risk factors for concurrent HIV and HCV transmission, such as intravenous drug use, were exceedingly rare in Uganda. Only 3 of 13 patients with detectable HCV antibodies were confirmed by HCV RNA detection. This result concurs with recent studies noting poor performance of HCV antibody testing when using African sera. These tests should be validated in the local population before implementation.

Performance characteristics of a combined hepatitis C virus core antigen and anti-hepatitis C virus antibody test in different patient groups

We evaluated the performance of a hepatitis C virus (HCV) antigen/antibody combination test [Murex HCV Antigen/Antibody Combination Test (Murex Ag/Ab test)] by comparing it with the current third-generation HCV antibody enzyme immunoassay (anti-HCV). A total of 403 serum samples were consecutively collected from four patient groups: healthy controls (n=100); HCV-infected patients (HCV group, n=102); Human immunodeficiency virus (HIV)/HCV-infected patients (HIV/HCV group, n=100); and patients with uremia (uremia group, n=101). Performances were evaluated for the Murex Ag/Ab, anti-HCV, and HCV RNA in the HIV/HCV and uremia patient groups. In the HCV group, all 102 samples showed concordant positive and negative results for anti-HCV, Murex Ag/Ab, and HCV RNA tests. In the HIV/HCV group, all 100 samples were positive for both anti-HCV and Murex Ag/Ab tests, whereas 88 patients (88%) were HCV RNA positive. In the uremia group, 14 (69.0%) of the 23 anti-HCV-positive patients were HCV RNA positive, whereas 14 (77.8%) of the 18 Murex Ag/Ab-positive patients were HCV RNA positive. None of anti-HCV-negative or Murex Ag/Ab-negative patients were HCV RNA positive. Based on the HCV RNA assay, the sensitivities for both anti-HCV and Murex Ag/Ab assays were 100%, whereas the specificities of these two assays were 89.7% and 95.4%, respectively. With good sensitivity and specificity, the Murex Ag/Ab assay could be a useful alternative diagnostic tool, especially in immunocompromised populations, such as patients with uremia or those infected with HIV.

Hepatocellular carcinoma in a teenager with perinatally acquired HIV Infection without hepatitis B or C coinfection: a case report

A 19-year-old male with perinatally acquired HIV infection and AIDS (clinical stage 3) presented with a 9.1 × 5.0 cm hepatic mass. The resected mass was determined to be a hepatocellular carcinoma (HCC) without metastasis. The patient did not have active hepatitis B or C coinfection, as revealed by polymerase chain reaction (PCR), nor other risk factors for development of cirrhosis or HCC, and comprises only the second explicitly stated case of an HIV-positive individual developing HCC in the absence of concomitant hepatitis virus infection or other risk factors. This case illustrates the fact that as survival of perinatally infected individuals increases in the highly active antiretroviral therapy (HAART) era, new associations between HIV infection and other disease processes may be uncovered.

Poor performance of hepatitis C antibody tests in hospital patients in Uganda

Most hepatitis C testing in Uganda is performed using commercial rapid strip assays (RSA) to detect antibodies to hepatitis C virus (anti-HCV), rather than enzyme immunoassays (EIA). The prevalence of hepatitis C antibodies in a Ugandan hospital population was determined using both methods to test their accuracy using nucleic acid testing (NAT) as a reference. Sera from 380 consecutive hospitalized Ugandan patients were tested for anti-HCV using an RSA in Uganda, with subsequent automated third-generation EIA testing in the United States, followed by NAT. Recombinant immunoblot assays (RIBA) were used as a supplementary test to detect anti-HCV epitopes. Overall, anti-HCV was detected in 48/380 (13%) by one or both antibody tests. Anti-HCV was detected in 19 (5.0%) patients by RSA and in 33 (8.7%) patients by EIA; only four patients were anti-HCV positive by both methods. Fourteen of the 48 anti-HCV positive patients had detectable serum HCV RNA, 7 each by bDNA assay or by PCR. RSA detected only 7 of 14 HCV RNA positive sera. Of 29 RNA negative but anti-HCV positive patients tested by RIBA, only two were anti-HCV positive; 27 were anti-HCV negative or indeterminate. Anti-HCV testing by RSA and/or EIA was neither sensitive nor specific for detection of ongoing HCV infection in hospitalized Ugandan patients. Our findings underscore the importance of confirmatory nucleic acid testing, which, despite its increased cost, appears essential to manage African patients with HCV.

Hepatitis C seropositivity is not a risk factor for sensory neuropathy among patients with HIV

BACKGROUND

Sensory neuropathy (SN) is common in patients with HIV. Hepatitis C (HCV) coinfection is often cited as an HIV-SN risk factor, but data to support this are lacking. This collaboration aimed to examine the association between HCV serostatus and SN risk among ambulatory HIV-positive patients.

METHODS

Patients with HIV were assessed in cross-sectional studies in Baltimore, Jakarta, Johannesburg, Kuala Lumpur, Melbourne, and Sydney for SN (defined by both supportive symptoms and signs). HCV seropositivity was assessed as an SN risk using a chi(2) test, followed by logistic regression modeling to correct for treatment exposures and demographics.

RESULTS

A total of 837 patients of African, Asian, and Caucasian descent were studied. HCV seroprevalence varied by site (Baltimore n = 104, 61% HCV+; Jakarta 96, 51%; Johannesburg 300, 1%; Kuala Lumpur 97, 10%; Melbourne 206, 16%; Sydney 34, 18%). HCV seropositivity was not associated with increased SN risk at any site, but was associated with reduced SN risk in Melbourne (p = 0.003). On multivariate analyses, the independent associations with SN were increasing age, height, and stavudine exposure. HCV seropositivity was not independently associated with an increased SN risk at any site, but associated independently with reduced SN risk in Baltimore (p = 0.04) and Melbourne (p = 0.06).

CONCLUSIONS

Hepatitis C (HCV) seropositivity was not associated with increased sensory neuropathy risk among HIV-positive patients at any site. While we were unable to assess HCV RNA or liver damage, the data suggest that HCV coinfection is not a major contributor to HIV-SN. HCV = hepatitis C; SN = sensory neuropathy.

Trends in hepatitis C virus infection among patients in the HIV Outpatient Study, 1996-2007

BACKGROUND

Coinfection with hepatitis C virus (HCV) contributes increasingly to the morbidity and mortality of persons infected with HIV. We assessed HCV infection screening practices and determined trends in the prevalence of HCV infection in the HIV Outpatient Study (HOPS) from 1996 to 2007.

METHODS

We calculated the proportion of patients eligible to be tested for HCV infection (i.e., never tested or previously tested negative) and the prevalence of HCV infection annually from 1996 to 2007 by sociodemographic, clinical, and HIV risk category characteristics. We used multiple logistic regression analyses to evaluate factors independently associated with HCV testing.

RESULTS

A total of 7618 patients were active in the HOPS from 1996 through 2007. The proportion of eligible patients tested for HCV infection increased from 10.7% in 1996 to 76.6% in 2007 and increased among all demographic and risk groups. Overall HCV prevalence decreased from 36.7% in 1996 to 19.7% in 2007; decreases in prevalence occurred among all groups except for injection drug users (IDUs). In multivariable analysis, age older than 35 years, nonwhite race, Hispanic ethnicity, high-risk heterosexual and IDU risk categories, and at least 3 years of enrollment in the HOPS were associated with increased odds of having been tested for HCV infection.

CONCLUSIONS

Screening for HCV infection in the HOPS has improved, although a sizable fraction of patients remain unscreened. The decline in overall HCV infection prevalence from 1996 to 2007 resulted primarily from a decline in the fraction of all prevalent infections in the cohort attributable to IDU patients.

Pathogen-pathogen interaction: a syndemic model of complex biosocial processes in disease

There is growing awareness of the health implications of fact that infectious agents often do not act independently; rather their disease potential is mediated in diverse and significant ways by their relationships with other pathogens. Pathogen-pathogen interaction (PPI), for example, impacts various virulence factors in human infection. Although still in its infancy, the study of PPI, a form of epidemiological synergism, is emerging as an important arena of new research and new understanding in health and clinical care. The aims of this paper are to: 1) draw attention to the role of PPI in human disease patterns; 2) present the syndemics model as a biosocial approach for examining the nature, pathways, contexts, and health implications of PPI; and 3) suggest the utility of this approach to PPI. Toward these ends, this paper (a) reviews three of case examples of alternative PPIs, (b) describes the development and key concepts and components of the syndemics model with specific reference to interacting infectious agents, (c) contextualizes this discussion with a brief review of broader syndemics disease processes (not necessarily involving infections disease), and (d) comments on the research, treatment and prevention implications of syndemic interaction among pathogens.

Effects of active HCV replication on neurologic status in HIV RNA virally suppressed patients

BACKGROUND

Hepatitis C virus (HCV) is a frequent copathogen with HIV. Both viruses appear to replicate in the brain and both are implicated in neurocognitive and peripheral neuropathy syndromes. Interaction of the viruses is likely to be complicated and better understanding of the contributions of each virus will be necessary to make evidence-based therapeutic decisions.

METHODS

This study was designed to determine if active HCV infection, identified by quantitative HCV RNA determination, is associated with increased neurocognitive deficits or excess development of distal sensory peripheral neuropathy in HIV coinfected patients with stable HIV viral suppression. The AIDS Clinical Trials Group Longitudinal Linked Randomized Trials (ALLRT) study was the source of subjects with known HIV treatment status, neurocognitive and neuropathy evaluations, and HCV status. Subjects were selected based on HCV antibody status (249 positive; 310 negative).

RESULTS

HCV RNA viral loads were detectable in 172 participants with controlled HIV infection and available neurologic evaluations in the ALLRT. These participants were compared with 345 participants with undetectable HCV viral load and the same inclusion criteria from the same cohort. Neurocognitive performance measured by Trail-Making A or B and digit symbol testing was not dissimilar between the 2 groups. In addition, there was no significant association between active HCV replication and distal sensory neuropathy.

CONCLUSION

Clinically significant neurocognitive dysfunction and peripheral neuropathy were not exacerbated by active hepatitis C virus infection in the setting of optimally treated HIV infection.

HIV and hepatitis C virus infections among hanka injection drug users in central Ukraine: a cross-sectional survey

BACKGROUND

Ukraine has experienced an increase in injection drug use since the 1990s. An increase in HIV and hepatitis C virus infections has followed, but not measures of prevalence and risk factors. The purposes of this study are to estimate the prevalence of HIV, HCV, and co-infection among injection drug users (IDUs) in central Ukraine and to describe risk factors for HIV and HCV.

METHODS

A sample of 315 IDUs was recruited using snowball sampling for a structured risk interview and HIV/HCV testing (81.9% male, 42% single, average age 28.9 years [range = 18 to 55]).

RESULTS

HIV and HCV antibodies were detected in 14.0% and 73.0%, respectively, and 12.1% were seropositive for both infections. The most commonly used drug was hanka, home-made from poppy straw and often mixed with other substances including dimedrol, diazepines, and hypnotics. The average period of injecting was 8.5 years; 62.5% reported past-year sharing needles or injection equipment, and 8.0% shared with a known HIV-positive person. More than half (51.1%) reported multiple sexual partners, 12.9% buying or selling sex, and 10.5% exchanging sex and drugs in the past year. Those who shared with HIV positive partners were 3.4 times more likely to be HIV positive than those who did not. Those who front- or back-loaded were 4 times more likely to be HCV positive than those who did not.

CONCLUSION

Harm reduction, addiction treatment and HIV prevention programs should address risk factors to stop further spread of both HIV and HCV among IDUs and to the general population in central Ukraine.

Critical issues in the treatment of hepatitis C virus infection in methadone maintenance patients

AIMS

Hepatitis C virus (HCV) infection is a common chronic complication of injection drug use. Methadone maintenance programs contain large numbers of patients infected with HCV. This paper reviews HCV infection with emphasis on the medical care of HCV-infected, or HCV and human immunodeficiency virus co-infected, patients on methadone or buprenorphine maintenance.

METHODS

Literature searches using PubMed, PsycINFO and SocINDEX were used to identify papers from 1990-present on antiviral therapy for HCV in methadone maintenance patients and on liver transplantation in methadone maintenance patients.

RESULTS

Injection drug use is the most significant risk factor for HCV infection in most western countries. The prevalence of HCV antibody is high in injection drug users (53-96%) and in patients enrolled in methadone maintenance programs (67-96%). Studies of antiviral therapy for HCV in methadone maintenance patients show rates of sustained virological response (SVR), defined as negative HCV-RNA 24 weeks after the end of treatment, of 28-94%. In studies with contrast groups, no significant differences in SVR between methadone and contrast groups were found. Excellent completion rates of antiviral therapy (72-100%) were found in five of six studies. There are many barriers to methadone maintenance patients' receiving antiviral therapy, and research on overcoming barriers is discussed. Liver transplantation has been successful in methadone maintenance patients but has not been utilized widely.

CONCLUSION

High quality medical care for all aspects of HCV infection can be provided to methadone maintenance patients. The literature supports the effectiveness of such services, but the reality is that most patients do not receive them.

Sensitivity of a rapid immuno-chromatographic test for hepatitis C antibodies detection

BACKGROUND AND OBJECTIVES

Enzyme-linked immunoassays (ELISA) are the most widely used anti-hepatitis C virus (HCV) screening tests but simple, instrument and electricity-free screening tests have been developed with results available in a few minutes.

METHODS

The sensitivity of a rapid immuno-chromatographic assay for the detection of anti-HCV antibodies was evaluated on 421 HCV RNA-positive samples from chronic carriers and compared with ELISA method.

RESULTS

The sensitivity of the ELISA method was 99.3% and the sensitivity of the rapid test was 95.5%. False negative results were independent of HCV genotype, but were associated with human immunodeficiency virus (HIV)-positive status. Among HIV-negative people, sensitivities of the rapid test and the EIA assay were 99.2% and 100%, respectively. Whereas among HIV-positive people, sensitivities were 77.5% and 96.3%.

CONCLUSIONS

The immuno-chromatographic test is rapid and simple, and could be used along with rapid anti-HIV determination, in settings with limited facilities or when rapid results are required.

Effect of antiretroviral therapy and hepatitis c co-infection on changes in lipid levels in HIV-Infected patients 48 weeks after initiation of therapy

Hepatitis C virus (HCV) commonly co-infects HIV-infected individuals. Antiretroviral therapy (ART) is associated with elevated serum lipid levels, and HCV infection is associated with low serum lipid levels. Fasting lipid levels were investigated in 1,434 ART-naïve HIV-infected people participating in the AIDS Clinical Trials Group (ACTG) Longitudinal Linked Randomized Trials (ALLRT) protocol who prospectively initiated ART with 3 agents. Subjects with elevated liver-associated enzymes (>5 x ULN) were excluded. Demographics, body mass index, HCV status, CD4 cell count, HIV RNA, liver enzymes, lipid levels, and glucose were assessed before and following 48 weeks of ART. HCV-positive subjects (n = 160; 11%) were older, more likely to be Black, have a history of intravenous drug use (IDU), have higher baseline liver-associated enzyme levels than the HCV-negative group (p < .001 for each), and to have diabetes at baseline (5% vs. 2%, p = .07). Lipid levels rose in both groups following ART, and the differences were not significant except that HDL levels increased significantly more in the HCV-positive group (p = .006). In summary, HCV infection did not appear to provide significant protection against ART-induced hyperlipidemia in this cohort of HIV-infected subjects prospectively enrolled in ART trials, although HDL levels rose to a greater degree.

Testing strategy to identify cases of acute hepatitis C virus (HCV) infection and to project HCV incidence rates

Surveillance for hepatitis C virus (HCV) is limited by the challenge of differentiating between acute and chronic infections. In this study, we evaluate a cross-sectional testing strategy that identifies individuals with acute HCV infection and we estimate HCV incidence. Anti-HCV-negative persons from four populations with various risks, i.e., blood donors, Veterans Administration (VA) patients, young injection drug users (IDU), and older IDU, were screened for HCV RNA by minipool or individual sample nucleic acid testing (NAT). The number of detected viremic seronegative infections was combined with the duration of the preseroconversion NAT-positive window period (derived from analysis of frequent serial samples from plasma donors followed from NAT detection to seroconversion) to estimate annual HCV incidence rates. Projected incidence rates were compared to observed incidence rates. Projected HCV incidence rates per 100 person-years were 0.0042 (95% confidence interval [95% CI], 0.0025 to 0.007) for blood donors, 0.86 (95% CI, 0.02 to 0.71) for VA patients, 39.8 (95% CI, 25.9 to 53.7) for young IDU, and 53.7 (95% CI, 23.4 to 108.8) for older IDU. Projected rates were most similar to observed incidence rates for young IDU (33.4; 95% CI, 28.0 to 39.9). This study demonstrates the value of applying a cross-sectional screening strategy to detect acute HCV infections and to estimate HCV incidence.

Hepatitis C virus (HCV) viremia in HIV-infected patients without HCV antibodies detectable by third-generation enzyme immunoassay

BACKGROUND

The detection of hepatitis C virus antibody (anti-HCV) by enzyme immunoassay to screen HCV infection in HIV-1-infected individuals may yield false negative results, especially in patients with advanced immunosuppression. In such cases, a diagnosis would be possible only by use of a viral RNA detection technique. Third-generation anti-HCV enzyme immunoassays seem to have superior performance compared to second-generation immunoassays in this context.

METHODS

A cross-sectional study was conducted to ascertain the presence of HCV by polymerase chain reaction (PCR) in 61 HIV-1-infected patients with CD(4)(+) cell counts <200 cells/mm(3), and no detectable HCV antibodies by a third-generation enzyme immunoassay.

RESULTS

Six (10%) of 61 patients tested HCV-RNA positive by PCR assay. There was one patient who seroconverted during observation. Hence, there were five patients with HCV viremia without detectable antibodies to HCV throughout the study, which represents 8.2% (95% confidence interval: 2.8-18.4) of 61 HIV-1-infected patients. All five carriers of HCV viremia had CD4 counts <100 cells/mm(3) and were diagnosed with an opportunistic disease at some stage.

CONCLUSIONS

The HCV viremia and no detectable HCV antibodies by third-generation immunoassay were found only in individuals with a CD(4) count of <100 cells/mm(3). Molecular assays to detect HCV-RNA should be considered as an important tool to diagnose hepatitis C in HIV-1-infected patients with advanced immunosuppression.

Therapy of hepatitis C in patients with HIV infection

Hepatitis C is found in approximately a third of patients infected with HIV. Therapy of hepatitis C in HIV patients is very important from several view points. First, hepatitis C in the setting of immunosuppression may progress faster, although recent data show that mortality from liver disease was decreased in highly active antiretroviral therapy. HIV/hepatitis C coinfection is associated with more frequent elevation in liver tests (drug-induced liver injury) during highly active antiretroviral therapy, and in some studies, hepatitis C has been associated with lower CD4+ recoveries. The therapeutic standard of care is a combination of peginterferon and ribavirin at a fixed dose, 800 mg/day, although higher ribavirin doses may further improve virologic outcomes. In patients that do not respond virologically, maintenance therapy with peginterferon monotherapy is a potential avenue to stem the advance of liver fibrosis, although controlled data in coinfected patients are needed to issue formal recommendations.

Factors associated with seronegative chronic hepatitis C virus infection in HIV infection

BACKGROUND

Chronic seronegative hepatitis C virus (HCV) infection is defined as being HCV antibody (anti-HCV) negative, but HCV RNA positivity occurs in individuals infected with human immunodeficiency virus (HIV). However, associated factors are not well established because of the small number of reported cases.

METHODS

Multivariate logistic regression analysis of HIV-infected subjects from 4 cohorts (Tien et al., 2006; Bonacini et al., 2001; George et al., 2002; and Hall et al., 2004) determined factors associated with HCV RNA positivity in anti-HCV-negative subjects. HCV enzyme immunoassay 2.0 was used to determine anti-HCV status.

RESULTS

Among 1174 anti-HCV-negative, HIV-infected subjects, the prevalence of seronegative HCV infection was 3.2% (95% confidence interval [CI], 2.2%-4.3%). History of injection drug use (IDU; OR, 5.8; 95% CI, 2.7-12.8), higher alanine aminotransferase (ALT) level (OR, 2.0 per doubling; 95% CI, 1.3-3.2), and CD4 cell count <200 cells/ micro L (OR, 2.3; 95% CI, 1.1-4.8) were associated with HCV RNA positivity in anti-HCV-negative subjects. Among those with a history of IDU who had either a CD4 cell count <200 cells/ micro L or an ALT level greater than the upper limit of normal, the prevalence of seronegative HCV infection was 24% (95% CI, 13%-39%).

CONCLUSIONS

Detectable HCV RNA in the context of a negative HCV enzyme immunoassay 2.0 result in HIV-infected patients is low, but higher than the reported prevalence in HIV-uninfected patients. Our findings suggest that HCV RNA testing should be performed in anti-HCV-negative, HIV-infected patients, especially those with a history of IDU and either a CD4 cell count <200 cells/ micro L or an abnormal ALT level.

[HIV and HCV coinfection]

Chronic hepatitis due to hepatitis C virus (HCV) infection is now one of the leading causes of morbidity and mortality among HIV-infected individuals. Coinfected patients present an accelerated course toward cirrhosis and an enhanced risk of liver toxicity associated with the use of antiretroviral agents. Treatment of chronic hepatitis C in HIV1 patients is less efficacious than in HCV-monoinfected individuals and requires particular expertise.

Protective immunity against hepatitis C virus infection

There is increasing evidence that a small percentage of individuals exposed to the hepatitis C virus have the capacity to generate a strong cellular immune response against the virus and avoid persistent infection, and perhaps do so repeatedly after re-exposure. This article reviews the evidence that the responses identified in this unique group of individuals represent the protective immunity that will need to be elicited by hepatitis C virus vaccines.

Co-infection with HIV and hepatitis C virus in former plasma/blood donors: challenge for patient care in rural China

BACKGROUND

Illegal commercial plasma donation in the late 1980s and early 1990s caused blood-borne infections in China.

OBJECTIVES

To estimate the prevalence of HIV and hepatitis C virus (HCV) infections and to identify associated risk factors in central China with a history of illegal plasma collection activities.

DESIGN AND METHODS

A cross-sectional study was carried out in 2004, in which all adult residents in four villages in rural Shanxi Province were invited for a questionnaire interview and testing of HIV and HCV antibodies.

RESULTS

Of 3062 participating villagers, 29.5% reported a history of selling whole blood or plasma. HIV seropositivity was confirmed in 1.3% of subjects and 12.7% were HCV positive. Their co-infection rates were 1.1% among all study subjects, 85% among HIV-positive subjects, and 8.7% among HCV-positive subjects. Selling plasma [odds ratio (OR), 22.5; 95% confidence interval (CI), 16.1-31.7; P < 0.001] or blood (OR, 3.1; 95% CI, 2.3-4.2; P < 0.001) were independently associated with HIV and/or HCV infections. Although a spouse's history of selling plasma/blood was not associated with either infection, the HIV or HCV seropositivity of a spouse was significantly associated with HIV and/or HCV infections (both OR, 3.2; 95% CI, 2.0-5.2 in men, 2.0-4.9 in women; P < 0.001). For men, residence in the village with a prior illegal plasma collection center (OR, 2.5; 95% CI, 1.7-3.7; P < 0.001) and for women, older age (OR, 3.4; 95% CI, 1.2-14.0; P = 0.04) were associated with HIV and/or HCV infections.

CONCLUSIONS

HIV and HCV infections are now prevalent in these Chinese communities. HIV projects should consider screening and care for HCV co-infection.

HIV-related liver disease: infections versus drugs

HIV-infected individuals have myriad causes of hepatotoxicity that range from mild hepatitis to significant liver failure with its associated morbidity and mortality, especially in the setting of chronic viral hepatitis (HCV and HBV). Immune restoration by HAART therapy can contribute liver-related toxicity in HIV-coinfected patients. Clinicians need to be aware of this problem and individualize management in this challenging clinical scenario. Avoidance of potentially hepatotoxic agents or close monitoring during treatment of HIV may prevent liver failure in patients who have HIV. Furthermore, vaccination against hepatitis A virus and HBV in nonimmune HIV individuals may prevent acquisition of hepatitis A virus and HBV infections in patients who have HIV. Finally, treatment of HIV, and, if appropriate, treatment of those who are coinfected with HCV and HBV with close monitoring, may improve the outcome of patients who have HIV and are at risk fo r significant hepatotoxicity during treatment from immune restoration or hypersensitivity reactions.

Treatment algorithm for the management of hepatitis C in HIV-coinfected persons

In the era of highly effective antiretroviral therapy (ART), HCV-related liver disease has emerged as a significant cause of morbidity and mortality. Accordingly, expert panels have recommend that coinfected patients undergo medical evaluation for HCV-related liver disease, consideration for HCV treatment and, if indicated, orthotopic liver transplantation. While the treatment of such patients is complicated by medical, and psychiatric comorbidities, HIV disease, and concurrent antiretroviral therapy, randomized controlled trials support the safety, tolerability and efficacy of HCV treatment with peginterferon alfa (PEG-IFN) plus ribavirin (RBV) in HIV-infected persons. Although, the available data has led to consensus among experts regarding the need to medically manage HCV disease in HIV-infected persons, uncertainty remains regarding the best treatment algorithm for coinfected patients.

Severe erythema multiforme responding to interferon alfa

Erythema multiforme (EM) is a targetoid eruption with interface pathology often triggered by a hypersensitivity response to a variety of infections, most commonly herpes simplex virus. Hepatitis C virus is rarely associated with EM. We present a 37-year-old man with an 8-year history of severe EM unresponsive to valacyclovir, acitretin, and cyclosporin, and marginally responsive to high-dose prednisone. The eruption had cleared 6 years previously during treatment with interferon for his concurrent hepatitis C virus. Although his viral titer was undetectable, we initiated therapy with interferon and ribavirin. The patient responded dramatically within 2 months and remained clear of EM after 1 year of continued interferon therapy. This is the third case reported in the world literature documenting a response of EM to interferon, and the first case in which hepatitis C virus was undetectable in serum prior to interferon therapy.

New paradigms in the management of HIV and hepatitis C virus coinfection

PURPOSE OF REVIEW

Chronic hepatitis C virus infection is currently one of the leading causes of morbidity and mortality in HIV-infected individuals, mainly in hemophiliacs and intravenous drug users. The bidirectional interferences between hepatitis C virus and HIV have clinical consequences and complicate the management of coinfected individuals.

RECENT FINDINGS

There is an increased rate of liver complications among coinfected patients due to the decrease in opportunistic infections resulting from the use of potent antiretroviral therapy and accelerated progression to liver cirrhosis in the HIV setting. Conversely, the risk of hepatotoxicity of antiretrovirals is higher in the presence of chronic hepatitis C. While the standard therapy for hepatitis C in HIV is the combination of pegylated interferon plus ribavirin, overall treatment responses are lower in HIV-coinfected than in hepatitis C virus-monoinfected patients. Moreover, interactions between ribavirin and HIV drugs (i.e. didanosine, zidovudine) are associated with higher risks of side effects.

SUMMARY

Given the accelerated progression to end-stage liver disease in coinfected patients, treatment of hepatitis C should be a priority. While hepatitis C therapy should not be denied in the absence of contraindication, it should be re-assessed at week 12 and therapy continued only in patients showing more than 2 log drops in viremia, to avoid side effects. Most recent data suggest that adequate selection of candidates, expert management of side effects, and prescription of appropriate ribavirin doses (in genotypes 1-4) and extending treatment (in genotypes 2-3) all might allow response rates in coinfected patients to approach those seen in hepatitis C virus-monoinfected individuals.

Hepatitis C virus infection in HIV-infected patients

Because of shared routes of transmission, hepatitis C and HIV coinfection is common in the United States, affecting 15% to 30% of HIV-infected individuals. In the era of highly effective antiretroviral therapy, hepatitis C virus (HCV)-related liver disease has emerged as a significant cause of morbidity and mortality. Accordingly, the Infectious Diseases Society of America and the American Association for the Study of Liver Disease guidelines for the management of HCV recommend that patients with HIV/HCV undergo medical evaluation for HCV-related liver disease and consideration for HCV treatment and, if indicated, orthotopic liver transplantation. However, the treatment of patients with HIV/HCV is complicated by the relatively high prevalence of medical and psychiatric comorbidities and the challenges of anti-HCV therapy in the setting of HIV disease and antiretroviral therapy. Nonetheless, recently completed randomized controlled trials provide evidence of the safety, tolerability, and efficacy of HCV treatment with pegylated interferon-alpha plus ribavirin in HIV-infected individuals. This review focuses on the epidemiology, natural history, and management of HCV in the HIV-infected patient.

Effect of serostatus for hepatitis C virus on mortality among antiretrovirally naive HIV-positive patients

BACKGROUND

We examined the effect of hepatitis C virus (HCV) seropositivity on risk of death among people receiving their first antiretroviral treatment (ART) for HIV infection.

METHODS

In British Columbia, the HIV/ AIDS Drug Treatment Program is the only source of free ART. Patients who initiated a triple-drug ART regimen between July 31, 1996, and July 31, 2000, were included if they were ART-naive and had baseline HCV serological data. Outcomes of interest for survival analysis were deaths from natural and HIV-related causes, with a data cutoff of June 30, 2003.

RESULTS

Of 1186 eligible subjects, 606 (51%) were HCV positive and 580, negative. Fewer HCV-positive people were male (78% v. 93%, p < 0.001) and had an AIDS diagnosis at baseline (11% v. 15%, p = 0.028). Their CD4 fraction was significantly higher at baseline (19% v. 16% of T lymphocytes, p < 0.001) but their absolute CD4 counts, log HIV viral load and the type of ART initiated were similar to those of HCV negative people. Of 163 deaths (from natural causes only) during the study period, 118 (19%) were in HCV positive and 45 (8%) in HCV negative patients (p < 0.001); of the 114 deaths attributed to HIV infection, these proportions were 79 (13%) versus 35 (6%; p < 0.001). After adjustment for potential confounders, HCV seropositivity remained predictive of death (adjusted hazard ratio [HR] 2.20, 95% confidence interval [CI] 1.50- 3.21, p < 0.001), especially HIV-related death (adjusted HR 1.75, 95% CI 1.13- 2.72, p = 0.012).

INTERPRETATION

In this population-based HIV treatment program, we found HCV seropositivity to be an independent predictor of mortality, especially death related to HIV infection.

Treatment of hepatitis C virus in HIV patients: a review

BACKGROUND

Survival in HIV infection has improved dramatically in the last decade due to antiretroviral therapy (ART). Due to shared routes of transmission, HCV is found in approximately 30% of HIV infected patients. HCV infection has emerged as a major issue in this population as manifest by a major increase in liver-related mortality. ART-associated hepatotoxicity has been demonstrated to occur more frequently in co-infected individuals and may be severe or fatal in some instances. Thus treatment of HCV has become a priority in HIV infected individuals.

OBJECTIVES

The main aims of this review are to summarise and illustrate the current evidence based management of anti-HCV therapy in HIV-infected patients.

METHODS

A systematic review of the literature was performed using Pubmed and Medline searches.

CONCLUSION

All HIV-infected patients should be screened for HCV infection via anti-HCV antibody and HCV RNA polymerase chain reaction. If HCV infection is present, treatment should be considered in those patients with evidence of liver inflammation and fibrosis. Recent studies have demonstrated the safety and efficacy of anti-HCV therapy in HIV-infected individuals with pegylated interferon and ribavirin combination therapy. HCV genotype is predictive of response to therapy and increasing the duration of therapy to 48 weeks has proven to be more effective in patients with genotypes 2 and 3. HCV treatment with interferon based therapy is associated with many unique side effects and toxicities in this population of which the clinician must be aware.

Management and treatment of hepatitis C virus infection in HIV-infected adults: recommendations from the Veterans Affairs Hepatitis C Resource Center Program and National Hepatitis C Program Office

Nearly 40% of human immunodeficiency virus- (HIV-) infected veterans on highly active antiretroviral therapy (HAART) in the United States are coinfected with hepatitis C virus (HCV). With the increased survival due to declining opportunistic infections as a result of HAART, HCV-associated liver disease has become a leading cause of death in HIV-infected individuals. HCV infection has been shown to lead to rapid progression of HCV-related liver disease in HIV infection. Results from recent clinical trials in HIV/HCV-coinfected patients show improved response rates using pegylated formulations of interferon plus ribavirin when compared to standard interferon plus ribavirin. However, the treatment of HCV in HIV/HCV-coinfected patients can be complicated by the hepatotoxic and myelosuppressive effects of HIV therapy and HIV infection itself. Prior to initiating HCV therapy, HIV therapy should be optimized by improving immune suppression and avoiding specific antiretroviral drugs that may cause hepatotoxicity and myelosuppression. In the event of treatment-related neutropenia or anemia during HCV therapy, the use of growth factors should be considered to maximize sustained virologic response to HCV therapy. In HIV/HCV-coinfected patients with end-stage liver disease, liver transplantation is being investigated and shows promise as a potential therapeutic option. With the recent advances in the treatment of HCV in HIV/HCV-coinfected individuals, all HIV/HCV-coinfected patients eligible for HCV treatment should be evaluated for HCV combination therapy with careful consideration of their HIV disease.

Detection of hepatitis C virus RNA by in situ hybridization in paraformaldehyde fixed biopsies

Fourteen hepatitis C virus (HCV) chronically infected patients were submitted to routine liver biopsy for histological evaluation. Liver samples were assayed to HCV-RNA by in situ hybridization, using digoxigenin labeled probe. HCV genotypes were found to be predominantly type 1 (71.4%), followed by genotype 3 (21.4%), and genotype 2 (7.2%). Alanine-aminotransferase levels were raised in 10 patients. The histopathological scores were minimal (21.4%), mild (57.2%), and moderate (21.4%). Viral RNA was detected in liver cells from nine patients (64.3%). ISH method provides localization and poor confirmation of HCV RNA in the liver tissue of HCV chronic patients.

GB virus type C NS5A sequence polymorphisms: association with interferon susceptibility and inhibition of PKR-mediated eIF2alpha phosphorylation

GB virus type C (GBV-C) causes persistent infection in humans, although the mechanism by which the virus avoids clearance by the host is unknown. To determine if amino acid polymorphisms in the GB virus type C (GBV-C) NS5A and E2 proteins alter response to interferon (IFN) therapy, we studied the sequence of GBVC NS5A and E2 obtained from people receiving IFN therapy. In addition, we expressed recombinant GBVC NS5A protein to determine if it interferes with RNA-activated protein kinase (PKR) function in vitro. GBVC NS5A amplified from a person whose virus was cleared by IFN therapy (IFN sensitive) demonstrated unique amino acid changes occurring in the region that aligns with the hepatitis C virus (HCV) IFN sensitivity-determining region (ISDR) compared with NS5A sequences from individuals who did not clear GBV-C (IFN resistant). There were no differences in the E2 sequences obtained from IFN-sensitive and IFN-resistant isolates. Using a yeast genetic system, IFN-resistant NS5A inhibited PKR-mediated phosphorylation of eukaryotic initiation factor 2alpha (eIF2alpha) in yeast, whereas IFN-sensitive NS5A did not inhibit PKR function. GBV-C NS5A amino acid polymorphisms appear to be involved in response to IFN therapy, and IFN-resistant GBV-C NS5A inhibited PKR-mediated eIF2alpha phosphorylation in a yeast genetic system, suggesting a mechanism by which GBV-C may evade clearance by naturally occurring host antiviral responses.

Characterization of humoral and cell-mediated immune responses directed against hepatitis C virus F protein in subjects co-infected with hepatitis C virus and HIV-1

BACKGROUND

Hepatitis C virus (HCV) F protein is encoded in an alternate reading frame overlapping the core protein region. Its precise sequence, biological function and mode of expression are currently unclear. This study was conducted to examine the prevalence and characteristics of host humoral and cell-mediated immune responses directed against F protein in patients co-infected with HCV and HIV-1.

METHODS

Mutations were introduced to allow the expression of HCV-1a F protein in the absence of core. This recombinant and a truncated form lacking the first 11 amino acid residues shared with core were expressed in Escherichia coli, and their amino acid sequences were verified by mass spectrometry. Vaccinia-F protein recombinants were used to test F protein-specific cytotoxic T lymphocyte (CTL) activity. The binding of F protein-derived peptides to HLA-A*0201 was studied to identify putative CTL epitopes.

RESULTS

Sera from 23 of 39 patients infected with various HCV genotypes recognized the truncated form, including 13 of 25 subjects co-infected with HIV-1, indicative of antigenic crossreactivity and consistent with the conservation of F protein coding sequences between HCV genotypes. Crossreactive F protein-specific CTL precursors were detected in nine of 11 HCV-infected subjects, including seven of nine patients co-infected with HCV and HIV-1. Finally, three novel putative HLA-A*0201-restricted CTL epitopes were identified.

CONCLUSION

These results indicate that patients co-infected with HCV and HIV-1 can mount immunoglobulin and CTL responses directed against HCV F protein that are fully comparable in scope and magnitude with those observed in individuals infected with HCV alone.