Hepatitis C Twice for HIV+ Gay Men

posted: 16/03/2011

Just over one-quarter of gay men with HIV cured of early stage hepatitis C in Amsterdam got it again within two years. The men got hepatitis C from different people the second time.
 

10 times more reinfection – better prevention needed
The hepatitis C reinfection rate among these Amsterdam HIV positive men is ten times higher than the rate they of first hepatitis C infection among men with HIV.
 

It is clear that much better health promotion work is needed if men are to avoid reinfection with hepatitis C.
 

Sexually transmission of hepatitis C among gay and bisexual men happens widely especially in cities like Manchester, Brighton, London, Amsterdam, Berlin, as well as in North America and Australia.
 

Sex risks and networks
Various explanations have been offered for the greater vulnerability of men with HIV infection, including chosing sexual partners who also have HIV (called sero-sorting), and networks of sexual partners where many of the men have HIV. However it is the sexual and drug-using practices which affects who gets hepatitis C.
 

Heptatitis C reinfection
Researchers from Amsterdam Academic Medical Centre and the Amsterdam Public Health Service reported HIV+ men reinfected after being successfully treated for hepatitis C.
Twenty-eight men were successfully treated. Two men relapsed and hepatitis C reappeared within two months of the end of their hepatitis C treatment. Of the remaining 26 men, 7 were reinfected within two years, an incidence of 19.6 per 100 person years of follow-up. The time to reinfection was typically one year but could be much sooner.
 

Different type of hepatitis C
In every man reinfected they had a different genetic version of hepatitis C - three who first had genotype 4 then got genotype 1, while two men who started with genotype 1 get genotype 4 the second time. One man got genotype 1 again but even this was from a different clade, a different subtype.
 

Better prevention
The researchers say that discussion about prevention measures needs to take place not only at the time of diagnosis, but during and after treatment.
In particular men need to understand all the possible sexual and drug sharing transmission routes, and must to feel free to have frank discussions with doctors about sexual practices, drug-using behaviour and other risk factors. Too many HIV positive men with hepatitis C feel unable to talk freely because they feel judged, shamed and blamed by their HIV clinic.
 

Keep testing
Regular HCV testing in previously-treated individuals is also essential. We reported recently that while around 8% of gay and bi men with HIV in the UK have hepatitis C, one quarter of positive gay men were not checked for this in 2008, when every person with HIV should be checked at least once a year.

A German study showed similar reinfection among HIV-positive men. 22% became reinfected within six years, despite the number of first hepatitis C infections in Germany falling. 

Treatment of acute hepatitis C infection with pegylated interferon and ribavirin prevents early HIV infection progressing to chronic infection, which is harder to treat in HIV-positive people.
European guidelines on treatment of acute hepatitis C infection note that HIV-positive patients have a good response rate to treatment begun within a year of infection.

Source  with reference

Hep C - relapsed or reinfected?

posted: 29/10/2009

About a third of HIV-positive people who have both hepatitis C and HIV relapse (become ill again) after being treated for hepatitis C. Gay men and people who have ever injected drugs are more likely to have hepatitis C than other people with HIV.

Cure possible, but different strains, relapses and reinfections

Unlike HIV, hepatitis C can be cured. It is treated with two drugs taken together, pegylated interferon and ribavirin. How long you need treatment for depends on which strain of hepatitis C you have. If you have the harder-to-treat genotypes 1 and 4, you need 48 weeks of treatment, but people with genotypes 2 and 3 usually have half this - 24 weeks treatment.
 

Undetectable hepatitis viral load?

Hepatitis C treatment aims for an undetectable hepatitis C viral load. There are two checks to see if it has worked, once at the end of treatment, and 6 months after treatment ended. If hepatitis is still undetectable after 6 months they call this a sustained virological response, and this is considered to be a cure.

1 in 3 success for people with HIV, but a relapse awaits 1 in 3
But only about a third of people with HIV who have had hepatitis C for a while are 'cured' in this way(a cure is more likely if you start hepatitis treatment soon after getting hepatitis C).

But now researchers have found that about a third of the people who are ‘cured’ of hepatitis C after 6 months find hepatitis C reappears later – they have a relapse. People without HIV, but with hepatitis C don’t normally have this relapse problem.

Researchers checked to see if people had really relapsed or whether they had got hepatitis C from someone else. Nearly all the people had a genuine relapse, although two seem to have been reinfected. But we know from a study in London that many HIV-positive gay men who have a hepatitis C ‘relapse’ had in fact been reinfected.

Reinfection a common risk
In the London study which looked at relapsing gay men, of 211 HIV/hepatitis C coinfected men, 16 got hepatitis C again after successful treatment. Looking at the relapsing men, almost all had yet another sexually transmitted infection at the same time - usually syphilis (ten cases), but also gonorrhoea (six cases) and herpes (three cases).

Last year, Dr Mark Nelson, of the Chelsea & Westminster told the August/September issue of HTU Treatment Update that he finds syphilis and lymphogranuloma venereum (LGV) in many of his patients with hepatitis C, and both of them “make HIV and hepatitis C transmission even more likely.”

Positive gay men need better information

He added that the continued sexual transmission of hepatitis C amongst HIV-positive men “underlines the importance of safer sex messages for HIV-positive men. Some men are having condomless sex because they think that they won’t pass on HIV to someone who already has HIV, or if they have an ‘undetectable’ viral load for HIV, they can’t pass on HIV to anyone. But it does seem they’re passing on—and getting—hepatitis C.”

Dr Jones suggests that healthcare providers are “failing our patients,” since they are becoming infected with hepatitis C not once, but multiple times. Since the paper was published two of the men who had been treated for a second episode of acute hepatitis C had become reinfected for a third time. “We need a much stronger public health information and screening programme” for hepatitis C, she said.

Source aidsmap 
 

HIV Superinfection - Not Likely

posted: 27/01/2009

Researchers in America have found no evidence that unprotected sex between people with HIV who are regular partners leads to superinfection with another strain of the HIV virus. They used a long-term study involving 49 people with HIV. No evidence of superinfection was found.

Superinfection and reinfection mean much the same thing and some hyping up of reports happens. Superinfection is reinfection with another strain of HIV, that harms health. Most HIV reinfection causes no apparent harm. Studies show that about 1 in 20 people with HIV who are checked for reinfection for one year show signs of this, so reinfection itself is fairly common. One of these studies was of gay men, the other of women in Kenya. There have been claims in 30-40 case reports of actual superinfection around the globe.

Instead of damage by superinfection, this study found a clear relationship between long-term frequent exposure to their partner’s virus and a strong immune response to that virus, suggesting that repeated exposure eventually builds immunity against superinfection, which is good news.

What harm can superinfection cause?

There’s been a lot of debate about whether unprotected sex between people with HIV can lead to superinfection with the virus. People with HIV are frequently advised not to have unprotected sex even with other HIV-positive people because of a risk of superinfection. Superinfection is reinfection with different HIV, from someone else, that goes bad and damages health. The damage to health is that treatment can get more complicated because the other person's HIV may carry drug resistance, and people may get infected with a more aggressive strain of HIV.

HIV can transmit with it drug resistance even if the person passing it on has never taken any HIV treatment, because the person who had infected them gave them HIV which had some drug resistance.

Aggressive and drug-resistant HIV

Some of the reported cases of superinfection have involved infection with more aggressive or drug-resistant strains of HIV. But this hasn’t always been the case – other documented cases of superinfection don’t seem to have done any harm. So researchers in San Francisco wanted to get a better understanding of the long-term risks of superinfection. What they found makes much clearer the risks of people living with HIV having unprotected sex together. Is there enough evidence of superinfection now to reasonably advise positive people to use condoms when having sex with another person living with HIV?
 

The study looked at changes in the immune system and HIV of 49 people with HIV. All the participants were taking HIV treatment and had an undetectable viral load. All 49 people had HIV-positive partners with whom they were having unprotected sex. The researchers divided the people in the study into two groups, those with partners who had a detectable (20) viral load, and those with partners with an undetectable (29) viral load.

Gay men studied

All 49 are gay men, a fact that is buried deep in the report. George House Trust suspects this is only due to the funding-threat Bush has cast over much HIV research and care for groups of people who are targets of US Christian conservatives' abhorence. Research into protective gels for anal sex has long been held back for the same reason. The early indications are that the new president is moving swiftly to end discrimination around HIV funding. 

Partners show strong immune response

The study found no evidence that any of the 49 men had been infected with another strain of HIV. Instead, they found that men who were exposed to their partner’s HIV developed a strong immune response to it. The men's immune systems were working well and seem to be preventing health damage from the partner's HIV.

Risks now much clearer

This study is important because it makes the risks of superinfection much clearer for the many people with HIV who choose to have unprotected sex with HIV-positive partners, which is known as sero-sorting.

The findings suggest that even where an individual has drug-resistant virus and a detectable viral load, the risks of superinfecting an HIV-positive partner with that drug-resistant virus are low, even for sexually receptive partners (receptive partners are at more risk than insertive ones).

What about people with more partners?

The findings provide no information about what happens if an individual with HIV has sex with many different partners with HIV (because the study only looked at HIV positive gay men and their regular positive partner), but the study’s lead author Chris Willberg, now of the Biomedical Research Centre at the University of Oxford, told aidsmap: “We would speculate that it is regular exposure to the same epitopes that is required to stimulate the responses. What we did not explore is the ability for new [epitope] responses to be developed through exposure.”

George House Trust takes that as a meaningful 'perhaps not, but we didn't study that' because there's evidence (from a study of Nairobi sex workers referred to in the aidsmap article) that superinfection is more likely if the sex is with many positive partners rather than just one.

And because the risks for transmission of HIV are always highest being receptive in anal sex, and then run in this order: being insertive in anal sex, being a woman in heterosexual vaginal sex, being a man in heterosexual vaginal sex, this means gay men who have multiple positive partners take rather more risk of superinfection than the Nairobi women sex workers.

And as the number of positive partners rises, the greater the risk.

It needs another study to answer the 'is there a risk of superinfection with multiple partners' question, and a scientific study seems very difficult to arrange. This is because casual partners cannot be identified in advance; some will have undetectable viral loads but others won't, and this means the numbers needed for such a study would have to be huge; obtaining agreement to take part from many casual partners doesn't seem possible; and some partners would be uncontactable, or refuse to take part. We can't realistically expect to see any scientific answer soon for people who want information now on the risks with multiple partners.

Low risk with more partners seems likely

It's inevitable that some people will speculate and want an informed view, following this reassuring superinfection study. Considering the evidence in the studies, how the body responds, and especially how few cases (just 30-40) have been reported from around the globe, one reasonable view is the risks are low of having much poorer health through superinfection resulting from unprotected sex with multiple partners, even if the partners have detectable viral loads.

This is because sero-sorting with multiple partners among gay men living with HIV is fairly common and has been happening for some years, and if superinfection damage was common, we would be having far more case reports from around the world. Superinfection is big news, so case reports are likely whenever serious problems occur.

However each person needs to make their own decisions on which risks to take when science can't give us an answer. People living with HIV interested in this should discuss with the doctor their advice and interpretation of the evidence. Then make their own decision.

More risk

If the person's health is not so good, exposing the immune system to even more stress from different people's HIV is rather more risky and the health damage could be more significant.   

The far more serious risk from unprotected sex with multiple partners for most positive gay men (whether or not the partners have HIV) is of other STIs. LGV, syphilis, and hepatitis C are particularly likely and harzardous to health when men with more partners already have HIV. Our advisers are always willing to discuss levels of risk and how men can keep these within limits that are comfortable while having a satisfying sex-life, without judging what men do or any associated drug use.

Women too

Aidsmap also asked the study's leading author a really important question many positive women and their partners need answering - do positive women have the same low risk of superinfection from a positive partner as men?

His reply means 'as long as things work in the same way for women, and this looks very likely,' which women and their partners will welcome, but he unhelpfully cloaks this in a long scientific answer: “The most logical explanation for the maintained responses that we observed is that they were driven by receptive exposure to HIV antigen derived from the viremic partner,” Chris Willberg commented. “Therefore, we would expect to see the same results in women also receptively exposed to viremic partners. If the mechanisms responsible for driving the responses in this study are the same as those that drive responses in exposed uninfected individuals, then there is plenty of evidence to suggest women would respond in a similar manner.”

We think 2/10 would be a fair mark for 'ability to communicate' with HIV positive women (and partners), who deserve a clear answer to this plain question. The scientific explanation is exact and complex, yet the actual answer disguised by all these words is clear - but only after repeated reading. Researchers need to make much better efforts to communicate plainly in everyday language the important lessons of their research and expertise, because the public ultimately fund most of the work carried out for our benefit. 17 words give the same answer, but plainly, as over 80.

Other risks - including STIs and pregnancy - remain

For both women and men, unprotected sex can have other health consequences. In the UK, LGV and syphilis are seen much more often in HIV-positive gay men, clearly due to unprotected sex. What’s more, unprotected sex between HIV-positive gay men is also linked to sexual transmission of hepatitis C virus.

Women may also expose themselves to the range of sexually transmitted infections and may become pregnant as a result of unprotected sex. A positive woman wanting to have a baby should talk first with her HIV doctor about when and how best to become pregnant and the ways of minimising the risk of having a positive child. With the right care and treatment this risk is now very low, about 1 in 100.

Further information and reference from aidsmap

The free online journal article