AASLD: HCV Now an STD in New York

AASLD: HCV Now an STD in New York
By John Gever, Senior Editor, MedPage Today
Published: November 04, 2009
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner Earn CME/CE credit
for reading medical news
Action Points

* Explain to interested patients that hepatitis C virus is usually transmitted by sharing injection-drug needles but can be transmitted sexually.


* Explain that HCV causes chronic progressive liver disease if not controlled, eventually requiring transplant. Explain, too, that drugs are available to control the infection.


* Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered preliminary until published in a peer-reviewed journal.

BOSTON -- HIV-infected men in New York City are facing a new threat, researchers said here -- a new form of hepatitis C virus (HCV) that rapidly damages the liver and is transmitted primarily through sex with other men.

More than 50 cases of the new HCV have been seen in New York in recent months, all in men with HIV and most often involving receptive anal sex with other men, said Daniel Fierer, MD, of Mount Sinai School of Medicine in New York City, who called it "an epidemic."

Fierer spoke here at the annual meeting of the American Association for the Study of Liver Diseases (AASLD).

A case-control study of 21 of these men indicated that injection drug use -- normally the primary mode of HCV transmission -- is not how they contracted the new form, Fierer said.

"It really looks like a sexually transmitted infection," he told attendees.

In addition, liver biopsies from 30 cases, taken a median of 4.4 months after the first sign of acute infection, found that 77% had substantial fibrosis (stage 2-3).

Fierer said the men generally lacked the usual risk factors for liver fibrosis, such as heavy drinking, chronic hepatitis B infection, or evidence of prior liver problems.

Such rapid onset of fibrosis has never been seen with HCV infection in the absence of HIV, he added.

"The good news is that the SVR [sustained virological response] rate in our hands is 75%, and perhaps better if treated sooner," he said.

In 16 cases treated with pegylated interferon-alfa (Pegasys, PEGIntron) and ribavirin (Rebetol) evaluable for SVR, four failed to achieve it.

Of the four, Fierer said, one failed to respond to treatment, two had viral breakthrough while on therapy, and one relapsed after a full course of treatment.

He said the rapid fibrosis meant this infection was "very worrisome" for patients who don't receive early treatment or who fail to respond to it.

Nearly all of the 50 New York cases genotyped so far involved HCV type 1, but one was found to be type 3a and four were 1b.

Fierer said the cases were identified as acute HCV on the basis of seroconversion, alanine aminotransferase levels at least five times the upper limit of normal, and HCV viral loads varying by at least ten-fold in one month.

Just over half the cases seen to date were in whites. Patients' median duration of HIV infection was seven years (range 0 to 20) with median CD4 cell count of 471 per μL. About one-quarter had never received antiretroviral drugs.

The case-control study, which involved detailed interviews on sexual history and drug use, found several factors more common among those with the novel infection:

* Unprotected receptive anal sex, with (P=0.04) or without ejaculation (P=0.03)
* Unprotected receptive oral sex with ejaculation (P=0.03)
* Use of sex toys (P=0.03)
* Having sex while high (P=0.01)
* Use of marijuana (P=0.04)

Controls in the study were an equal number of HIV-infected men who have sex with men but who did not have HCV coinfection. They were matched to cases by ethnicity, duration of HIV infection, CD4 count, and HIV viral load.

Fierer said use of injection drugs and sharing drug implements were not significantly increased in the cases versus controls, nor were rates of reported insertive sex.

Scott Friedman, MD, president of AASLD, commented that most cases of HCV are usually detected in the chronic phase, often years after the initial infection.

"This is a very unusual presentation" in the New York cases, said Friedman, a hepatologist at Mount Sinai.

"It's very clear ... that there is something different about this epidemic," he said, adding that similar cases have been seen in Australia and Europe.

The rapid fibrosis, he added, "is astounding to me, and a fact that I think merits a lot of scientific scrutiny because there's clearly something very different about either the immunologic milieu or the fibrotic response of these coinfected livers that makes fibrosis run rampant."

No external funding for the study was reported.

Fierer and co-authors reported no potential conflicts of interest.

Friedman reported relationships with Exalenz, sanofi-aventis, Axcan, Angion, Intercept, 7TM, Stromedix, and Celera.

Primary source: Hepatology
Source reference:
Fierer D, et al "Characterization of an epidemic of sexually-transmitted acute hepatitis C infection in HIV-infected men in New York City" Hepatology 2009; 50: 342A-343A.