The influence of HTLV-III infection on the natural history of hepatitis B virus infection in male homosexual HBsAg carriers

Low Prevalence of Hepatitis B Vaccination Among Patients Receiving Medical Care for HIV Infection in the United States, 2009 to 2012

BACKGROUND

Persons with HIV infection are at increased risk for hepatitis B virus infection. In 2016, the World Health Organization resolved to eliminate hepatitis B as a public health threat by 2030.

OBJECTIVE

To estimate the prevalence of hepatitis B vaccination among U.S. patients receiving medical care for HIV infection ("HIV patients").

DESIGN

Nationally representative cross-sectional survey.

SETTING

United States.

PARTICIPANTS

18 089 adults receiving HIV medical care who participated in the Medical Monitoring Project during 2009 to 2012.

MEASUREMENTS

Primary outcomes were prevalence of 1) no documentation of hepatitis B vaccination or laboratory evidence of immunity or infection (candidates to initiate vaccination), and 2) initiation of vaccination among candidates, defined as documentation of at least 1 vaccine dose in a 1-year surveillance period during which patients received ongoing HIV medical care.

RESULTS

At the beginning of the surveillance period, 44.2% (95% CI, 42.2% to 46.2%) of U.S. HIV patients were candidates to initiate vaccination. By the end of the surveillance period, 9.6% (CI, 8.4% to 10.8%) of candidates were vaccinated, 7.5% (CI, 6.4% to 8.6%) had no documented vaccination but had documented infection or immunity, and 82.9% (CI, 81.1% to 84.7%) remained candidates. Among patients at facilities funded by the Ryan White HIV/AIDS Program (RWHAP), 12.5% (CI, 11.1% to 13.9%) were vaccinated during the surveillance period versus 3.7% (CI, 2.6% to 4.7%) at facilities not funded by RWHAP. At the end of surveillance, 36.7% (CI, 34.4% to 38.9%) of HIV patients were candidates to initiate vaccination.

LIMITATION

The study was not designed to describe vaccine series completion or actual prevalence of immunity.

CONCLUSION

More than one third of U.S. HIV patients had missed opportunities to initiate hepatitis B vaccination. Meeting goals for hepatitis B elimination will require increased vaccination of HIV patients in all practice settings, particularly at facilities not funded by RWHAP.

PRIMARY FUNDING SOURCE

Centers for Disease Control and Prevention.

Chronic Hepatitis B, C, and D

Chronic hepatitis B, C, and D virus infections contribute significantly to the morbidity and mortality of immunocompromised individuals. To contextualize discussion of these infections in immunocompromised patients, this paper provides an overview of aspects of infection in normal hosts. It then describes differences in disease, diagnostic testing, and therapeutic management observed in immunocompromised patients.

Human immunodeficiency virus coinfection with hepatitis B virus leads to a decrease in extracellular and intracellular hepatitis B antigen

Chronic hepatitis B virus (HBV) infection could cause severe liver disease including cirrhosis, hepatocellular carcinoma, and end-stage liver failure in HIV-positive individuals. The available data from clinical studies suggest that HIV infection modulates the HBV-specific T cell response. However, the virological and molecular aspects of HIV-HBV coinfection are currently poorly understood due to the lack of appropriate model systems. In this study, the effect of HIV infection on the life cycle of HBV was explored using an in vitro model system. The present data show that the extracellular and intracellular hepatitis B surface antigen (HBsAg) and e antigen (HBeAg) decrease significantly in HepG2 cells cotransfected with HIV NL4-3 and pHBV1.3 as compared to those cells transfected only with pHBV1.3. Moreover, a significant decrease in HBV DNA and mRNA expression was also observed in the cotransfected cells. HIV Rev protein, an RNA-bound regulatory protein, could significantly decrease the expression levels of extracellular and intracellular HBsAg and HBeAg by mediating the expression of HBV mRNA in cells cotransfected with plasmids containing HIV-1 Rev and pHBV1.3. Further experiments demonstrate that HIV Rev manipulated neither the promoters of HBV nor the nuclear export of HBV mRNA. These results from the in vitro model system might provide clues to further understand the rapid progression of liver disease in HIV-HBV-coinfected patients.

Management of HIV and hepatitis virus coinfection

IMPORTANCE OF THE FIELD

Liver disease related to infection with hepatitis C virus (HCV) and/or hepatitis B virus (HBV) is a frequent cause of morbidity and mortality in those infected with the human immunodeficiency virus (HIV) in this era of highly active antiretroviral therapy (HAART). Although progress has been made in the treatment of HBV and HCV in the setting of HIV-coinfection, there is a lack of data in certain areas and several aspects of the management are unclear at this time.

AREAS COVERED IN THIS REVIEW

Available data on the treatment of HBV and HCV infections, especially in the HIV-coinfected patient, are presented. Practical aspects of the management of these patients are reviewed, including diagnosis, treatment indications, monitoring, and toxicities. The impact of HAART on liver disease, end-stage-liver disease, and new therapeutic approaches are also reviewed.

WHAT THE READER WILL GAIN

There are two modalities for the treatment of chronic HBV infection: interferon and nucleos(t)ide reverse transcriptase inhibitors (NRTI). The latter is the mainstream of therapy for HIV-HBV-coinfected patients. The double antiviral activity of NRTI requires coordination and careful selection of treatment for both viruses to avoid selection of resistance mutations and toxicity. Combination of pegylated interferon and ribavirin, the current standard treatment for chronic hepatitis C, has significant toxicity and limited efficacy in HIV-HCV-coinfected individuals. Oral anti-HCV treatments are currently under development and need to be studied in the HIV-coinfected population. Liver transplantation has a better outcome in HBV- than in HCV-HIV-coinfected patients. HAART seems to have a positive impact on the liver disease of HBV- and/or HCV-coinfected subjects but the CD4 threshold above which the benefit might take place is unknown at this time.

TAKE HOME MESSAGE

Anti-HBV treatment in the HIV-coinfected patient relies on the available NRTIs with activity against both viruses. Whereas HBV suppression can be achieved with this approach, toxicities and the selection of HBV-resistant variants result in challenging clinical scenarios. Current anti-HCV treatment (pegylated interferon and ribavirin) has limited efficacy in the HIV-coinfected patient, and STAT-C drugs are eagerly awaited.

Treatment of hepatitis B in decompensated liver cirrhosis

Chronic hepatitis B infection progresses from an asymptomatic persistently infected state to chronic hepatitis, cirrhosis, decompensated liver disease, and/or hepatocellular carcinoma. About 3% of patients with chronic hepatitis develop cirrhosis yearly, and about 5% of individuals with hepatitis B cirrhosis become decompensated annually. The outcome for patients with decompensated cirrhosis is bleak. Lamivudine, the first oral antiviral agent available for hepatitis B treatment is safe and effective and can improve or stabilize liver disease in patients with advanced cirrhosis and viraemia. Viral resistance restricts its prolonged use. Entecavir and tenofovir are newer agents with excellent resistance profile to date. These and some other antiviral agents are being investigated for optimal use in this rather challenging patient group.

Hepatitis B and human immunodeficiency virus coinfection

Coinfection with human immunodeficiency virus-1 (HIV) and hepatitis B virus (HBV) is common; worldwide, an estimated 10% of HIV-infected persons have chronic hepatitis B. Because the incidence of traditional acquired immunodeficiency syndrome-related opportunistic infections has decreased with successful anti-HIV therapy, liver disease has emerged as a leading cause of morbidity and mortality in HIV-infected individuals. HIV infection negatively impacts all phases of the natural history of hepatitis B leading to increased rates of persistent infection, higher HBV DNA levels, lower rates of hepatitis B e antigen loss, increased cirrhosis and liver-related mortality, and increased risk of hepatocellular carcinoma at lower CD4+ T cell counts. The management of hepatitis B in HIV infection is complicated by the dual activity of several nucleoside analogs, the more rapid development of lamivudine-resistant HBV in patients who are HIV-positive, and the paucity of studies in this population. Until further research emerges on the optimal treatment for this population, data from HBV monoinfected persons will need to be extrapolated to the HIV-HBV coinfected population. Further research is also needed to determine the mechanism(s) for the increased liver disease progression and optimal treatment goals.

Hepatitis A, B and C viral co-infections among HIV-infected adults presenting for care and treatment at Muhimbili National Hospital in Dar es Salaam, Tanzania

Background

Tanzania is currently scaling-up access to anti-retro viral therapy (ART) to reach as many eligible persons as possible. Hepatitis viral co-infections are known to influence progression, management as well as outcome of HIV infection. However, information is scarce regarding the prevalence and predictors of viral hepatitis co-infection among HIV-infected individuals presenting at the HIV care and treatment clinics in the country.

Methods

A cross-sectional study conducted between April and September 2006 enrolled 260 HIV-1 infected, HAART naïve patients aged ≥18 years presenting at the HIV care and treatment clinic (CTC) of the Muhimbili National Hospital (MNH). The evaluation included clinical assessment and determination of CD4+ T-lymphocyte count, serum transaminases and serology for Hepatitis A, B and C markers by ELISA.

Results

The prevalence of anti HAV IgM, HBsAg, anti-HBc IgM and anti-HCV IgG antibodies were 3.1%, 17.3%, 2.3% and 18.1%, respectively. Dual co-infection with HBV and HCV occurred in 10 individuals (3.9%), while that of HAV and HBV was detected in two subjects (0.8%). None of the patients had all the three hepatitis viruses. Most patients (81.1%) with hepatitis co-infection neither had specific clinical features nor raised serum transaminases. History of blood transfusion and jaundice were independent predictors for HBsAg and anti-HBc IgM positivity, respectively.

Conclusion

There is high prevalence of markers for hepatitis B and C infections among HIV infected patients seeking care and treatment at MNH. Clinical features and a raise in serum alanine aminotransferase were of limited predictive values for the viral co-infections. Efforts to scale up HAART should also address co-infections with Hepatitis B and C viruses.

Current treatment of HIV/hepatitis B virus coinfection

Coinfection with HIV and hepatitis B virus (HBV) has become a significant global health problem. Liver disease is now one of the leading causes of morbidity and mortality in individuals with HIV, particularly those with viral hepatitis. There are a number of agents available with dual activity against HIV and HBV, and effective treatment depends on understanding the potential advantages and pitfalls in using these agents. There are a number of unresolved issues in the management of HIV/HBV coinfection. These include the role of liver biopsy, the significance of normal aminotransferase levels, serum HBV DNA threshold for treatment, treatment end-points, and the treatment of HBV when HIV does not yet require treatment. Treatment of HBV should be considered in individuals with HIV/HBV coinfection with evidence of significant fibrosis (>/=F2), or with elevated serum HBV DNA levels (>2000 IU/mL). Sustained suppression of serum HBV DNA to below the level of detection by the most sensitive available assay should be the goal of therapy, and, at present, treatment of HBV in HIV/HBV coinfection is lifelong. If antiretroviral therapy is required, then two agents with anti-HBV activity should be incorporated into the regimen. If antiretroviral therapy is not required, then the options are pegylated interferon, adefovir or the early introduction of antiretroviral therapy. Close monitoring is necessary to detect treatment failure or hepatic flares, such as immune reconstitution disease. Further studies of newer anti-HBV agents in individuals HIV/HBV coinfection may advance treatment of this important condition.

Understanding the pathogenesis and management of hepatitis B/HIV and hepatitis B/hepatitis C virus coinfection

The approach to the hepatitis B virus (HBV)-infected patient who is also infected with HIV or hepatitis C virus (HCV) is very different from the approach to the patient with only one virus infection. HBV/HIV coinfection is common. Agents that have dual activity against HBV and HIV should be considered as treatment of choice in combination regimens in HBV/HIV-coinfected patients beginning antiretroviral therapy. In HBV/HCV coinfection HCV usually tends to predominate over HBV. More investigation is needed into the mechanisms by which viral pathogenesis is altered and the optimal treatment modalities for coinfected patients.

Hepatitis B in the HIV-Coinfected Patient

HIV and hepatitis B virus (HBV) infection share transmission patterns and risk factors; therefore, it is not surprising that the prevalence of chronic HBV infection is elevated among HIV-infected persons. HBV does not significantly affect the course of HIV disease, but HIV does alter the course of HBV. HIV-infected persons are less likely to clear acute HBV infection spontaneously, and HIV/HBV-coinfected persons face a higher risk of liver-related death than those monoinfected with either virus. The immune restoration associated with highly active antiretroviral therapy (HAART) can improve control of HBV replication but can also lead to increased immune-mediated liver injury. On balance, use of HAART before severe immunosuppression develops may be beneficial. Still, the complexity of HBV, HIV, and HAART interactions must be evaluated for each individual. There is a dearth of high-quality evidence about management of coinfected patients. A recent consensus conference has issued recommendations. HBV DNA thresholds for starting anti-HBV therapy are the same in coinfected and HBV-monoinfected patients. Continuing drugs with anti-HBV activity is important, because stopping such therapy has been associated with HBV reactivation. Development of resistance is a risk with the long-term maintenance therapy required in most patients.

Natural history of chronic hepatitis B in co-infected patients

HIV co-infection influences the course and natural history of hepatitis B virus (HBV) infection by impairing the quantity and quality of the innate and adaptive immune response. The rates of spontaneous resolution after acute infection and spontaneous anti-HBe and anti-HBs seroconversions are decreased, and levels of HBV replication are increased in HIV-infected patients. A more rapid progression of liver fibrosis and a higher rate of cirrhosis decompensation (but not hepatocellular carcinoma) have been demonstrated in co-infected patients. The risk of HBV-associated end-stage liver disease and liver-related mortality may be increased by HIV co-infection. Antiretroviral therapy may trigger spontaneous anti-HBe and anti-HBs seroconversion and/or a better immune control of HBV replication by restoring adaptive immunity, but can also increase hepatitis flares. Reactivation of chronic hepatitis B has been observed after suspension of anti-retrovirals with anti-HBV activity or after occurrence of HBV resistance to lamivudine. Future research should focus on: the impact of HIV-induced changes in innate and adaptive immune response and modifications induced by anti-retroviral therapy that may impact on progression of advanced chronic hepatitis B; the association between HBV genotype and clinical course of disease; and the role of occult HBV infection as a co-factor with other causes of liver injury.

Occult hepatitis B in HIV-infected patients

Prevalence of hepatitis B virus (HBV) markers, including occult HBV, has not been described in diverse cohorts among HIV-infected patients. The objective of this study was to assess prevalence and significance of active and occult HBV infection in an HIV-positive US cohort. A random sample was taken from 2 prospective multicenter treatment intervention cohorts. The sample population (n = 240) was HIV-1 infected and highly active antiretroviral therapy-naive. Prevalence of HBV serologic markers and quantitative HBV DNA were determined. Serum alanine aminotransferase (ALT) levels were measured to evaluate correlates of hepatocyte injury. A total of 64.6% of subjects demonstrated reactivity for any marker of current or past HBV infection or prior vaccination. Chronic HBV infection characterized by hepatitis B surface antigen (HBsAg) reactivity was present in 7.1% while 15.8% exhibited HB anticore IgG only. Approximately 10% of the latter group was HBV DNA positive by a polymerase chain reaction-based assay. Only patients with a serologic pattern of HBsAg or HB anticore alone reactivity had HBV DNA. Occult HBV was observed in approximately 10% of HIV-infected patients with HB anticore IgG antibody in a geographically representative national cohort. Though viral titers and serum ALT levels were low, screening of this subset of HIV-infected patients may have implications in terms of antiretroviral therapy and risk of immune reconstitution-associated flares.

Randomized trial of recombinant hepatitis B vaccine in HIV-infected adult patients comparing a standard dose to a double dose

Because HIV and hepatitis B virus share many common risk factors, it is important to try to vaccinate HIV patients against hepatitis B. There are numerous reports describing a variety of dose schedules, limited success and markers associated with impaired response to HBV vaccine in these individuals. All studies have been small in size making it difficult to draw conclusions within and between studies. The purpose of this study was to evaluate a double dose of hepatitis B vaccine under more definitive guidelines: double blinded, randomized, controlled, with numbers for statistical validity. Two hundred and ten HIV infected subjects received a standard dose (20 microg) or a double dose (40 microg) of recombinant hepatitis B vaccine IM 0, 1 and 6 months. Ninety-four receiving standard dose and 98 receiving double dose completed the study. The seroconversion rate (anti-HBs > or = 10 mIU/mL) was 47 and 34% for double dose and standard dose, respectively (p = 0.07). A statistically significant higher seroconversion rate was associated with double dose comparing with standard dose for patients with CD4 cell counts > or = 350 cells/mm3 (64.3% x 39.3%; p = 0.008) but made no difference to seroconversion in those with CD4 <350 (23.8% x 26.3%; p = 0.80). Double dose also improved seroconversion comparing with standard dose for patients with HIV viral load <10,000 copies/mL (58.3% x 37.3%; p = 0.01) but made no difference to seroconversion in those with HIV viral load > or = 10,000 copies/mL (16% x 17%; p = 0.7). Based on the results of this study, the best current strategy for hepatitis B vaccination in HIV patients would be to use a double dose as a primary series when the viral load is likely to be low and CD4> or = 350, when there is likely to be an adequate immune response.

Management of hepatitis B and C in HIV co-infected patients

Morbidity and mortality from co-morbid hepatitis B (HBV) and hepatitis C (HCV) infection in HIV co-infected patients are increasing; hence, the management of HIV and HBV or HCV co-infected individuals is now one of the most challenging clinical management issues. Less than 10% of all HIV-infected patients show markers of chronic HBV infection. Hepatitis B in HIV co-infected patients is characterized by high levels of HBV replication and a high risk for cirrhosis. Treatment of HBV with lamivudine (3TC) remains the best treatment option at this time. Initial results of studies of adefovir or tenofovir, however, demonstrate good antiretroviral efficacy, even in patients with 3TC-resistant HBV. In Europe, it is estimated that approximately 30% of HIV-infected individuals are co-infected with HCV. HIV accelerates HCV liver disease especially when HIV-associated immune deficiency progresses. Within 10-15 years of initial HCV infection, 15-25% of patients who are co-infected with HIV develop cirrhosis compared with 2-6% of patients without HIV infection. With the introduction of pegylated interferon in combination with ribavirin, promising treatment options have become available for HIV/HCV co-infected patients leading to early virological response rates of approximately 50%. The high number of HIV/HCV and HIV/HBV co-infections, as well as the much more unfavorable course of HBV and HCV in these patients, underlines the need to establish treatment strategies for HBV and HCV in HIV co-infected individuals.

Treatment of chronic hepatitis B in the human immunodeficiency virus-infected patient: present and future

The management of chronic hepatitis B poses specific problems in the presence of human immunodeficiency virus (HIV) coinfection, because therapeutic approaches have to address both hepatitis B virus (HBV) and HIV infections. Response to interferon (IFN-alpha) is lower in HBV-HIV-coinfected than in HIV-negative subjects, especially in patients in advanced stages of immunosuppression. Thus far, there are no data on the performance of the new pegylated forms of IFN-alpha in HBV- and HIV-coinfected persons. After prolonged use of lamivudine, resistance develops in the majority of HBV-HIV-coinfected patients treated with the drug. The more recently approved tenofovir has shown excellent short-term results, and data from longer follow-up studies are eagerly awaited. Several drugs with combined anti-HIV and anti-HBV activity have recently been approved (emtricitabine) or are currently under development. Preliminary results with some of them are quite promising and probably will widen the therapeutic armamentarium against hepatitis B in patients with HIV infection.

Prevalence and incidence of hepatitis B virus infection in STD clinic attendees in Pune, India

OBJECTIVES

To estimate the prevalence and incidence of hepatitis B virus (HBV) infection among patients attending three STD clinics in Pune, India, and to identify associated risk factors.

METHODS

Of the 2098 patients screened at STD clinics in Pune during 1996, 497, who returned for at least one follow up visit, were screened for various markers of HBV infection (HBsAg, anti-HBs, anti-HBc), HIV antibody, and VDRL.

RESULTS

Of the 497 participants 3.6%, 26.5%, and 43.2% were positive for HBsAg, anti-HBs, and anti-HBc respectively. Tattooing (AOR 1.64, 95% CI 1.03 to 2.64) was found to be independently associated with presence of core antibody. Additionally, history of being in commercial sex work and history of a genital ulcer were independently associated with a positive anti-HBc antibody test (AOR 12.45, 95% CI 5.58 to 27.82 and AOR 1.70, 95% CI 1.09 to 2.66, respectively). 72 out of 497 (14.5%) participants were HIV positive at baseline. HIV-1 antibody positive patients were more likely to have a positive anti-HBc test (69.4% v 39.0%, p<0.001). 30 out of 282 participants, negative for anti-HBc antibody at enrolment, seroconverted subsequently, resulting in an incidence of 10.86 per 100 person years (95% CI 7.2%, 14.5%) (mean and accumulated follow up of 11.7 months and 276.17 person years, respectively).

CONCLUSIONS

A high prevalence and incidence of HBV infection, seen in STD clinic attendees underscore the need to provide HBV vaccine to commercial sex workers and their clients in India.

Management of chronic viral hepatitis in HIV-infected patients: Spanish Consensus Conference. October 2000

Co-infection by human immunodeficiency virus and hepatitis B and C viruses is quite common because they share similar routes of transmission. The introduction of highly active antiretroviral therapy has significantly improved the life expectancy of HIV-infected patients in the last few years. However, chronic viral hepatitis represents an emerging cause of morbidity and mortality in this population, either as a result of end-stage liver disease or as a consequence of hepatotoxicity induced by antiretroviral drugs. The main goal of the Consensus Conference was to establish specific recommendations for the management of chronic viral hepatitis B and C in HIV-infected patients. The role of orthotopic liver transplantation for co-infected individuals with end-stage liver disease was also assessed.

Acute flares in chronic hepatitis B: the natural and unnatural history of an immunologically mediated liver disease

Acute flares in chronic hepatitis B are common and may be caused by a number of identifiable and potentially treatable factors. The common link for many of these exacerbation episodes is a change in the immunologic response to hepatitis B virus (HBV), and this may have no identifiable cause or be triggered by an increase in viral replication or genotypic change. It is important to keep in mind the clinical situations in which patients are at increased risk of reactivated infection and secondary exacerbations. Reactivation is frequently induced by medical treatments such as cancer chemotherapy, antirejection drugs used in organ transplantation, and corticosteroids. The immunologic flares that often result from sudden withdrawal of these medications can be life-threatening unless recognized and treated promptly with antivirals, and there is increasing experience that preemptive antiviral treatment can diminish their occurrence and improve the outcome. The experience with lamivudine and other nucleoside analogues has increased our understanding of the molecular events behind hepatitis flares that occur when chronic hepatitis B is treated with drugs that potently inhibit HBV DNA polymerase. However, not all flares are explainable by events related to HBV infection alone. Depending on the population studied, as many as 20%-30% of flares may be caused by infection with other hepatotropic viruses, and this situation may inhibit HBV replication. Proper understanding of the etiology and effective treatment of acute flares in chronic hepatitis B requires an appreciation of high-risk clinical situations, assessment of HBV replication status, and testing for other viruses when appropriate.

Hepatitis B and C virus co-infection and the risk for hepatotoxicity of highly active antiretroviral therapy in HIV-1 infection

OBJECTIVE

To investigate the risk of hepatotoxicity after initiation of protease inhibitor-containing highly active antiretroviral therapy (HAART) for HIV-1 infected patients with chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) co-infection.

DESIGN

Retrospective study with 394 HIV-1-infected patients initiating HAART at a single university clinic.

METHODS

Liver enzyme elevation (LEE) was defined as alanine aminotransferase or aspartate aminotransferase at least five times the upper limit of normal and an absolute increase of > 100 U/l. Relative risks for time to LEE were estimated using Cox proportional hazards models.

RESULTS

Of 394 patients 7% were hepatitis B surface antigen (HBsAg)-positive and 14% were anti-HCV-positive. Patients with chronic hepatitis had a higher risk for LEE compared with patients without co-infection: 37% versus 12% respectively. After adjustment for higher baseline transaminases, the presence of HBsAg or anti-HCV remained associated with an increased risk of LEE - relative risk 2.78 (95% confidence interval, 1.50-5.16) and 2.46 (95% confidence interval, 1.43-4.24) respectively. In patients with LEE, transaminases declined whether HAART was continued or modified. Of patients with chronic HBV infection 38% lost HBeAg or developed anti-HBe after initiation of HAART, and one seroconverted from HBsAg-positive to anti-HBs-positive. However, there was no clear relationship with LEE.

CONCLUSIONS

HIV-1-infected patients co-infected with HBV or HCV were at considerably higher risk of developing LEE when HAART was initiated compared with patients without co-infection, but it is usually not necessary to modify antiretroviral therapy.

Mortality for liver disease in patients with HIV infection: a cohort study

We undertook this study to assess the association between the various potential causes of liver disease in HIV-seropositive patients and mortality due to liver failure. Three hundred and eight in-hospital deaths were observed from 1987 to December 1995 in a prospectively followed cohort of 1894 HIV-seropositive patients. For each study subject, clinical data were evaluated to assess whether liver failure had substantially contributed to mortality. A case control study nested in the cohort was then performed, which compared demographic and clinical variables observed at enrollment and during follow-up between patients who died for liver disease as the main or concurrent cause of death (cases) and those who died as a result of illness related to AIDS or other causes (controls). Among 308 in-hospital deaths, liver failure was found the cause of death in 35 patients (12%); in 16 cases, it was the primary cause and in 19 cases it was concurrent. Multivariate analysis showed that in-hospital liver-disease-related mortality was independently associated with hepatitis B surface antigen reactivity (odds ratio [OR], 9; 95% confidence interval [CI], 3.8-21.7) and history of alcohol abuse (OR, 2.3; 95% CI, 1-5.2). Prevention and treatment of hepatitis B virus infection and alcohol intake are management priorities in HIV-seropositive patients.

Seroprevalence and risk factors of hepatitis B, hepatitis C, and human cytomegalovirus among HIV-infected and high-risk uninfected adolescents: findings of the REACH Study. Adolescent Medicine HIV/AIDS Research Network

BACKGROUND AND OBJECTIVES

In adolescents and young adults, multiple studies have identified sexual activity and behaviors as significant risk factors for acquiring both human cytomegalovirus (HCMV) and hepatitis B virus (HBV). However, there are no reports on the prevalence or risk factors for infection of these viruses and hepatitis C virus (HCV) in an adolescent population with sexually acquired HIV.

GOALS

To examine the seroprevalence and risk factors of HBV, HCV, and HCMV infection in a population of HIV-infected male and female adolescents and in an age- and risk behavior-matched HIV-uninfected cohort.

STUDY DESIGN

A cross-sectional analysis of HBV, HCV, and HCMV infections in a cohort of HIV-infected and HIV-uninfected adolescents.

RESULTS

Adolescent males infected with HIV were more likely to have evidence of HBV and HCMV infection than HIV-uninfected males (23.7% versus 0%, respectively, for HBV, P = 0.008; 79.7% versus 50%, respectively, for HCMV, P = 0.004). HIV-infected females were more likely to have evidence of HCMV infection (78.5% versus 61.4%, P = 0.003) than HIV-uninfected females. No significant difference was found for HBV infection in the two groups of females. The rate of HCV infection (1.6%) was too small to make comparisons between the groups. To determine whether the differences in infection rates for HBV and HCMV could be explained by factors other than HIV status, a variety of possible risk factors were examined using univariate and multivariate analyses. A significant risk factor for HBV and HCMV infections for males was a homosexual or bisexual orientation. For females, a risk factor for HBV infection was having more than 10 lifetime sexual partners; for HCMV infection, HIV infection was the only risk factor. In addition, in the HIV-infected cohort, 15% of females and 36% of males who were seropositive for HBV had evidence of active HBV infection.

CONCLUSIONS

These results emphasize the need for continued development of primary and secondary prevention programs and clinical screening and treatment for HBV and HCMV in adolescents.

Prevalence, patterns, and course of past hepatitis B virus infection in intravenous drug users with HIV-1 infection

OBJECTIVE

Hepatitis B virus (HBV) and human immunodeficiency virus (HIV) share common routes of transmission. Therefore, markers of either active or past HBV infection are present in many HIV-infected patients, particularly in intravenous drug users (IDUs). The aim of this study was to analyze the serological pattern of past HBV infection (presence or absence of anti-HBs) and the course of past HBV infection (changes in anti-HBs status, and HBV reactivation) in two cohorts of IDUs with and without HIV infection.

METHODS

HBV serum markers were studied in 388 HIV-positive and 197 HIV-negative IDUs. Among them, 263 HIV-positive and 50 HIV-negative patients with past HBV infection (serum HBsAg negative and anti-HBc positive, with or without anti-HBs) were followed-up for a median of 21 and 13 months, respectively, to detect changes in anti-HBs status and HBV reactivation.

RESULTS

The prevalence of HBV infection (either active or past) was higher in HIV-positive than in HIV-negative cases (90% vs 62%, p < 0.001), even when stratified by years of drug use. Most cases (92% of HIV-positive and 89% of HIV-negative) had markers of past infection. Among those patients with past HBV infection, 60% of HIV-positive and 72% of HIV-negative presented serum anti-HBs (p = 0.03). The incidence of anti-HBs loss was 1.8 cases/100 person-year in HIV-positive, and 1.8 cases/100 person-year in HIV-negative patients (RR 1.0, 95% CI 0.1-94, p = NS). Incidence of anti-HBs development was 17.6 cases/100 person-year in HIV-positive and 25.6 cases/100 person-year in HIV-negative IDUs (RR, 1.5, 95% CI, 0.6-3.5, p = NS). Only one HIV-positive patient with markers of past HBV infection developed an active infection (0.2 events/100 person-year).

CONCLUSIONS

HBV infection (either active or past) is particularly frequent in HIV-positive IDUs. Most cases have markers of past infection. Isolated detection of anti-HBc (absence of anti-HBs) is more common in HIV-positive than in HIV-negative IDUs. Despite their progressive immunosuppression, both anti-HBs loss and HBV reactivation are rare in HIV-infected IDUs.

Long-term follow-up of a randomized trial of interferon therapy for chronic hepatitis B in a predominantly homosexual male population

BACKGROUND/AIMS

Extended follow-up of a previously published therapeutic trial with interferon alfa is now available to further clarify the long-term outcome of HIV-negative and HIV-positive subjects with chronic hepatitis B virus infection after interferon alfa therapy.

METHODS

Forty-five subjects with compensated liver disease and chronic hepatitis B infection with evidence of active hepatitis B replication were studied. These subjects were enrolled between 1986 and 1991 and had been randomized, stratified by HIV status, to either receive interferon therapy (10 MU/m2 of lymphoblastoid interferon alfa 3 times per week for 12 weeks) or no treatment. Hepatitis B serology, serum hepatitis B viral DNA and alanine aminotransferase were measured on an annual to biannual basis. CD4-positive T lymphocyte counts and HIV RNA concentration were also obtained.

RESULTS

From 9 months post-interferon alfa treatment to the end of the extended follow-up (4 to 9 years), the relative risk of seroconverting to anti-HBe positive for subjects who had received interferon alfa therapy compared to those who did not was not significant in either HIV-negative (p = 0.80) or HIV-positive (p = 0.62) subjects.

CONCLUSIONS

Unlike the first 9 months following interferon alfa therapy, the rate of elimination of markers of hepatitis B virus replication, regardless of HIV status, was not increased above the natural rate beyond 9 months following interferon alfa therapy.

Influence of human immunodeficiency virus infection on chronic hepatitis B in homosexual men

The aim of this study was to assess the influence of human immunodeficiency virus (HIV) infection on chronic hepatitis B. In a series of 132 (65 anti-HIV positive) homosexual non-drug addicted men with chronic hepatitis B, the liver function was assessed with biochemical tests; the degree of hepatitis B virus (HBV) replication was assessed with serum HBV DNA level and with immunoperoxidase staining of hepatitis B core (HBc) antigen on liver specimens; and the severity of liver lesions was assessed with an histology activity index. Anti-HIV-positive and anti-HIV-negative patients were not different for serum aspartate transaminase activity, bilirubin, prothrombin, and histology activity index. Anti-HIV-positive patients had lower serum alanine transaminase activity levels (P =.0001), lower serum albumin levels (P =.0009), and higher serum HBV DNA levels (P =.01). There was a higher prevalence of cirrhosis in anti-HIV-positive patients (P =.04). In homosexual men with chronic hepatitis B, HIV infection is associated with a higher level of HBV replication and a higher risk for cirrhosis without increased liver necrotico-inflammatory process.

Frequent chronic hepatitis B virus infection in HIV-infected patients positive for antibody to hepatitis B core antigen only. Swiss HIV Cohort Study

Persons with immune deficiency may present with atypical results in serological tests for hepatitis B virus (HBV). Frozen serum specimens that were sequentially obtained over time from a cohort of 57 HIV-infected patients, all of whom tested positive only for antibody to hepatitis B core antigen (anti-HBcAg), were therefore retested for HBV markers, including HBV DNA. The results were assessed for their time course and correlated with clinical data and alanine aminotransferase (ALT) values. Forty-eight patients were male; intravenous drug users constituted the principal risk group (n = 30), followed by homosexual men (n = 22). Thirty-three persons tested positive for antibody to hepatitis C virus (anti-HCV). During a median of 31 months from the first to the last serum, anti-HBcAg remained the sole marker of HBV infection in 98.2% of the patients. Polymerase chain reaction (PCR) to detect DNA for HBV core and HBV surface gene was positive in 126 (62.4%) and 121 (59.9%) of all 202 serum samples, respectively. Over time, HBV DNA was detected at least once in 51 (89.5%) patients. In contrast, decomplexed hepatitis B surface antigen (HBsAg) was detected at least once in 14 (24.6%) patients. Among patients positive for HBV DNA and negative for anti-HCV, eight (36.4%) of 22 had chronic hepatitis (ALT elevation > or = 6 months) that was attributable only to persisting HBV infection. Similarly, 12 (41.4%) of 29 patients positive for both HBV DNA and anti-HCV had chronic viral hepatitis, but their ALT values were significantly higher. In HIV-infected patients, anti-HBcAg as the sole serological HBV marker detected must be considered indicative of chronic HBV infection and is in part associated with chronic hepatitis and ALT elevation.

Interactions between HIV and hepatitis B virus in homosexual men: effects on the natural history of infection

OBJECTIVES

Hepatitis B virus (HBV) and HIV infections share risk-factors; therefore coinfection is common. Interactions have been reported but controlled studies have been limited. Our objective was to study the effect of HIV infection on the natural history of chronic HBV infection and the reverse effect of the HBV carrier state on HIV infection.

DESIGN

Prospective observational cohort study.

SETTING

Open-access outpatient HIV/genitourinary medicine clinic at a Central London hospital.

PATIENTS

Total of 152 untreated homosexual male HBV carriers and 212 HBV surface antigen-negative controls (41.4 and 70.3% HIV-seropositive, respectively).

OUTCOME MEASURES

The rate of loss of serum HBV e antigen (HBeAg) and its reappearance in HIV-infected and HIV-uninfected HBV carriers; serum HBV DNA levels measured by dot-blot hybridization assay), HBV DNA polymerase activity and liver transaminase activities, the progression of HIV infection to symptomatic disease or AIDS in HIV-infected compared with HBV-HIV coinfected patients.

RESULTS

In HIV-infected HBV carriers, serum HBV DNA polymerase activity was higher, alanine aminotransferase was lower and loss of serum HBeAg (mean follow-up, 2.8 years) occurred at a lower rate when compared with HIV-uninfected HBV carriers (estimated relative hazard, 0.39; 95% confidence interval, 0.161-0.942) Concomitant chronic HBV infection had no detectable effect on the rate of progression of HIV disease after correction for lead-time bias.

CONCLUSION

This study strengthens the evidence for a significant effect of HIV infection on the natural history of chronic HBV infection, which by prolonging the period of infectivity could have an important impact on the epidemiology of HBV infection in regions, or patient groups, with high HIV seroprevalence. There was no evidence of an important effect of HBV carriage on HIV disease progression.

Liver histopathology in patients with concurrent chronic hepatitis C and HIV infection

To investigate the influence of human immunodeficiency virus (HIV) coinfection on preexisting long-term chronic C hepatitis (HCV) 68 liver biopsies from 22 HIV/HCV-coinfected, 13 HIV- and 33 HCV-monoinfected patients and 71 livers obtained at autopsy from 26 HIV/HCV-coinfected and 45 HIV-monoinfected patients were studied by histo- and immunohistochemistry. All HIV patients had reached the advanced stage of immunodeficiency (stage III CDC), except for 3 haemophilias (stage II CDC). HCV infection was associated with a higher degree of portal, periportal and lobular inflammation-regardless of whether there was concurrent HIV infection. HIV/HCV coinfection was associated with a significantly higher rate of granulocytic cholangiolitis than HCV and HIV monoinfection (P < 0.05), a histological feature uncommon in C hepatitis. In HIV/HCV coinfection cholestasis was a predominant histological feature. HCV monoinfection and HCV/HIV coinfection were associated with the highest fibrosis index. In HIV/HCV coinfection centrilobular fibrosis was significantly more marked than in HCV monoinfection (P < 0.05), suggesting an HIV-associated fibrogenic effect. Patients with chronic C hepatitis showed a significantly increased rate of posthepatitic cirrhosis compared with the patients without HCV infection (P < 0.05). At autopsy, 10 of the 20 HIV/HCV-coinfected haemophiliacs had developed cirrhosis because of chronic C hepatitis, whereas cirrhosis was found in only 2 of 6 HIV/HCV-coinfected non-haemophiliacs (1 case of chronic B and C hepatitis, and 1 case of chronic alcohol abuse). No cirrhosis was observed in the 45 autopsy patients with HIV monoinfection. The findings suggest that HIV coinfection aggravates the course of preceding long-term chronic C hepatitis by a more marked (centrilobular) fibrosis. HIV/HCV-coinfected patients are threatened by a higher rate of posthepatitic cirrhosis-particularly in multitransfused haemophiliacs-and cholestatic hepatopathy.

Long-term effects of interferon-alpha in five HIV-positive patients with chronic hepatitis B

Chronic hepatitis B viral infection is common in human immunodeficiency virus (HIV) carriers, but the effectiveness of interferon therapy is still unknown. We report the results of a long-term pilot study of five patients, who were infected with HIV and chronic hepatitis B, treated by interferon. Five males co-infected with HIV and hepatitis B virus (HBV) (mean age 27 years) were given a 6-month course of interferon (IFN)-alpha 2b 5 million units (MU) three times weekly. On initiating the treatment, their CD4 lymphocyte count was 340-553 mm-3, their CDC stage was IIa-III; all had histologically proven chronic hepatitis, with Knodell's score ranging from 6-10, and active HBV replication (HBV DNA and hepatitis B e antigen (HBeAg) were detectable). There was no associated hepatitis delta virus (H delta V) or hepatitis C virus (HCV) infection. Follow-up was for 53 months on average (24-74 months). After the treatment, hepatitis B e antibody (HBeAb) and hepatitis B s antibody (HBsAb) seroconversion was observed in one patient, HBeAb seroconversion alone in two patients, HBV DNA was absent from serum in three patients, and HBV DNA significantly decreased in one patient. The serum alanine aminotransferase (ALT) activity was normal in four patients. Histological improvement was obtained in four patients. The HIV stage remained unchanged in all patients during the whole follow-up. These preliminary results suggest that interferon can be successfully used in immunocompetent HIV carriers with chronic hepatitis B as well as in HIV-negative patients.

The interaction of human immunodeficiency virus infection and hepatitis B virus infection in infected homosexual men

A retrospective analysis of 99 hepatitis B-positive homosexual men with known human immunodeficiency virus (HIV) status was conducted to study the interaction of concurrent HIV infection on the course of their chronic hepatitis B virus (HBV) infection. All 99 subjects had chronic hepatitis B, 43 of whom were HIV antibody negative and 56 of whom were HIV antibody positive at the time of their initial presentation. Serial serum aminotransferase levels were used as an indirect estimate of the severity of hepatic inflammation. Factors that may influence the course of hepatitis B, HIV status, hepatitis B e antigen (HBeAg)/hepatitis B e antibody (HBeAb) status, alcohol intake, and zidovudine (AZT) therapy were correlated with aminotransferase values. Overall, there was no difference in mean serum alanine aminotransferase (ALT) levels between HIV antibody-negative and HIV antibody-positive patients. There is a higher prevalence rate of HBeAg in HIV antibody-positive patients (p < 0.05), and the seroconversion rate from HBeAg to HBeAb was lower in HIV antibody-positive patients compared with HIV antibody-negative patients (p < 0.05). However, reactivation rates from HBeAb to HBeAg were no different in the HIV antibody-positive and negative hepatitis B carriers. With mild, moderate, or heavy alcohol intake, we observed no statistically significant difference in mean serum alanine aminotransferase levels and no mean serum aspartate aminotransferase levels between HIV antibody-negative patients versus HIV antibody-positive patients. Similarly, there was no significant difference in the pattern of serum aminotransferase in those subjects treated with or without AZT. The mortality rates were higher in HIV antibody-positive patients (n = 8) compared with in HIV antibody-negative patients (n = 2). Seventy-five percent (n = 6) of the HIV antibody-positive patients died from acquired immunodeficiency syndrome (AIDS), and overall only two patients died of liver disease, one in each group. We conclude that there is no overt influence by HIV or the treatment thereof on the course of chronic HBV infection in a population of homosexual men. In HIV-infected patients, death from AIDS predominated; hence, the main target for therapy should be HIV rather than HBV.

Seroconversion to HBV associated with seroconversion to HIV in a cohort of intravenous drug misusers in Turin, Italy

Between March 1986 and March 1994, the seroconversion to HBV associated to the seroconversion to HIV was investigated in 120 HIV seroconverters drawn from 2368 i.v. drug misusers screened for HIV, HBV and STDs. Among the 185 individuals susceptible to HIV and HBV at intake (41/120 HIV seroconverters and 144/364 HIV-negative controls), HBV seroconversion was associated with the seroconversion to HIV (p = 0.006) and history of more than 3 sexual partners per year (p = 0.000). Only the history of more than 3 partners per year remained associated with the HBV seroconversion in the conditional regression. The associated seroconversion to HIV and HBV was linked to the short period of i.v. drug injections (p = 0.032), history of more than 3 partners per year (p = 0.000) and more than 3 i.v. drug injections per day (p = 0.016). Compared to the seroconverters to HBV alone, the seroconverters to HBV and HIV were likely to have higher frequency of i.v. drug injection per day on univariate (p = 0.031) and multivariate analysis (p = 0.024). The seroconverters to both the viruses differed from the seroconverters to HIV alone in the year of drug debut (p = 0.045), short period of i.v. drug use (p = 0.048) and high frequency of injection per day (p = 0.008). The multivariate analysis confirmed only the association with high frequency of injection per day (p = 0.033). Higher risk of HIV seroconversion from the debut of i.v. drug use was observed in the subjects with concurrent HBV seroconversion (Log-Rank test: p = 0.0008).

Association between an MHC class II allele and clearance of hepatitis B virus in the Gambia

BACKGROUND

The course of hepatitis B virus (HBV) infection does not appear to be determined by variations in viral virulence and may be influenced by the host immune response. We studied the distribution of human leukocyte antigens in children and adult men in the Gambia who spontaneously recovered from HBV infection as compared with the distribution of these antigens in subjects with persistent infection.

METHODS

In a two-stage, case-control study, we analyzed the frequency of MHC class I antigens and class II haplotypes in people with either transient or persistent HBV infection. MHC class I typing was performed by microlymphocytotoxicity assays. MHC class II typing was performed with analysis of restriction-fragment-length polymorphisms (RFLPs), supplemented by other techniques.

RESULTS

In the first stage (the study of children up to the age of 10 years), the RFLP pattern 25-1, which includes the class II allele HLA-DRB1*1302, was found in 58 of 218 subjects with transient HBV infection (26.6 percent) and 30 of 185 subjects with persistent infection (16.2 percent) (relative risk of carrying the 25-1 pattern in the persistently infected group as compared with the transiently infected group, 0.53; 95 percent confidence interval, 0.32 to 0.90; P = 0.012). In the second stage (the study of adults), HLA-DRB1*1302 was found in 50 of 195 subjects with transient HBV infection (25.6 percent) and in 3 of 40 subjects with persistent infection (7.5 percent) (relative risk, 0.24; 95 percent confidence interval, 0.04 to 0.80; P = 0.012). The RFLP pattern 13-2, which includes the class II allele DRB1*1301, was less frequent in children with persistent infection than in those with transient infection, an association that was neither confirmed nor excluded by the data on adults. Possible associations with HLA class I antigens found in children were not supported by the data on adults.

CONCLUSIONS

The MHC class II allele DRB1*1302 was associated with protection against persistent HBV infection among both children and adults in the Gambia.

Prevalence of HBV, HDV and HCV hepatitis markers in HIV-positive patients

Since HIV infection could condition the natural history of parenterally transmitted viral hepatitis (HBV, HCV, HDV), with possibly differing effects in different risk groups, we decided to retrospectively examine sera from a cohort of 637 HIV seropositive patients in different stages of infection, seen from 1985 to 1992, to study the prevalence and temporal course of these infections. Virological markers of HBV, HCV and HDV were determined by ELISA and RIBA methods. The severity of HIV infection was higher in homosexuals than in drug addicts. Prevalence of antiHBc antibodies was 82% in drug addicts and 77% in homosexuals, whereas antiHCV antibodies prevalence was 72% in drug addicts and only 7% in homosexuals (p < 0.000001). When only antiHBc-positive patients were considered, there was a significant difference in antiHBs antibodies between drug addicts (DA) and homosexuals (OR for DA 0.29, 95% CI 0.08/0.83, p = 0.02), suggesting that drug addicts are less able to produce a protective response. This fact cannot be explained by the severity of HIV infection (which was higher among the homosexual group) and suggests some immunodepressive effect of drug abuse. Delta infection was only detected in the drug addict group, and the prevalence was low. Finally, we cannot confirm the interference of HCV infection with the speed of HBsAg clearance: in this study the prevalence of HBsAg was almost the same in HCV-positive and negative patients.

Human immunodeficiency virus infection and hepatitis C pathology

To investigate the possible influence of human immunodeficiency virus (HIV) infection on hepatitis C virus-related liver disease, liver morphology was evaluated in 160 HBsAg-negative patients with chronic hepatitis C, including 68 HIV-positive and 92 HIV-negative cases. No differences were detected in the severity of necro-inflammatory hepatic lesions between HIV-negative and HIV-positive patients when the CD4+ lymphocytes count exceeded 400 cells/mm3. In contrast, HIV-positive patients with CD4+ lymphocytes below 400 cells/mm3 showed a significantly lower grade of portal inflammation and piecemeal necrosis. These results suggest that liver lesions in hepatitis C may largely depend on immunomediated mechanisms.

Influence of human immunodeficiency virus infection on hepatitis delta virus superinfection in chronic HBsAg carriers

It is generally agreed that hepatitis B virus (HBV) replication is reduced by hepatitis delta virus infection (HDV) and augmented by human immunodeficiency virus (HIV) infection. However, the precise nature of the interactions between HBV, HDV and HIV is controversial. The aim of this study was to evaluate the impact of HIV infection on HBV and HDV replication, and on histological scores during delta virus superinfection in HDV-positive, chronic carriers of hepatitis B surface antigen (HBsAg). We studied 38 men and six women, 15 of whom were HIV-positive and all of whom had at least one marker of HDV infection. Serum hepatitis B e antigen (HBeAg), HBV DNA, HDV RNA, anti-delta antigen antibodies (anti-HD) IgM, anti-HD IgG and hepatitis delta antigen (HDAg) were tested for in the serum and liver, respectively; anti-hepatitis C virus (HCV) antibodies were detected using a second-generation recombinant immunoblot assay. Histological specimens were scored blindly according to Knodell's classification for periportal and intralobular necrosis, portal inflammation and fibrosis. HBV DNA was detected more frequently in the HIV-positive patients than in those who were HIV-negative (25 vs 0%; P = 0.01), while markers of HDV replication (serum anti-HD IgM, serum HDV RNA and liver HDAg) were as frequent in the HIV-positive patients (69%, 40% and 50%, respectively) as in those who were HIV-negative (75%, 52% and 30%, respectively; P > 0.05). By contrast, 31% of the HIV-positive patients were serum HDAg-positive compared to only 6% of the HIV-negative patients (P = 0.001). HDV antigenaemia and anti-HD antibodies usually fluctuated in the HIV-positive patients during follow-up. The mean Knodell score was similar in the HIV-positive (11.5 +/- 3.2) and HIV-negative (10.7 +/- 2) subgroups, as was the mean semi-quantitative index of hepatic necrosis, inflammation and fibrosis. Our results provide evidence that in HDV-positive patients: (1) HIV infection counters the inhibitory effect of HDV superinfection on HBV replication; (2) serum anti-HD IgM. HDV RNA and liver HDAg are not more frequent in HIV-positive than in HIV-negative patients, suggesting that HIV infection has no effect on HDV replication (although the significance of the increased frequency of HD antigenaemia remains unclear); (3) the histological severity of liver disease is not influenced by HIV status.

The treatment effect of alpha interferon in chronic hepatitis B is independent of pre-treatment variables. Results based on individual patient data from 10 clinical controlled trials. European Concerted Action on Viral Hepatitis (Eurohep)

Alpha interferon induces HBeAg seroconversion in about one third of treated patients and has become an established treatment of chronic hepatitis B. A number of smaller studies have suggested that response to treatment is more likely to occur in patients with higher levels of transaminases, with recent (adult) onset, a history of acute hepatitis, low levels of HBV DNA and in heterosexual males. The aim of this European co-operative study was to estimate the effect of alpha interferon more accurately and to evaluate the influence of host pre-treatment variables on the effect of interferon. Individual data were collected from 751 patients from 10 controlled clinical trials on alpha interferon (lymphoblastoid or recombinant) treatment for chronic hepatitis B. Alpha interferon was administered to 496 patients, while 255 were untreated controls. Individual patient data were analysed by survival analysis (log rank test and Cox regression analysis), stratified by trial, with the disappearance of HBeAg as the major endpoint. The results showed that the HBeAg disappearance rate with or without interferon treatment was higher in patients with high aminotransferase levels, with a history of acute hepatitis and in male heterosexual patients disregarding HIV status. If HIV-positive patients were excluded, the effect of sexual orientation was not significant. Therapy with alpha interferon increased the a priori HBeAg disappearance rate by a factor of 1.76; the relative treatment effect of alpha interferon was independent of the tested pretreatment host variables, but dependent on the total (intended) interferon dose (low dose < or = 200 MU/m2 increased HBeAg disappearance by a factor 1.37; medium/high dose > or = 200 MU/m2 increased HBeAg disappearance by a factor 2.05). In conclusion, this meta-analysis suggests that the effect of alpha interferon is less than previously assumed and independent of pretreatment host variables tested. It confirms the higher therapeutic benefit of a total dose exceeding 200 MU/m2 and of selection of patients based on disease activity and immune reactivity. Although all patient seem to have the same relative benefit, the absolute benefit of alpha interferon treatment seems to be greatest in patients with high transaminase levels and with a history of acute hepatitis.

Heroin addicts infected by HBV and HIV have a low prevalence of HBV DNA in peripheral blood mononuclear cells

Several reports show that the prevalence of HBV (hepatitis B virus) carriers in HIV (human immunodeficiency virus) infected populations is significantly higher than in HIV seronegative individuals, independent of the risk group for HIV, that is, homosexuals or drug abusers. In this context, evaluation of the simultaneous presence of HBV and HIV in PBMCs (peripheral blood mononuclear cells) is of particular interest for at least 2 reasons: 1) the possible reciprocal influence of the 2 viruses when they infect the same cell; 2) the possibility that HIV-induced hematological disorders could indirectly influence the settling of HBV in blood cell populations. We report data on the frequency of PCR positivity for HBV DNA in PBMCs from 62 HIV infected patients, rigorously selected by risk group, that is, intravenous use of heroin for at least 3 years and syringe promiscuity. Sixty-seven HIV negative individuals who never used any drug formed the control group. The analysis of the cases positive for HBV DNA in PBMCs showed that: 1) the overall prevalence of PCR positivity found in HIV infected patients was significantly lower than that registered in the control group; 2) PCR positivity among the subjects who were HBsAg negative and anti-HBV positive was extremely low in the HIV infected patients (3.7%) but quite frequent in the HIV negative subjects (37.0%). The results support the hypothesis that, unlike the HIV negative individuals, our HIV infected patients exhibited HBV DNA in PBMCS almost exclusively when they presented with active HBV replication.

Toward routine diagnosis of hepatitis B virus desoxyribonucleic acid

Although a multitude of hepatitis B markers are available to discriminate different states of hepatitis B virus (HBV) infection, there remains a need to detect the HBV DNA itself. The HBV DNA test is the only test that can quantify the number of complete virions. As shown in this review, the diagnostic value of testing for HBV DNA depends on quantification, and there are situations in which in vitro amplification is necessary and others in which testing for HBV DNA without preamplification is best. Indications for analysis of HBV DNA include the early recognition of chronic hepatitis B, discrimination of different HBsAg carrier states, recognition of the evolution of variants, indication and follow-up of anti-viral therapy with interferon, and assessment of blood products for infectivity. In each of these cases quantification of HBV DNA improves the diagnosis of HBV infection and will become an important tool in the routine diagnosis of hepatitis B virus infection in the future.

A comparison of risk factors for human immunodeficiency virus and hepatitis B virus infections in homosexual men

We analyzed cross-sectional data from 1062 homosexual men recruited in Baltimore during 1984, to directly compare risk factors for human immunodeficiency virus (HIV) and hepatitis B virus (HBV). Using polychotomous logistic regression, risk factor odds ratios (ORs) and 95% confidence intervals were determined for men with HIV alone, men with HBV alone, and men with both HIV and HBV, compared to seronegative men, and paired comparisons among these subgroups. Factors associated with the serologic prevalence of HIV alone and HBV alone (with respective ORs) included and receptive intercourse (HIV OR = 1.23; HBV OR = 1.12), history of gonorrhea (HIV OR = 4.58; HBV OR = 2.52), and rectal douching (HIV OR = 1.41; HBV OR = 1.20). Additional factors associated with HBV alone were years of homosexual activity (OR = 1.65), sexual activity with a person who developed acquired immunodeficiency syndrome (AIDS) (OR = 1.98), and lifetime number of male sex partners (OR = 1.25). HIV and HBV coprevalence was associated with anal receptive intercourse (OR = 1.36), history of gonorrhea (OR = 2.94), rectal douching (OR = 1.45), sexual activity with a person who developed AIDS (OR = 3.87), lifetime number of male sex partners (OR = 1.21), and the lifetime sum of sexually transmitted diseases (OR = 1.47). These findings reinforce the need for following safer-sex guidelines to prevent both infections and in the case of HBV, the prevention strategies should include vaccination.

Hepatobiliary complications in patients with human immunodeficiency virus infection

Human immunodeficiency virus (HIV) infection has been associated with a number of hepatic and biliary tract disorders. Case reports, series of liver biopsies, and postmortem studies that examined the hepatobiliary system were retrieved with a MEDLARS search and form the basis of this review. The liver and biliary tract are frequently involved with opportunistic infections (most commonly mycobacteria and cytomegalovirus) and neoplasms (mainly Kaposi's sarcoma) in patients with HIV infection. The patients are often asymptomatic but may have elevated levels of serum liver enzymes. These abnormalities are nonspecific. Sulfa drugs, pentamidine, and ketoconazole are the medications used in HIV-related infections that are most likely to result in abnormalities on liver tests. Acalculous cholecystitis and sclerosing cholangitis also occur in HIV infection. Cytomegalovirus and Cryptosporidium are the organisms most commonly associated with these conditions. Imaging studies of the liver may detect parenchymal abnormalities and guide liver biopsy. The role of this procedure in the diagnosis of opportunistic infections and neoplasms is controversial because these lesions are generally disseminated at the time liver abnormalities are evident. A liver biopsy is best used when other less invasive procedures have failed to provide a diagnosis. Endoscopic retrograde cholangiopancreatography is a useful diagnostic procedure with therapeutic potential in patients with abdominal pain, fever, or an elevated serum alkaline phosphatase level.

Interactions between human immunodeficiency virus-1, hepatitis delta virus and hepatitis B virus infections in 260 chronic carriers of hepatitis B virus

To evaluate the factors determining the severity of chronic hepatitis B virus infection and the interactions of human immunodeficiency virus and hepatitis delta virus infections, we retrospectively analyzed 260 patients, 146 of whom were followed for a mean of 31.4 +/- 1.8 mo. Human immunodeficiency virus, hepatitis B virus, and hepatitis delta virus status and aminotransferase activities, histological activity index, alcohol consumption and the prevalence of cirrhosis were investigated. The patients included 54 homosexuals, 19 parenteral drug abusers and 187 subjects with other or unidentified risk factors for exposure to hepatitis B virus. Thirty-five patients (13%) were positive for antibody to human immunodeficiency virus; 27 were homosexual and 8 were drug abusers. The mean aminotransferase activities, histological activity index and the prevalence of cirrhosis were similar in the human immunodeficiency virus-positive and human immunodeficiency virus-negative subgroups. Actuarial survival was significantly lower in the human immunodeficiency virus-negative subgroups. Actuarial survival was significantly lower in the human immunodeficiency virus-positive group than in the human immunodeficiency virus-negative subjects (p = 0.004); the cause of death was clearly related to liver failure in four of the five human immunodeficiency virus-positive patients and two of the six human immunodeficiency virus-negative subjects who died. To evaluate the factors determining the severity of liver disease, we compared homogeneous subgroups of subjects. Among the homosexual patients, the prevalence of HBeAg and hepatitis B virus DNA, aminotransferase activities and the histological activity index did not differ according to human immunodeficiency virus antibody status.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of duration of hepatitis B virus infection on the association between human immunodeficiency virus type-1 and hepatitis B viral replication

This study examined the effect of duration of hepatitis B virus infection on the association between human immunodeficiency virus type-1 infection and hepatitis B viral replication. Twenty-five chronic HBsAg carriers were studied. Presence of hepatitis B virus DNA and expression of HBeAg were more frequent among 20 chronic HBsAg carriers positive for human immunodeficiency virus type-1 antibody compared with five chronic HBsAg carriers negative for human immunodeficiency virus type-1 antibody, but the associations were not statistically significant. Hepatitis B virus DNA and HBeAg were inversely related to duration of hepatitis B virus infection (p less than 0.001). Stratifying for duration of hepatitis B virus infection, the presence of viral replication was similar among patients negative and positive for antibody to human immunodeficiency virus type-1. Hepatitis B virus DNA levels did not increase with the decline of cellular immunity over time. In conclusion, hepatitis B virus replication among chronic carriers may be a function of duration of hepatitis B virus infection rather than of an effect of human immunodeficiency virus type-1.