Hepatitis C in the patient with human immunodeficiency virus infection

Fluctuations in serological hepatitis C virus levels in HIV patients

INTRODUCTION

Hepatitis C virus (HCV) and human immunodeficiency virus (HIV) have identical transmission routes, explaining the high prevalence of coinfections. The main aim of this study was to detect fluctuations in serological HCV levels in HIV patients.

METHODS

We analyzed samples of 147 patients who attended an outpatient service that supports HIV/AIDS patients in São Paulo city. We also recruited 22 HCV-monoinfected patients who attended the Instituto Adolfo Lutz Laboratory in São Paulo city, to compare the test results. Serological testing of the blood samples was performed for the detection of HCV antibodies. The samples were then analyzed using real-time PCR for RNA viral quantification and sequencing.

RESULTS

We found that 13.6% of the study population was coinfected with HIV and HCV. In 20% of coinfected patients, fluctuations in serology results were detected in samples collected during the follow-up. No changes in anti-HCV serological markers were observed in HCV-monoinfected patients. An HCV viral load was detected in 9,5% of the samples collected from HIV patients.

CONCLUSIONS

Our findings provide important clinical data to public health professionals and highlight the importance of periodic monitoring of HCV/HIV coinfected patients.

Factors associated with prevalent hepatitis C infection among HIV-infected women with no reported history of injection drug use: the Women's Interagency HIV Study (WIHS)

Although the primary mode of hepatitis C virus (HCV) transmission is exposure to blood products or injection drug use (IDU), studies have found varying independent risk factors for HCV infection among persons with no history of IDU or exposure to blood products. For HIV-infected women, sexual transmission may be another potential source of HCV infection. HIV-infected and HIV-negative women at risk for HIV enrolled in the Women's Interagency HIV Study (WIHS) during October 1994 to November 1995 and again between October 2001 and November 2002 were studied. Clinical and demographic factors associated with HCV seroprevalence were assessed in multivariate logistic regression models controlling for history of blood transfusion and IDU. Among 3636 women with HCV results, 31.5% were HCV antibody positive (HCV+) including 13.5% with no reported history of IDU or blood transfusions. Multivariate logistic regression analyses stratified on IDU showed that among women with no history of IDU, sex with an IDU male was independently associated with HCV positivity (odds ratio [OR] = 2.8, 95% confidence [CI] = 2.1, 3.8, p < 0.0001) after controlling for blood transfusion, age, HIV infection, unemployment, birth in the United States, history of hepatitis B infection, and current smoking status. Further stratification on HIV status showed that the association was significant only for the HIV+ (OR = 1.9, 95% CI = 1.3, 2.7, p = 0.0007) compared to the HIV- women (OR = 1.1, 95% CI = 0.4, 2.7) although these odds ratios were not significantly different (p = 0.25). For HIV-positive women with no reported history of IDU, sex with an IDU male was independently associated with HCV suggesting that sexual transmission may be an important mode of HCV transmission for these high-risk women.

Serological markers and risk factors for hepatitis B and C viruses in patients infected with human immunodeficiency virus

Both hepatitis B and hepatitis C viruses (HBV and HCV) infection are common in HIV-infected individuals as a result of shared risk factors for acquisition. A serological study for HBV and HCV was performed in 251 HIV-positive individuals from Medellín, Colombia. A qualitative RT-PCR for HCV was done in 90 patients with CD4+ T-cell count < 150 per mm(3). Serological markers for HBV infection were present in 97 (38.6%) patients. Thirty six of them (37.1%) had isolated anti-HBc. A multivariate analysis indicated that the following risk factors were significantly associated with the presence of these markers: age (OR = 1.05, 95% CI: 1.01-1.08), pediculosis pubis (OR = 1.83, 95% CI: 1.01-3.33), men who have sex with men and women (OR = 3.23, 95% CI: 1.46-7.13) and men who have sex only with men (OR = 3.73, 95% CI: 1.58-8.78). The same analysis restricted to women showed syphilis as the only significant risk factor. Thus, HBV infection was considerably associated with high risk sexual behavior. HCV was present in only two (0.8%) of HIV patients. Both of them were positive by RT-PCR and anti-HCV. This low frequency of HIV/HCV coinfection was probably due to the uncommon intravenous drug abuse in this population. The frequent finding of isolated anti-HBc warrants molecular approaches to rule out the presence of cryptic HBV infection.

Barebacking, the Internet, and harm reduction: an intercept survey with gay and bisexual men in Los Angeles and New York City

Researchers have suggested that intentional unprotected anal intercourse (UAI) among gay and bisexual men (colloquially called barebacking), is on the rise. Further, they have linked this increase in barebacking to the growth of the Internet as a medium for men to meet sex partners. Data were used from large-scale gay, lesbian, and bisexual (GLB) community events in New York and Los Angeles collected between 2003 and 2004. In total 1178 men who have sex with men (MSM) responded to questions about the use of the Internet, willingness to have unplanned UAI, intentions toward planned UAI, and "barebacker identity." Compared to nonbarebackers, barebackers spent significantly more time on the Internet looking for sex and looking for dates. Further, HIV-positive barebackers specifically spent the most time online looking for dates. Further analyses of willingness and intentions to have UAI, and the specific sexual behaviors of self-identified barebackers, found evidence of strategic positioning and serosorting, both harm reduction strategies. These data suggest both HIV-positive and HIV-negative barebackers may be engaged in efforts to reduce the risk of HIV transmission when engaged in unprotected sex.

Impact of human immunodeficiency virus infection in patients infected with the hepatitis C virus

BACKGROUND/AIMS

The objective of the present study is to evaluate the impact of human immunodeficiency virus (HIV) in patients with hepatitis C virus (HCV) infection.

METHODS

Three different groups of patients were considered: group 1, 385 HCV/HIV coinfected; group 2, 198 HIV monoinfected; and group 3, 311 HCV monoinfected. Demographic and epidemiological data were collected. Blood tests included anti-HCV, HCV-RNA test, genotyping, CD4 cell count, anti-HIV, and HIV viral load. Treatment with interferon and ribavirin was proposed. The fibrosis progression rate was assessed.

RESULTS

The most prevalent risk factor in the group of coinfected was the use of intravenous drugs; in the HIV monoinfection group, heterosexual relations at risk; in the HCV monoinfection group, the transfusion of blood. There was no difference concerning the distribution of genotypes or HCV viral load between groups 1 and 3. Although the mean time of duration of HCV infection was greater in group 3 than in group 1, there was no difference when the fibrosis progression rate was evaluated. The response to treatment was similar.

CONCLUSION

In the present series there was no relevant impact of HCV infection in patients with HIV.

Barebacking websites: electronic environments for reducing or inducing HIV risk

Barebacking, or intentional unprotected anal intercourse (UAI), among men who have sex with men (MSM) has been a growing concern for the public health community because of UAIs link to HIV incidence and sexually transmitted infections (STIs). Men who bareback have created online spaces through websites that host thousands of profiles throughout the US and world. Adapting two domains from person-environment theory, this study contrasted the health messages surrounding the risks of UAI within two mainstream US-based barebacking websites. One website developed intensive systems to promote harm reduction, such as encouraging frequent HIV-testing, discussing STIs with partners, and limiting the number of partners. In contrast, the other site analysed negated the seriousness of HIV and STIs, which can have clear negative outcomes for patrons whom relied on this information. This analysis implicates the need to explore electronic environments as viable tools for HIV prevention and programme development.

Bug chasing and gift giving: the potential for HIV transmission among barebackers on the internet

"Bug chasing" and "gift giving" are colloquial terms used by some men who have sex with men (MSM) to describe intentional unprotected anal sex ("barebacking") with the goal of spreading HIV. There is little large-scale descriptive research that has investigated the prevalence of this phenomenon. This study analyzed the Internet profiles of MSM who self-identified as bug chasers or gift givers (n = 1,228) on a single U.S.-based barebacking-centered Web site in the fall of 2004. Most men (79%) were White, and most (70%) lived in the U.S. Six categories of bug chasing and gift giving were identified based on the HIV serostatus of men and the desired serostatus of partners they wanted to meet. Only a small portion of men were genuinely seeking partners of discordant serostatus: 1.1% of HIV-positive men and 21.3% of HIV-negative men. A larger portion were ambivalent about their partners HIV serostatus: 72% of HIV-positive men and 35% of HIV-negative men. Having identified online as a bug chaser or gift giver did not consistently correspond to behavioral intentions, as 24% of HIV-positive men and 36% of HIV-negative men were specifically seeking partners of the same serostatus. These data suggest bug chasing and gift giving do exist; however a sizable portion of both bug chasers and gift givers were not intent on spreading HIV.

[Ambulatorial prevalence of hepatitis B and C markers in patients with human immunodeficiency virus infection in a general hospital]

BACKGROUND

Hepatitis B and C viruses and human immunodeficiency virus share the same route of transmission, and the prevalence of HBV and HCV infection in patients infected with HIV is greater than it is in the general population.

AIM

To determine the prevalence of hepatitis B and C markers in a population of patients with HIV as well as the risk factors involved.

PATIENTS AND METHODS

From 5,870 registration forms of patients with HIV of an Infectology Unit, 587 were randomly selected. From these, the 343 which had investigated the presence of any hepatitis B (HBsAg, anti-HBc or anti-HBs) or C (anti-HCV) marker were retrospectively analyzed.

RESULTS

HBsAg was positive in 14/306 (4.6%), anti-HBs was positive in 40/154(26.0%), and anti-HBc in 79/205 (38.5%). The anti-HCV test was reactive in 126/330 (38.2%). HBV and HCV co-infection was observed in 7 of the 296 patients who had both HBsAg and anti-HCV tests (2.4%). For those who were HBsAg positive, the main exposure factor was homosexual intercourse (50.0%). For those who were anti-HCV reactive, the main risk factor was intravenous drug use (75.3%). In the HIV mono-infected (185 patients), the most prevalent exposure risk factor was promiscuous heterosexual practices or sexual intercourse with a spouse infected with HIV (83 patients - 44.9%).

CONCLUSION

In our environment HBV-HIV and HCV-HIV co-infections are frequent, a greater relevance being observed in the association between HCV and HIV.

Barebacking identity among HIV-positive gay and bisexual men: demographic, psychological, and behavioral correlates

OBJECTIVES

To determine the correlates associated with barebacking identity among HIV-positive gay and bisexual men.

DESIGN

An analysis of data from the baseline quantitative assessment of a randomized controlled intervention study of 1168 HIV-positive gay and bisexual men from New York City and San Francisco.

METHODS

Participants were actively and passively recruited from mainstream gay venues, AIDS service organizations, and public and commercial sex environments. Participants completed a computerized quantitative questionnaire assessing their identity as a barebacker, sexual behavior, demographic factors, psychosocial states, perceptions of health risks, and substance use.

RESULTS

Men of color were less likely to identify themselves as barebackers. Men who did identify themselves as barebackers were slightly younger. They were more likely to miss a dose of medication; report drug use (non-injection and injection); exhibit higher levels of sexual compulsivity and lower personal responsibility for safer sex; and report higher rates of unprotected insertive anal intercourse, unprotected receptive anal intercourse, and unprotected insertive oral intercourse with all partners, regardless of their HIV serostatus.

CONCLUSION

Barebacking and its corresponding behaviors pose immediate public health risks for HIV-positive gay and bisexual men. Further work is needed to understand this phenomenon more fully in relation to the psychological, sociological, biomedical, and cultural realities.

Hepatitis C virus viral recurrence and liver mitochondrial damage after liver transplantation in HIV-HCV co-infected patients

BACKGROUND/AIMS

As life expectancy in HIV-HCV co-infected patients improves, end stage liver disease requiring liver transplantation (LT) may become an emerging problem. We report the Paul Brousse Hospital experience of transplantation for end stage cirrhosis in HIV-HCV co-infected patients.

METHODS

Seven consecutive HIV-HCV co-infected patients were transplanted between December 1999 and December 2002 for end stage liver disease due to HCV. All patients were treated by highly active antiretroviral therapy (HAART), HIV plasma viral load was <400 copies/ml and median CD4 lymphocyte count was 306 cells/mm3 (range, 103-510) before LT. At the time of evaluation (March 2003), the median follow-up was 21 months (range, 4-40).

RESULTS

Two patients died, 4 and 22 months, respectively after LT. At the last biopsy, METAVIR score was staged F4 in two patients, F3 in two, and F1 in one. Microvesicular steatosis was noted in nearly all patients. The ratio of mitochondrial to nuclear DNA was low in three of four patients examined as compared with the amount of liver mtDNA found in eight HIV-negative, HCV-infected controls (P=0.01).

CONCLUSIONS

A significant defect in the activity of the respiratory chain complex IV was noted in all five patients studied. Mitochondrial hepatotoxicity and severe HCV recurrence occur in HIV-HCV co-infected patients after LT.

Differing patterns of liver disease progression and hepatitis C virus (HCV) quasispecies evolution in children vertically coinfected with HCV and human immunodeficiency virus type 1

Hepatitis C virus (HCV) quasispeciation was studied in two children vertically coinfected with HCV and human immunodeficiency virus type 1 (HIV-1). HCV quasispecies diversification and liver injury were more significant in patient C1, who was immunocompetent with anti-HIV therapy, than in patient C2, who was immunosuppressed, in consistency with modulation of HCV quasispeciation and liver injury by immunocompetence in coinfected children.

Differing patterns of liver disease progression and hepatitis C virus (HCV) quasispecies evolution in children vertically coinfected with HCV and human immunodeficiency virus type 1

Hepatitis C virus (HCV) quasispeciation was studied in two children vertically coinfected with HCV and human immunodeficiency virus type 1 (HIV-1). HCV quasispecies diversification and liver injury were more significant in patient C1, who was immunocompetent with anti-HIV therapy, than in patient C2, who was immunosuppressed, in consistency with modulation of HCV quasispeciation and liver injury by immunocompetence in coinfected children.

Hepatitis C virus genetic variability in 52 human immunodeficiency virus-coinfected patients

The aim of this study was to examine whether hepatitis C virus (HCV) pretreatment quasispecies complexity was linked to virological response or other clinical and biological parameters, in human immunodeficiency virus (HIV)-coinfected patients undergoing anti-HCV treatment. In addition, HCV quasispecies composition is described longitudinally in these patients before, during, and after treatment. The 52 HIV-coinfected patients were included in a randomized therapeutic trial. At inclusion, they had CD4(+) counts of >250/micro l, HIV plasma load of <10,000 copies/ml, and chronic HCV infection with genotype 1 (n = 27), 2 (n = 2) or 3 (n = 23). These values were compared at baseline with 32 HCV-only-infected, interferon-naive patients who were infected with genotype 1, 2, or 3 (n = 16, 1, or 15, respectively). HCV complexity was studied by single-strand conformation polymorphism (SSCP) in E2 hypervariable region 1 (HVR1), and diversity was evaluated at inclusion in 20 coinfected patients by sequencing four major SSCP bands. The baseline number of SSCP bands was identical in HIV-infected and control patients. In HIV-infected patients, HCV complexity was not predictive of sustained virological response to anti-HCV treatment and was unrelated to epidemiological factors, immunological parameters linked to HIV infection (CD4(+) counts, T CD4(+) proliferative responses to HIV-1 p24), protease inhibitor treatment, HCV plasma load, or genotype. HCV diversity was lower in genotype 2- and 3-infected patients. Six months after completion of the anti-HCV treatment, in comparison with baseline, SSCP profiles were modified in 13 of the 21 nonresponding coinfected patients with analyzable samples. In conclusion, in HIV-infected patients, HCV variability had no significant influence on virological response to anti-HCV treatment.

Comparison of 2 regimens that include interferon-alpha-2a plus ribavirin for treatment of chronic hepatitis C in human immunodeficiency virus-coinfected patients

An open-label, randomized trial was conducted to compare the efficacy and safety of 2 regimens of interferon-alpha-2a (IFN-alpha-2a) plus ribavirin for management of chronic hepatitis C virus (HCV) infection in human immunodeficiency virus (HIV)-coinfected patients. Sixty-eight patients were randomized to receive IFN-alpha-2a at a dosage of either (1) 6 MU given 3 times per week for 24 weeks, followed by 3 MU 3 times per week for an additional 24 weeks (group A; 31 patients); or (2) 9 MU per day for 2 weeks, followed by 3 MU per day for 22 weeks, followed by 3 MU 3 times per week for 24 weeks (group B; 37 patients). Ribavirin was added at week 16 of therapy if HCV RNA remained detectable at week 12. Sustained virological response was achieved in 10 patients (15%; 6 in group A and 4 in group B). HCV genotypes 2 or 3 and a decrease in the HCV load of >or=3 log(10) copies/mL between inclusion and week 4 were associated with virological response. In conclusion, the combination of conventional IFN-alpha-2a and ribavirin has poor virological efficacy in HCV-HIV-coinfected patients.

Coinfection and superinfection in RNA virus populations: a selection-mutation model

In this paper, we present a general selection-mutation model of evolution on a one-dimensional continuous fitness space. The formulation of our model includes both the classical diffusion approach to mutation process as well as an alternative approach based on an integral operator with a mutation kernel. We show that both approaches produce fundamentally equivalent results. To illustrate the suitability of our model, we focus its analytical study into its application to recent experimental studies of in vitro viral evolution. More specifically, these experiments were designed to test previous theoretical predictions regarding the effects of multiple infection dynamics (i.e., coinfection and superinfection) on the virulence of evolving viral populations. The results of these experiments, however, did not match with previous theory. By contrast, the model we present here helps to understand the underlying viral dynamics on these experiments and makes new testable predictions about the role of parameters such the time between successive infections and the growth rates of resident and invading populations.

Intrafamilial transmission of hepatitis C virus in patients with hepatitis C and human immunodeficiency virus coinfection

OBJECTIVE

The aim of this study was to determine whether hepatitis C virus (HCV)/HIV coinfection of index cases increases intrafamilial transmission (sexual and nonsexual contacts) of HCV.

METHODS

We prospectively enrolled 347 subjects, including 87 family members of 53 HCV/HIV-coinfected index cases and 134 family members of 73 HCV-monoinfected index cases, which served as a control group. All index cases and family members were interviewed, and a screening for HCV and HIV using enzyme-linked immunosorbent assays was performed. Positive samples were confirmed by polymerase chain reaction and tested for genotype and HCV RNA viral load. A meta-analysis designed to assess the pooled risk of sexual transmission of HCV among HCV/HIV-coinfected patients was performed.

RESULTS

Anti-HCV was detected in 2.2% of family members of HCV-monoinfected index cases and 2.3% of family members of HCV/HIV-coinfected index cases. Viral load was higher in coinfected index cases (7.2 x 10(6) mEq/ml) compared with HCV alone (1.9 x 10(6) mEq/ml), p = 0.01. HCV genotype concordance was observed in three family members of HCV-monoinfected index cases and in two family members of HCV/HIV-coinfected index cases. The pooled OR of the meta-analysis evaluating HIV as a cofactor of sexual transmission of HCV was 1.54 (95% CI = 0.76-3.12).

CONCLUSIONS

Our data demonstrate a low prevalence of intrafamilial transmission of HCV, independent of the presence of HCV/HIV coinfection. This finding is supported by meta-analysis, which failed to identify HIV as an important cofactor of sexual transmission in HCV/HIV-coinfected patients.

The clinical spectrum of hepatitis C virus in HIV coinfection

The biochemical, virologic, and histologic spectrum of hepatitis C virus (HCV) in 66 consecutive patients with HIV-HCV coinfection and 119 HCV controls was compared: 86% of coinfected patients had CD4 counts >200 cells/mm3, 51% had a normal alanine aminotransferase (ALT) value, the mean HCV RNA titer was 5.7 log IU/mL, 92% of coinfected patients were of genotype 1, and the mean histologic activity index was 6.86 with advanced fibrosis in 32% of patients. The biochemical, virologic, and histologic findings of HCV in coinfected patients were similar to those observed in HCV controls. For both groups of patients, no clinical, biochemical, or virologic factors could reliably identify patients with advanced fibrosis or cirrhosis, underscoring the importance of liver biopsy in the evaluation of these patients. The spectrum of liver disease in coinfection includes a significant proportion of patients with normal ALT values, and excluding these patients from previous studies has led to an overestimation of HCV disease severity.

Clinical experiences with interferon as monotherapy or in combination with ribavirin in patients co-infected with HIV and HCV

Human immunodeficiency virus (HIV) co-infection accelerates progression of hepatitis C virus (HCV) toward cirrhosis. Thus, with the increase of life expectancy observed after introduction of combination antiretroviral treatment, liver disease is becoming an increasing cause of morbidity and mortality in HIV-infected patients. In addition, HCV co-infection blunts CD4 restoration induced by HAART and increases HAART hepatotoxicity. For all these reasons, anti-HCV treatment is mandatory in HIV seropositives. The perfect treatment of hepatitis C should not only be safe and effective, but it should not have any adverse impact on HIV diseases and concurrent anti-HIV therapy. Two drugs are currently licensed for treatment of HCV: interferon alfa (IFNalpha) and ribavirin. Three hundred and thirty-eight patients have been included in pilot studies on the efficacy and tolerability of IFNalpha monotherapy: 16% showed sustained response and 10% dropped out. No significant adverse impact of IFNalpha monotherapy on HIV diseases or antiretroviral treatment has been observed. IFNalpha and ribavirin in combination have been introduced more recently: only 88 patients were included in pilot studies published as full papers with a 25% sustained response and an 11% rate of drop outs. Anemia and cumulative toxicity with didanosine were the most important side effects of combination treatment, but it did not affect HIV disease progression. Higher rates of sustained response (33%) without increase of side effects have been observed in preliminary experiences with the new long-acting pegylated interferons in combination with ribavirin. The search for the perfect treatment continues.

HIV coinfection does not compromise liver histological response to interferon therapy in patients with chronic hepatitis C

OBJECTIVE

Although discrepancies between histological and virological responses to anti-hepatitis C virus (HCV) therapy are well-established in HIV-negative patients, the liver histological outcome has never been assessed in HIV-HCV co-infected patients receiving anti-HCV therapy. We compared histological responses to interferon (IFN) alpha therapy between HIV-positive and HIV-negative injecting drug users (IDU) and determined factors associated with histological response.

DESIGN

Retrospective cohort study.

SETTING

Hepatology unit of a tertiary referral hospital.

PATIENTS/INTERVENTIONS

Seventy-nine HCV-infected IDU (32 HIV-positive) receiving a 6-month course of IFN-alpha2b therapy, 3 x 106 U three times a week.

PRIMARY OUTCOME MEASURE

Histological response, defined by a > or =2 point decrease in total Knodell score measured on paired liver biopsies over a 2-year follow-up period.

RESULTS

The sustained response rate to IFN therapy was lower in HIV-positive patients than in HIV-negative patients (6.2% versus 29.8%;P = 0.012). Conversely, the rates of histological response (40.6% versus 36.2%) were not different between HIV-positive and HIV-negative patients. Independent factors associated with histological response were first total Knodell score (P = 0.0007) and sustained response to IFN therapy (odds ratio, 12.34; P = 0.005). Histological response was observed in 25% of IFN non-responders whatever their HIV status. In HIV-positive patients, the CD4 cell count did not influence the histological response.

CONCLUSIONS

in HIV-HCV co-infected patients treated with IFN, liver histological improvement is frequently observed, similarly to that observed in HIV-negative patients. Such beneficial effect of interferon therapy supports early treatment of chronic hepatitis C in HIV-infected patients.

Does HIV infection favor the sexual transmission of hepatitis C?

BACKGROUND

There are widely discrepant findings on the sexual transmission of hepatitis C virus (HCV), commonly transmitted by the parenteral route. Coinfection with HCV is common in subjects infected with HIV.

GOAL

This case-control study evaluated the prevalence of anti-HCV in subjects with hetero- or homosexual contact and no history of intravenous drug abuse or blood transfusion, according to the presence or absence of HIV infection.

STUDY DESIGN

In this case-control study, the cases considered were 106 consecutive patients who showed positive anti-HIV test results. For each case, two control subjects were selected who had been screened for HIV infection at the authors' center and found to have anti-HIV-negative test results, and who matched the case in terms age (+/- 5 years), gender, and risk factor for parenterally transmitted infections.

RESULTS

The prevalence of subjects with positive test results for hepatitis B surface antigen (HBsAg) was similar between cases and control subjects (4.7% versus 2.4%). Positivity for anti-hepatitis B core antigen in connection with negative test results for HBsAg was observed more frequently in the 106 cases than in the 212 control subjects (33.9% versus 15.6%; P = 0.0003). Anti-HCV positivity was more frequent in the cases than in the control subjects (15.1% versus 5.2%; P = 0.005). In particular, among subjects who had hetero- or homosexual intercourse with a steady partner who had positive anti-HIV test results, anti-HCV positivity was observed in 18.7% of the 32 cases and 1.6% of the 64 control subjects (P = 0.008).

CONCLUSION

This study demonstrated that in subjects who had only a sexual risk factor for parenterally transmitted infections, HIV may enhance the sexual transmission of HCV.

Influence of the dynamics of the hypervariable region 1 of hepatitis C virus (HCV) on the histological severity of HCV recurrence after liver transplantation

Recurrence of hepatitis C virus (HCV) infection after liver transplantation is almost universal and usually leads to chronic hepatitis with different degrees of severity. The pathogenic mechanisms underlying the variable outcome of HCV infection recurrence are not well defined, but recent data suggest that the dynamics of HCV quasispecies may be involved. HCV quasispecies evolution was traced by longitudinal single strand conformation polymorphism, direct sequencing, and cloning analyses of pre- and post-transplant HCV-1b isolates from patients with histologically severe (seven cases) or mild or moderate (nine cases) HCV infection recurrence. Differences between the two groups of patients that concerned the level of viremia or the degree of HCV quasispecies complexity and diversity were not observed at any of the three time points analyzed. However, emergence of nucleotide and amino acid changes during the 12 months follow-up was significantly more frequent in patients with mild or moderate than in those with severe HCV infection recurrence. The ratio of non-synonymous to synonymous nucleotide substitutions 12 months after transplantation was also greater in the former, suggesting that the HVR1 of HCV is under stronger selective pressure in these subjects. These findings suggest that the degree of amino acid diversification in the HVR1 of HCV, which probably reflects the strength of immune pressure on HCV, is inversely related to the histological severity of HCV infection recurrence.

Hepatitis C is more severe in drug users with human immunodeficiency virus infection

Drug users with chronic hepatitis C virus (HCV) infection are frequently co-infected with human immunodeficiency virus-1 (HIV-1), but it is still not clear whether HIV-1 worsens the natural history of hepatitis C. To investigate this, we conducted a multicentre observational study in 163 drug addicts with histologically documented hepatitis C, 92 of whom were also infected with HIV-1: 25 (27%) were CDC stage II, 53 (58%) were CDC stage III and 14 (15%) were CDC stage IV. Eighty-eight (54%) patients had chronic hepatitis (CH) with minimal activity, 28 (17%) had CH with moderate activity, 40 (25%) had CH with severe activity and seven (4%) had active cirrhosis. Twenty-one HIV-negative patients and 15 HIV-positive patients admitted to alcohol abuse (29% vs 16%, P=0.0665). Liver disease was more severe in HIV-positive patients than in HIV-negative ones (P=0.0198): 34 HIV-positive patients and 13 HIV negatives had severe CH and cirrhosis. These two severe liver diseases were seen more often in HIV-positive patients with a history of alcohol abuse than in HIV-negative patients (10 out of 16 vs seven out of 21). Age, alcohol abuse and distribution of the histological categories of liver disease were statistically different in HIV-infected and HIV-uninfected patients. Multivariate analysis showed that age, alcohol abuse and serum antibodies to HIV were independently associated with severe CH or cirrhosis. Thus, HIV may enhance the risk of severe liver disease in drug users with hepatitis C, independently of the degree of immune dysfunction. Alcohol abuse may contribute independently, aggravating the cause of HCV-dependent liver disease.

Pathology of the liver

At the close of the 20th century, a selection of articles published in 1999 with relevance to liver pathology reflects the wealth of technological and intellectual progress made during the span of the century. Immunohistochemical staining for hepatitis B virus antigens focused attention on a correlation between cytoplasmic expression of core antigen in individuals with precore mutants and higher activity of hepatitis. Infection of ducklings with a presurface mutant strain of duck hepatitis B virus produced cytopathic liver cell damage. Fibrosing cholestatic hepatitis, originally described as an unusual form of recurrent hepatitis B after liver transplantation, has now been described in hepatitis C virus-positive patients with renal transplants. It may be related to the emergence or selection of hepatitis C virus quasispecies. In biliary tract disease, researchers investigated the canal of Hering as a possible source of hepatic stem cells, sporadic mutations in the JAGGED1 gene (involved in cell differentiation) in Alagille syndrome, and several models of nonsuppurative destructive cholangitis. Further work was accomplished on nonalcoholic steatohepatitis, including a proposal of a grading and staging system as well as its detection in workers exposed to volatile petrochemicals. Among hepatic neoplasms and proliferative disorders, epithelioid hemangioendothelioma, angiomyolipoma and Langerhans' cell histiocytosis received coverage in articles describing the diagnostic pathology in collected series of patients.

Prevalence of hepatitis B and C in the sera of patients with HIV infection in São Paulo, Brazil

The objective of this study was to evaluate the prevalence of hepatitis B and C viruses in a group of HIV infected patients, followed at a single institution since 1996. 1,693 HIV positive patients (1,162 male, 531 female) were tested for HBV infection. Virological markers for HBV included HBsAg and total anti-HBc by ELISA. 1,457 patients (1,009 male, 448 female) were tested for HCV infection. Detection of HCV antibodies was carried out by ELISA. A sample of HCV antibody positive patients was tested for HCV by PCR to confirm infection. Of 1,693 patients tested for HBV, 654 (38.6%) and 96 (5.7%) were anti-HBc and HBsAg positive, respectively. Of 1, 457 patients tested for HCV, 258 (17.7%) were anti-HCV positive. 82 of these patients were also tested by PCR and 81 were positive (98%). Of 1,411 patients tested for HBV and HCV 26 (1.8%) were positive for both viruses.

Pathologic features of chronic hepatitis. A review and update

The general histopathologic changes of chronic hepatitis and those related to the various causes are reviewed. Consideration also is given to underlying or associated diseases and to mixed infections in chronic viral hepatitis. Changes occurring in exacerbations or relapses are described. Selected histopathologic changes are illustrated. The nomenclature is reviewed briefly, with emphasis on separation of activity from stage of disease.