Lack of evidence for the heterosexual transmission of hepatitis C

Simultaneous determination of HCV genotype and NS5B resistance associated substitutions using dried serum spots from São Paulo state, Brazil

Hepatitis C virus (HCV) is responsible for more than 180 million infections worldwide, and about 80 % of infections are reported in Low and Middle-income countries (LMICs). Therapy is based on the administration of interferon (INF), ribavirin (RBV) or more recently Direct-Acting Antivirals (DAAs). However, amino acid substitutions associated with resistance (RAS) have been extensively described and can contribute to treatment failure, and diagnosis of RAS requires considerable infrastructure, not always locally available. Dried serum spots (DSS) sampling is an alternative specimen collection method, which embeds drops of serum onto filter paper to be transported by posting to a centralized laboratory. Here, we assessed feasibility of genotypic analysis of HCV from DSS in a cohort of 80 patients from São Paulo state Brazil. HCV RNA was detected on DSS specimens in 83 % of samples of HCV infected patients. HCV genotypes 1a, 1b, 2a, 2c and 3a were determined using the sequence of the palm domain of NS5B region, and RAS C316N/Y, Q309R and V321I were identified in HCV 1b samples. Concerning therapy outcome, 75 % of the patients who used INF +RBV as a previous protocol of treatment did not respond to DAAs, and 25 % were end-of-treatment responders. It suggests that therapy with INF plus RBV may contribute for non-response to a second therapeutic protocol with DAAs. One patient that presented RAS (V321I) was classified as non-responder, and combination of RAS C316N and Q309R does not necessarily imply in resistance to treatment in this cohort of patients. Data presented herein highlights the relevance of studying circulating variants for a better understanding of HCV variability and resistance to the therapy. Furthermore, the feasibility of carrying out genotyping and RAS phenotyping analysis by using DSS card for the potential of informing future treatment interventions could be relevant to overcome the limitations of processing samples in several location worldwide, especially in LMICs.

Serological test results of sexually transmitted diseases in patients with condyloma acuminata

INTRODUCTION

Human papillomavirus (HPV) is one of the most common causes of sexually transmitted diseases (STD). The incidence of condyloma acuminata (CA) has increased in recent years.

AIM

To determine demographical features and serological test results of STD in patients with CA.

MATERIAL AND METHODS

A cross-sectional survey was conducted on 94 patients presenting to a dermatology clinic in Ankara, Middle Anatolia, Turkey. Dermatological examinations were made and the patients completed a questionnaire which consisted of questions about their marital status, partners and condom use. In all cases, VDRL/RPR, anti-HIV, HBsAg, anti-HCV and in 57 cases - HSV type 1-2 IgM and IgG were studied. If the value of VDRL or RPR was positive, TPHA was conducted.

RESULTS

In our study, 83 men and 11 women had CA. We could not analyze whether our cases had multiple partners and a habit of condom use as some of the patients did not answer questions about their sexual life. We observed VDRL and TPHA positivity in 3 (3.1%) cases, none of those cases had clinical findings of syphilis and they denied using any therapy for syphilis. HBsAg positivity was found in 3 cases. No anti-HIV and anti-HCV antibody positivity was detected.

CONCLUSIONS

The seroprevalence of HBsAg in our study was similar to that of the general population of Turkey. But as we found positive syphilis serology in 3 patients, we suggest that syphilis serology should be investigated in patients with CA.

Prevalence of hepatitis C in a Swiss sample of men who have sex with men: whom to screen for HCV infection?

BACKGROUND

While the numbers of hepatitis-C-virus (HCV) infections among men who have sex with men (MSM) who are co-infected with the human immunodeficiency virus (HIV) are on the rise, with vast evidence for sexual transmission of HCV in this population, concerns have also been raised regarding sexual HCV-transmission among MSM without HIV infection. Therefore, the aim of this study was to estimate the prevalence of hepatitis C among MSM without HIV diagnosis in Zurich (Switzerland).

METHODS

Participants were recruited from a gay health centre and various locations such as dark rooms, saunas and cruising areas in Zurich. Participants self-completed a questionnaire assessing known and suspected risk factors for HCV-infection, and provided a blood sample for detection of past (antibodies) and present (core antigen, RNA) infections with HCV.

RESULTS

In total, 840 MSM aged 17-79 (median: 33 years) underwent HCV-testing and completed the questionnaire, among whom 19 reported living with HIV. Overall, seven tested positive for HCV-antibodies, and two were also positive for HCV core antigen and HCV-RNA-these two were immigrants, one from a country where HCV is endemic. None of the seven were aware of their infection. The seroprevalence of hepatitis C among the 821 non-HIV-diagnosed MSM was 0.37% (95%-CI: 0.12-1.69%), and one man harboured replicating virus (0.12%; 0.02-0.69%), resulting in a number needed to test of 821 to detect one active infection. Significant univariable associations of lifetime HCV-infection were found with known HIV-diagnosis (OR=72.7), being tattooed (OR=10.4), non-injection use of cocaine/amphetamines (OR=8.8), and non-Swiss origin (OR=8.5). For MSM without HIV-diagnosis, the only variable marginally associated with positive HCV-serostatus was being tattooed (OR=8.3). No significant associations were observed with reported injection drug use, unprotected anal intercourse, sexual practices that may lead to mucosal trauma, or proxy measures for group sex and lesion-prone STIs.

CONCLUSIONS

Our findings suggest that in Switzerland, hepatitis C among MSM without diagnosed HIV is not more prevalent than in the general population. We found no evidence of elevated rates of sexual transmission of HCV among MSM without HIV-infection. Therefore, we currently see no reason for promoting HCV-testing among all MSM in Switzerland.

Sexual transmission of viral hepatitis

Identification and vaccination of adults at risk for hepatitis B virus acquisition through sexual contact is a key strategy to reduce new hepatitis B virus infections among at-risk adults. Hepatitis C has emerged as a sexually transmitted infection among men with male sex partners (MSM). Several biological and behavioral factors have been linked to hepatitis C virus transmission among MSM, including human immunodeficiency virus coinfection; participation in sexual practices that result in mucosal damage or result in exposure to blood; presence of sexually transmitted diseases (STIs), particularly ulcerative STIs; multiple/casual sex partners; and unprotected anal intercourse.

Injecting practices in sexual partnerships: hepatitis C transmission potentials in a 'risk equivalence' framework

BACKGROUND

Evidence indicates minimal hepatitis C (HCV) sexual transmission risk among HIV negative heterosexual partners. Limited HCV literacy has been demonstrated among people who inject drugs, yet there is a dearth of research exploring perceptions of HCV heterosexual transmission risk among this high risk population.

METHODS

We conducted a qualitative life history study with people who had been injecting drugs for over six years, to explore the social practices and conditions of long-term HCV avoidance. Participants were recruited through London drug services and drug user networks. The sample comprised 10 women and 27 men (n=37), of whom 22 were HCV antibody negative. Participants were aged from 23 to 57 years and had been injecting for 6 to 33 years. Twenty participants were in long term heterosexual partnerships.

FINDINGS

The majority of participants in relationships reported 'discriminate' needle and syringe sharing with their primary sexual partner. Significantly, and in tension with biomedical evidence, participants commonly rationalised syringe sharing with sexual partners in terms of 'risk equivalence' with sexual practices in regard to HCV transmission. Participants' uncertain knowledge regarding HCV transmission, coupled with unprotected sexual practices perceived as being normative were found to foster 'risk equivalence' beliefs and associated HCV transmission potential.

CONCLUSION

HCV prevention messages that 'add on' safe sex information can do more harm than good, perpetuating risk equivalence beliefs and an associated dismissal of safe injecting recommendations among those already practicing unprotected sex.

Should HCV discordant couples with a seropositive male partner be treated with assisted reproduction techniques (ART)?

OBJECTIVE

The debate on HCV discordant couples requiring assisted reproduction is still open today, and specific guidelines have not yet been established on whether or not physicians should treat HCV discordant couples who require ART. We studied the results of our reproductive assistance with sperm washing in HCV discordant couples, all treated in a single center, including the serological status of mothers and babies, and the outcome of the pregnancies.

STUDY DESIGN

Prospective study conducted between January 2008 and December 2010 in our Reproductive Center in Sacco Hospital, University of Milan. Thirty-five HCV serodiscordant infertile couples with an HCV viremic positive male partner were enrolled. All of them completed the immuno-virological and fertility triage, and were treated according to our clinical protocols.

RESULTS

Forty-seven superovulation and IUI and 38 second-level ART procedures are reported. The pregnancy rates for IUI and ICSI are similar to those reported by the Italian ART register. All the 85 sperm samples were treated with sperm washing technique to reduce HCV in semen and the possible risk of transmission. We did not observe any preterm delivery or negative perinatal outcome. No mothers or babies are infected by HCV.

CONCLUSION

This is the biggest prospective study conducted in a single center involving HCV discordant infertile couples in an ART program. Although sexual transmission of HCV is very low, in subfertile or infertile couples sperm washing should be used to treat HCV positive semen before ART. We suggest that it is not necessary to perform nested PCR to detect HCV RNA in the final swim-up. Since the presence of HCV in semen implies a possible risk of nosocomial contamination, safety regulations must be strictly applied in assisted reproduction laboratories.

Clarification of interspousal hepatitis C virus infection in acute hepatitis C patients by molecular evolutionary analyses: Consideration on sexual and non-sexual transmission between spouses

AIM

  Previous studies evaluating the possibilities of interspousal sexual transmission of hepatitis C virus (HCV) have yielded many conflicting results. The aim of this study was to clarify the source of HCV infection in acute hepatitis C patients using phylogenetic analyses of nucleotide sequences of HCV E1 region.

METHODS

  Four acute hepatitis C patients were hospitalized in 2002-2007. The diagnosis was based on medical records, laboratory tests including HCV markers, and ultrasonographic examination of the liver. In each spouse of four patients, serum HCV antibody was assayed. In the subjects whose serum HCV antibody was positive, additional tests on HCV viral load and genotype were carried out. Then phylogenetic analyses of nucleotide sequences of partial HCV E1 region (440 nucleotides) of the patients and their spouses were performed.

RESULTS

  Hepatitis C virus antibody changed from negative to positive in the course of hospitalization and HCV RNA could be detected in every patient. Therefore they were diagnosed as acute hepatitis caused by HCV infection. In every spouse of four patients, HCV antibody and HCV RNA were positive. Three of four couples had the identical genotype and homogeneity of nucleotide sequences of HCV E1 region in three couples ranged from 97.9% to 100%. The results of phylogenic analyses suggested that interspousal HCV infection occurred in the three couples.

CONCLUSION

  In conclusion, interspousal infection might be one of the important sources of acute HCV infection in Japan. The usefulness of phylogenetic analysis of nucleotide sequences of HCV E1 region for clarifying interspousal HCV infection was validated.

Trouble with bleeding: risk factors for acute hepatitis C among HIV-positive gay men from Germany--a case-control study

OBJECTIVES

To identify risk factors for hepatitis C among HIV-positive men who have sex with men (MSM), focusing on potential sexual, nosocomial, and other non-sexual determinants.

BACKGROUND

Outbreaks of hepatitis C virus (HCV) infections among HIV-positive MSM have been reported by clinicians in post-industrialized countries since 2000. The sexual acquisition of HCV by gay men who are HIV positive is not, however, fully understood.

METHODS

Between 2006 and 2008, a case-control study was embedded into a behavioural survey of MSM in Germany. Cases were HIV-positive and acutely HCV-co-infected, with no history of injection drug use. HIV-positive MSM without known HCV infection, matched for age group, served as controls. The HCV-serostatus of controls was assessed by serological testing of dried blood specimens. Univariable and multivariable regression analyses were used to identify factors independently associated with HCV-co-infection.

RESULTS

34 cases and 67 controls were included. Sex-associated rectal bleeding, receptive fisting and snorting cocaine/amphetamines, combined with group sex, were independently associated with case status. Among cases, surgical interventions overlapped with sex-associated rectal bleeding.

CONCLUSIONS

Sexual practices leading to rectal bleeding, and snorting drugs in settings of increased HCV-prevalence are risk factors for acute hepatitis C. We suggest that sharing snorting equipment as well as sharing sexual partners might be modes of sexual transmission. Condoms and gloves may not provide adequate protection if they are contaminated with blood. Public health interventions for HIV-positive gay men should address the role of blood in sexual risk behaviour. Further research is needed into the interplay of proctosurgery and sex-associated rectal bleeding.

Is sexual contact a major mode of hepatitis C virus transmission?

Medical opinion varies considerably regarding the transmission of hepatitis C virus (HCV) through sexual contact. Based on the study design, representativeness of the study population, and the methods used for case ascertainment, we analyzed 80 qualifying reports regarding the evidence for or against sexual transmission. Regarding heterosexual transmission, the weight of evidence is that there is no increased risk of sexual transmission of HCV among heterosexual couples in regular relationships. This risk increases among persons with multiple sexual partners (adjusted odds ratio [aOR] 2.2-2.9), but this association may be confounded by increased likelihood of injection drug use with increased number of partners. There appears to be a real increased risk for women coinfected with human immunodeficiency virus (HIV) or other sexually transmitted infections (aOR 3.3-3.9) and especially for HIV-infected gay men who are having sex with one another compared with HIV-uninfected men (aOR 4.1-5.7). HIV-infected gay men increase their risk of such transmission in association with practices that lead to mucosal trauma (multiple sexual partners, fisting, use of sex toys) and the presence of genital ulcerative disease.

CONCLUSION

This review should inform, and not distract from, recommendations to reduce the risk of HCV transmission. Health care providers need to pay special attention to sexual transmission of HCV among HIV-infected individuals.

Viral hepatitis and injection drug use in Appalachian Kentucky: a survey of rural health department clients

OBJECTIVES

We identified correlates of exposure to hepatitis B and C viruses among health department clients in Appalachian Kentucky, a rural region noted for high poverty and low education. Additionally, we investigated risk factors for transmission, and the frequency of use of preventive measures.

METHODS

Patients screened for hepatitis B or C at four county health departments in Appalachian Kentucky were administered a routine prescreening questionnaire and an additional survey designed to obtain detailed personal and behavioral risk factor data. These data were linked to produce a more comprehensive dataset for analysis, including test results, which were attached to the prescreening questionnaire.

RESULTS

In total, 92 health department clients participated in the study survey. Of these, test results were available for 80 of the clients. Very few subjects who enrolled in this study tested positive for hepatitis B. Twelve out of 80 participants (15%) tested positive for previous exposure to hepatitis C. No participants reported having human immunodeficiency virus.

CONCLUSIONS

Transmission of hepatitis C in these rural Appalachian communities is predominantly due to injection drug use. Patients with hepatitis C exposure are similar in their demographic and risk profiles as those seen in urban areas and, despite small numbers, can have a serious impact on small, rural public health systems.

Prospective evaluation of the threat related to the use of seminal fractions from hepatitis C virus-infected men in assisted reproductive techniques

BACKGROUND

The risk of hepatitis C virus (HCV) transmission during assisted reproductive techniques (ARTs) is still disputed and no report concerning its prospective evaluation is available.

METHODS

The aim of this 4-year follow-up multicentre study that enrolled 86 HCV-serodiscordant couples was to determine whether a sperm-processing method was able to reduce levels of HCV in semen and the risk of HCV transmission to the newborn. All the men were chronically infected by HCV and 10 of them by human immunodeficiency virus. A total of 181 seminal plasmas and 153 sperm fractions were tested for the presence of HCV RNA.

RESULTS

HCV RNA tested positive in 20.4% of the seminal samples. All of the 153 final sperm fractions tested negative for HCV. The detection of HCV RNA in semen was significantly correlated with a high viral load in blood (P < 0.05). The presence of HCV RNA in seminal plasma impaired neither semen parameters nor ART issue. From the 58 couples enrolled effectively in an ART programme, 24 pregnancies and 28 newborns were obtained. All of them tested negative for HCV RNA in blood.

CONCLUSION

These results emphasize the safety of the semen-processing method. The negligible risk of transmitting HCV reduces the value of the systematic analysis of HCV RNA in seminal fractions prior to ART. Since use of this analytical procedure involves the freezing of semen, its avoidance would result in an increase in sperm quality and reduce the need to perform intracytoplasmic sperm injection techniques.

The role of obstetrician/gynecologists in the management of hepatitis C virus infection

Chronic infection with hepatitis C virus (HCV) is a major cause of liver disease-related death and is also the most frequent indication for liver transplantation in USA. Infected individuals can remain asymptomatic for 20 years or more, but they remain at risk for progressive liver disease. They also represent a potential source of infection for others. For reducing the future disease burden due to HCV, obstetrician/gynecologists and primary health care practitioners should be aware of the factors that promote HCV transmission: how to provide counseling and testing, and when specialist referral is needed.

Sexual transmission of hepatitis C

It is generally agreed that the hepatitis C virus (HCV) can be efficiently transmitted parenterally, although data on viral transmission by sexual or non-sexual intrafamilial contact are conflicting. Since data collection began in 1989, the first study dealt with the risk of sexual transmission among multiple sex partners. Other investigations followed, emphasizing that risk increases in specific groups such as patients co-infected with HIV and HBV, sex workers, homosexuals, illicit drug users and patients attended at sexually transmittable disease clinics. The question arises as to what might be the risk for monogamous heterosexuals in the general population, in which one of the partners has HCV? The literature provides overall rates that vary from zero to 27%; however, most studies affirm that the chances of sexual transmission are low or almost null, with rates for this mode fluctuating from zero to 3%. Intrafamilial transmission is strongly considered but inconclusive, since when mentioning transmission between sex partners within the same household, specific situations also should be considered, such as the sharing of personal hygiene items, like razorblades, toothbrushes, nail clippers and manicure pliers, which are important risk factors in HCV transmission. In this review, we discuss the hypotheses of sexual and/or intrafamilial transmission.

Hepatitis C Virus Infection: Sexual or Non-Sexual Transmission Between Spouses? A Case Report and Review of the Literature

The most efficient route of transmission of hepatitis C virus (HCV) infection is through contaminated blood. Sexual transmission or other close human contact could play a role in sporadic infections. We describe a case of acute hepatitis C progressing to chronic hepatitis over a follow-up of 4 years in a 44-year-old woman having a long-standing monogamous relationship with an HCV infected partner. The infection followed the accidental exposure to her husband's contaminated blood containing a high viral load. The case reported here is the first characterized by a documented direct percutaneous HCV transmission outside the healthcare setting, and suggests that sexual exposure to HCV should be considered only after an accurate exclusion of other routes of intrafamilial spread of the infection. Such conclusion is based on a thorough and updated review of the literature concerning both sexual and household transmission of HCV.

Nanomedicines in the treatment of patients with hepatitis C co-infected with HIV--focus on pegylated interferon-alpha

In immuno-competent individuals, the natural course of chronic hepatitis C virus (HCV) infection is highly variable and 5%–30% of patients develop cirrhosis over 20 years. Co-infection with HCV and human immunodeficiency virus (HIV) is an important prognostic factor and associated with more frequent and accelerated progression to cirrhosis. Until recently HIV/AIDS-related complications were life limiting in patients co-infected with HCV; the introduction of highly active antiretroviral treatment (HAART) and the better prognosis of HIV infection has made HCV-related complications an emerging health problem in HCV/HIV co-infected individuals. Treatment of chronic HCV infection has also evolved since the introduction of interferon-alpha. Recently, introduction of pegylated interferon-alpha (peginterferon-alpha) has resulted in an increase in sustained virus clearance rates of up to 80% in selected genotypes and patient populations. The safety and efficacy of modern anti HCV treatment regimens – based on peginterferon-alpha in combination with ribavirin – was evaluated in 4 controlled trials. Sustained clearance of hepatitis C virus can be achieved in up to 35% of patients with HIV/HCV co-infection, and novel HCV treatment regimens based on peginterferon-alpha have no negative effect on the control of HIV disease. In conclusion, if HIV infection is well controlled and CD4⁺ cell counts >100/mm³, treatment of chronic hepatitis C with peginterferon in combination with ribavirin is safe and should be given for 48 weeks regardless of the HCV genotype. Introduction of peginterferon-alpha has significantly improved adherence to treatment and treatment efficacy; in particular sustained virologic response in patients with HCV genotype 1 or 4 infection improved, but sustained viral clearance in only 7%–38% of patients infected with genotype 1 and 4 cannot be the final step in development of effective treatments in patients with HCV/HIV co-infection.

[Risk of hepatitis C related to traditional medicine: a case control study in Ho Chi Minh City, Vietnam]

BACKGROUND

The transmission of hepatitis C virus (HCV) is strongly associated with blood transfusion and drug abuse. However, in about a third of HCV-infected subjects, the risk factors are not clearly identified though some cases are likely to be healthcare associated. In an Asian country such as Vietnam, invasive procedures used for traditional and beauty care could be potential risk factors. The aim of the present study was to identify the risk factors of HCV infection in a population sample in Ho Chi Minh City.

METHOD

A case-control study matched by gender and age was performed among blood adults donors at the Centre of hematological diseases and blood transfusion. Cases were defined as blood donors with HCV-positive Elisa. Controls were selected at random among ELISA HCV-negative donors. A standardized questionnaire was used to collect data focusing on invasive medical procedures, beauty care and on invasive procedures related to traditional medicine.

RESULT

Among the 80 cases and 240 controls, the independent predictors of anti-HCV positivity using a stepwise logistic regression were: blood transfusion, intravenous drug abuse, acupuncture, ventoused scarification and practice of scarification (adjusted odds ratio and IC95%: 3.8 [1.1-13.1], 3.5 [1.7-7.3], 5.4 [2.3-12.7], 5.4 [2.5-11.7], 6.6 [1.6-26.4] respectively). The other risk factors such as past hospitalization surgery, tattooing, being a healthcare worker, or practising tattooing or piercing were not associated with HCV infection.

CONCLUSION

To be exposed to ventoused scarifications or acupuncture are risk factors for the transmission of HCV in Vietnam. A wide information campaign on hygiene practices for general population as well as the practitioners is needed to ensure safer health cares in traditional medicine.

Assisted procreation in cases of hepatitis B, hepatitis C or human immunodeficiency virus infection of the male partner

Guidelines for assisted procreation impose a special responsibility upon physicians for the health of the expected child because of their active role in inducing pregnancy. Therefore, careful clinical evaluation of both partners has to precede every application of these methods. Risks for the mother's health or the development of the child count as a relative contraindication for a treatment. To balance these relative contraindications, the existing risk factors have to be recognized through screening examination. If a chronic infection occurs in the male partner, prevention for the female partner is theoretically possible by using a condom. As this inhibits a pregnancy, at least in cases of human immunodeficiency virus and hepatitis C virus infections, realization of a pregnancy requires assisted procreation. The main question in these cases is whether infectious particles can be eliminated by sperm processing to ensure the safe treatment of the healthy female partner.

[Sexual transmission of hepatitis C virus]

Hepatitis C virus (HCV) is usually transmitted parenterally, but sexual transmission is considered likely in the 20% of cases with no other risk factors. Retrospective cohort studies conducted among persons who have never injected drugs show that factors predictive of HCV seropositivity include the number of lifetime sexual partners, high-risk sexual practices, other sexually transmitted infections, and HIV seropositivity. Persons in long-term monogamous heterosexual relationships with a partner seropositive for HCV are at lower risk of HCV acquisition (0 to 0.6% peryear) than persons with multiple partners or those at risk for sexually transmitted diseases (0.4 to 1.8% per year). HCV RNA is detectable in genital fluids, but there is not yet any proof that the HCV RNA in genital secretions represents infectious virus. HCV can be transmitted by sexual intercourse but much less efficiently than other sexually transmitted viruses, such as HBV and HIV. Sexual transmission of HCV may be enhanced by other concomitant sexually transmitted infections with genital erosive lesions or via traumatic sexual intercourse with abrasion of the genital mucosa.

Unsafe sex and increased incidence of hepatitis C virus infection among HIV-infected men who have sex with men: the Swiss HIV Cohort Study

BACKGROUND

Data on the incidence of hepatitis C virus (HCV) infection among human immunodeficiency virus (HIV)-infected persons are sparse. It is controversial whether and how frequently HCV is transmitted by unprotected sexual intercourse.

METHODS

We assessed the HCV seroprevalence and incidence of HCV infection in the Swiss HIV Cohort Study between 1988 and 2004. We investigated the association of HCV seroconversion with mode of HIV acquisition, sex, injection drug use (IDU), and constancy of condom use. Data on condom use or unsafe sexual behavior were prospectively collected between 2000 and 2004.

RESULTS

The overall seroprevalence of HCV infection was 33% among a total of 7899 eligible participants and 90% among persons reporting IDU. We observed 104 HCV seroconversions among 3327 participants during a total follow-up time of 16,305 person-years, corresponding to an incidence of 0.64 cases per 100 person-years. The incidence among participants with a history of IDU was 7.4 cases per 100 person-years, compared with 0.23 cases per 100 person-years in patients without such a history (P<.001). In men who had sex with men (MSM) without a history of IDU who reported unsafe sex, the incidence was 0.7 cases per 100 person-years, compared with 0.2 cases per 100 person-years in those not reporting unsafe sex (P=.02), corresponding to an incidence rate ratio of 3.5 (95% confidence interval, 1.2-10.0). The hazard of acquiring HCV infection was elevated among younger participants who were MSM.

CONCLUSIONS

HCV infection incidence in the Swiss HIV Cohort Study was mainly associated with IDU. In HIV-infected MSM, HCV infection was associated with unsafe sex.

Lack of evidence of sexual transmission of hepatitis C among monogamous couples: results of a 10-year prospective follow-up study

The risk of sexual transmission of hepatitis C virus (HCV) infection was evaluated among 895 monogamous heterosexual partners of HCV chronically infected individuals in a long-term prospective study, which provided a follow-up period of 8,060 person-years. Seven hundred and seventy-six (86.7%) spouses were followed for 10 yr, corresponding to 7,760 person-years of observation. One hundred and nineteen (13.3%) spouses (69 whose infected partners cleared the virus following treatment and 50 who ended their relationship or were lost at follow-up) contributed an additional 300 person-years. All couples denied practicing anal intercourse or sex during menstruation, as well as condom use. The average weekly rate of sexual intercourse was 1.8. Three HCV infections were observed during follow-up corresponding to an incidence rate of 0.37 per 1,000 person-years. However, the infecting HCV genotype in one spouse (2a) was different from that of the partner (1b), clearly excluding sexual transmission. The remaining two couples had concordant genotypes, but sequence analysis of the NS5b region of the HCV genome, coupled with phylogenetic analysis showed that the corresponding partners carried different viral isolates, again excluding the possibility of intraspousal transmission of HCV. Our data indicate that the risk of sexual transmission of HCV within heterosexual monogamous couples is extremely low or even null. No general recommendations for condom use seem required for individuals in monogamous partnerships with HCV-infected partners.

Molecular investigation of interspousal transmission of hepatitis C virus in two Japanese patients who acquired acute hepatitis C after 40 or 42 years of marriage

A 65-year-old woman (C1I) and a 65-year-old man (C2I) contracted acute hepatitis C 40 or 42 years after marriage, respectively, in Japan. They had no discernible risk factors for acquiring hepatitis C virus (HCV) infection, except that they had monogamous sexual relationships with their spouses (C1S [66-year-old] with hepatocellular carcinoma and C2S [64-year-old] with liver cirrhosis, respectively) who were infected with HCV of the same genotype (1b) and had a high-titer HCV RNA in the serum (bDNA probe assay, 17 Meq/ml [C1S] and 15 Meq/ml [C2S]). The HCV isolates from Patients C1I and C1S and those from Patients C2I and C2S shared identity of 99.9% and 99.1%, respectively, in the 1,087-nucleotide (nt) sequence of the NS5B region, although these four isolates were only 91.7%-96.2% identical to the 94 reported genotype 1b isolates including those from Japanese patients. To confirm the high degree of genetic relatedness among ten HCV clones from each spouse within each pair of spouses, the E1 and E2 junctional region sequence (268 or 271 nt) including hypervariable region 1 (HVR-1) was analyzed. There was a close relationship between clones obtained from each spouse within each couple. Regarding the HVR-1 amino acid sequence, nine of the ten C1I clones were 100% identical with six of the ten C1S clones, and one each of the C2I and C2S clones differed by only one amino acid residue. This study indicates that two Japanese patients with acute hepatitis C had acquired HCV infection most probably by interspousal sexual transmission during a long-lasting marriage.

Association of hepatitis C virus infection with sexual exposure in southern India

To determine the association between sexual exposure and hepatitis C virus (HCV) infection in urban Chennai, India, a random sample of adults who live in a slum community completed interviews and provided samples to test for HCV, herpes simplex virus type 2 (HSV-2), and other sexually transmitted infections (STIs). All analyses excluded recent and current injection drug users. HCV infection was not associated with the reported number of sex partners for men or women. Women were more likely to be HCV infected if they reported previous genital ulcer disease (adjusted odds ratio [AOR], 3.88; 95% confidence interval [95% CI], 0.94-16.0; marginally statistically significant). Men were more likely to be HCV infected if they were HSV-2 infected (AOR, 3.85; 95% CI, 1.18-12.6) or reported having had sex with men (AOR, 3.61; 95% CI, 1.00-13.1). Sexual transmission of HCV infection may be facilitated by ulcerative STIs and male-male sexual practices, but it appears to occur infrequently in this population.

Managing occupational risks for hepatitis C transmission in the health care setting

Hepatitis C virus (HCV) infection is a significant contemporary health problem in the United States and elsewhere. Because it is primarily transmitted via blood, hepatitis C infection presents risks for both nosocomial transmission to patients and occupational spread to health care workers. Recent insights into the pathogenesis, immunopathogenesis, natural history, and treatment of infection caused by this unique flavivirus provide a rationale for the use of new strategies for managing occupational hepatitis C infections when they occur. This article reviews this developing information. Recently published data demonstrate success rates in the treatment of "acute hepatitis C syndrome" that approach 100\%, and although these studies are not directly applicable to all occupational infections, they may provide important clues to optimal management strategies. In addition, the article delineates approaches to the prevention of occupational exposures and also addresses the difficult issue of managing HCV-infected health care providers. The article summarizes currently available data about the nosocomial epidemiology of HCV infection and the magnitude of risk and discusses several alternatives for managing exposure and infection. No evidence supports the use of immediate postexposure prophylaxis with immunoglobulin, immunomodulators, or antiviral agents. Based on the very limited data available, the watchful waiting and preemptive therapy strategies described in detail in this article represent reasonable interim approaches to the complex problem of managing occupational HCV infections, at least until more definitive data are obtained.

Sexual activity as a risk factor for hepatitis C

The accumulated evidence indicates that hepatitis C virus (HCV) can be transmitted by sexual contact but much less efficiently than other sexually transmitted viruses, including hepatitis B virus and human immunodeficiency virus (HIV). However, because sex is such a common behavior and the reservoir of HCV-infected individuals is sizable, sexual transmission of HCV likely contributes to the total burden of infection in the United States. Risk of HCV transmission by sexual contact differs by the type of sexual relationship. Persons in long-term monogamous partnerships are at lower risk of HCV acquisition (0% to 0.6% per year) than persons with multiple partners or those at risk for sexually transmitted diseases (0.4% to 1.8% per year). This difference may reflect differences in sexual risk behaviors or differences in rates of exposure to nonsexual sources of HCV, such as injection drug use or shared razors and toothbrushes. In seroprevalence studies in monogamous, heterosexual partners of HCV-infected, HIV-negative persons, the frequency of antibody-positive and genotype-concordant couples is 2.8% to 11% in Southeast Asia, 0% to 6.3% in Northern Europe, and 2.7% in the United States. Among individuals at risk for sexually transmitted diseases (STDs), the median seroprevalence of antibody to HCV (anti-HCV) is 4% (range, 1.6% to 25.5%). HIV coinfection appears to increase the rate of HCV transmission by sexual contact. Current recommendations about sexual practices are different for persons with chronic HCV infection who are in steady monogamous partnerships versus those with multiple partners or who are in short-term sexual relationships.

Sexual activity as a risk factor for hepatitis C

The accumulated evidence indicates that hepatitis C virus (HCV) can be transmitted by sexual contact but much less efficiently than other sexually transmitted viruses, including hepatitis B virus and human immunodeficiency virus (HIV). However, because sex is such a common behavior and the reservoir of HCV-infected individuals is sizable, sexual transmission of HCV likely contributes to the total burden of infection in the United States. Risk of HCV transmission by sexual contact differs by the type of sexual relationship. Persons in long-term monogamous partnerships are at lower risk of HCV acquisition (0% to 0.6% per year) than persons with multiple partners or those at risk for sexually transmitted diseases (0.4% to 1.8% per year). This difference may reflect differences in sexual risk behaviors or differences in rates of exposure to nonsexual sources of HCV, such as injection drug use or shared razors and toothbrushes. In seroprevalence studies in monogamous, heterosexual partners of HCV-infected, HIV-negative persons, the frequency of antibody-positive and genotype-concordant couples is 2.8% to 11% in Southeast Asia, 0% to 6.3% in Northern Europe, and 2.7% in the United States. Among individuals at risk for sexually transmitted diseases (STDs), the median seroprevalence of antibody to HCV (anti-HCV) is 4% (range, 1.6% to 25.5%). HIV coinfection appears to increase the rate of HCV transmission by sexual contact. Current recommendations about sexual practices are different for persons with chronic HCV infection who are in steady monogamous partnerships versus those with multiple partners or who are in short-term sexual relationships.

Is a review of standard procedures for cryopreservation needed?: safe and effective cryopreservation-should sperm banks and fertility centres move toward storage in nitrogen vapour?

A recent consultation documentation by the Human Fertilisation and Embryology Authority (HFEA) which focused on the safe cryopreservation of gametes and embryos highlighted the need for a review of the way that fertility clinics in the UK store potentially infective material. The main points for consideration were to: (i) ensure containers used for cryopreservation are guaranteed by manufacturers to withstand low temperatures; (ii) use secondary containers, i.e. 'double bagging' of samples if stored in the liquid phase; and (iii) store in nitrogen vapour as a 'safer' alternative. In this article we examine a number of issues related to vapour storage which need careful consideration, including safety, cost and the effectiveness of various storage techniques in maintaining gamete and embryo viability. We also discuss the effectiveness of vapour storage in comparison with current liquid nitrogen storage techniques. In conclusion, we propose that fertility clinics should be compelled to review their cryopreservation procedures, not just because of new legislation or indeed fear of litigation but by a moral obligation.