Sexual transmission of hepatitis C virus and its relation with hepatitis B virus and HIV

Should we start looking at the elderly for human immunodeficiency virus infections? A study of trends of human immunodeficiency virus, hepatitis B virus, and hepatitis C virus in Mumbai, Maharashtra, India

Background

There is limited information on the trends of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) co-infections in India - particularly from private health-care settings. We designed the present research to estimate the prevalence of HIV, HBV, and HCV over a period of 7 years and study the factors associated with them.

Materials and Methods

The present study is a secondary data analysis of data from the laboratory records of 24,086 individuals who were tested over a period of 7 years (2009-2015). We estimated the proportion and 95% confidence intervals (CIs) for HIV, hepatitis B surface antigen (HBsAg), and HCV antibodies.

Results

The overall seroprevalence of HIV was 0.35% (95% CI: 0.27%, 0.44%), HBsAg was 1.65% (95% CI: 1.48%, 1.82%), and HCV was 1.73% (95% CI: 1.56%, 1.90%). The prevalence of HIV among those who were more than 70 years of age was 0.14% (95% CI: 0.04%, 0.32%). The prevalence of HBsAg was highest in those aged 30-39 years (2.27%, 95% CI: 1.74%, 2.92%) (P = 0.008). The prevalence of HIV/HBsAg co-infection was 0.019% (95% CI: 0.005%, 0.050%), HIV/HCV co-infection was 0.005% (95% CI: 0.000, 0.027%), and HBsAg/HCV co-infection was 0.059% (95% CI: 0.030%, 0.102%). We did not encounter even a single case of all the three infections.

Conclusions

HIV infection is relatively high in those who were aged 50 years of more; thus, they need to be included in the National AIDS Control Programme. HIV/HBV/HCV co-infections should be regularly monitored in surveillance programs, and antiretroviral therapy officers and counselors should be trained on the management of HIV in those who are co-infected.

Seroprevalence of markers of hepatitis C virus exposure and associated factors in adults aged 18-39 years in the Arctic Russian city of Arkhangelsk: a cross-sectional study

Hepatitis C, caused by the hepatitis C virus (HCV), is a major public health issue in Russia. The aim of our study was to assess the seroprevalence of markers of HCV exposure and factors associated with HCV seropositivity among the general population aged 18–39 years in the city of Arkhangelsk, Northwest Russia. A social research agency applied a quota sampling method to recruit study participants using cell phone numbers. All participants (n = 1243) completed a self-administered questionnaire and provided a blood sample. Sixty-five participants (5.2%, 95% confidence interval [CI] 4.9–5.5) tested positive for HCV IgM+G antibodies, and of these, 55 (84.6%) did not know that they were exposed to HCV. In multivariable logistic regression analysis, HCV seropositivity was significantly associated with older age, a history of injecting drug use, and having ever received a blood transfusion. To reach the goal of the World Health Organisation’s Global Health Sector Strategy on Viral Hepatitis, regional preventive programmes should include measures to reduce injecting drug use as well as scaling up harm-reduction and treatment programs for drug addicts.

HCV epidemiology in high-risk groups and the risk of reinfection

Injecting risk behaviours among people who inject drugs (PWID) and high-risk sexual practices among men who have sex with men (MSM) are important routes of hepatitis C virus (HCV) transmission. Current direct-acting antiviral treatment offers unique opportunities for reductions in HCV-related liver disease burden and epidemic control in high-risk groups, but these prospects could be counteracted by HCV reinfection due to on-going risk behaviours after successful treatment. Based on existing data from small and heterogeneous studies of interferon-based treatment, the incidence of reinfection after sustained virological response range from 2-6/100 person years among PWID to 10-15/100 person years among human immunodeficiency virus-infected MSM. These differences mainly reflect heterogeneity in study populations with regards to risk behaviours, but also reflect variations in study designs and applied virological methods. Increasing levels of reinfection are to be expected as we enter the interferon-free treatment era. Individual- and population-level efforts to address and prevent reinfection should therefore be undertaken when providing HCV care for people with on-going risk behaviour. Constructive strategies include acknowledgement, education and counselling, harm reduction optimization, scaled-up treatment including treatment of injecting networks, post-treatment screening, and rapid retreatment of reinfections.

High rate of seronegative HCV infection in HIV-positive patients

Co-infection with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) is a significant global health problem. The two viruses are transmitted with high efficacy via blood-to-blood contact, mainly intravenous drug use (IVDU), whereas HCV is less easily transmitted sexually. Antibody testing is the main screening method for HCV infection, although it may not be the optimal option for HIV infection. The aim of this study was to investigate HCV infection in HIV-positive patients, with and without a detectable anti-HCV antibody response. A total of 187 plasma samples were obtained from HIV-positive patients in Surabaya, Indonesia and examined for anti-HCV [HCV enzyme immunoassay (EIA) 3.0], HCV genotype/subtype [reverse transcription-polymerase chain reaction (RT-PCR) using primers targeting a part of NS5B/5'UTR followed by sequencing] and HCV viral load (quantitative RT-PCR). A total of 119 patients (63.6%) were found to be anti-HCV-positive and, among these, HCV RNA was detected in 73 (61.3%), with HCV-1a as the predominant subtype (31.5%). Of the 68 anti-HCV-negative samples, HCV RNA was detected in 26/68 (38.2%) mostly as the HCV-3a subtype (50%). High HCV viral loads were more common among the HCV-seropositive patients. The HCV-seropositive samples with detected HCV RNA were mostly obtained from HIV-positive patients with parenteral transmission (IVDU) (76.7%); however, the HCV-seronegative samples with detected HCV RNA were mostly from patients who had acquired HCV through heterosexual transmission (61.5%). In conclusion, HIV-positive patients were at high risk of becoming co-infected with HCV and several remained HCV-seronegative. Furthermore, there may exist differences in HCV seropositivity and subtypes between HIV-positive patients who acquired HCV sexually and those who acquired HCV parenterally.

Incarceration is a major risk factor for blood-borne infection among intravenous drug users: Incarceration and blood borne infection among intravenous drug users

BACKGROUND

There is a strong association between hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) infection which are mainly transmitted by contamination with blood via intravenous drug abuse (IVDU) or sexual contact.

OBJECTIVES

To determine the prevalence of these infections and the risk factors associated with them among prisoner and non-prisoner IVDUs in Tehran, Iran.

PATIENTS AND METHODS

This cross-sectional study was performed in two jails and three drug rehabilitation centers between 2001 and 2002 in Tehran. HBsAg and HBcAb were checked using highly specific third generation enzyme immunoassays (DIA.PRO, Italy, specificity >99%, and Radim, Italy, specificity 99.7%, respectively). HCVAb was detected using ELISA (DIA.PRO, Italy) with both sensitivity and specificity >98%. HIVAb test (DRG Diagnostics kit, Germany) was performed for 459 of the 468 IDU subjects.

RESULTS

392 prisoners and 135 individual attending drug rehabilitation centers were approached. Of the 518 subjects studied, 464 (89.5%) were male, 386 (74.5%) were prisoners and 132 (25.5%) were non-prisoners. In this study, HBsAg, HCVAb and HIVAb were positive in 19 (3.7%), 359 (69.5%) and 70 (15.5%) of subjects, respectively. These tests were positive in 17 (4.5%), 311 (80.5%) and 63 (17%) among prisoners and 2 (1.5%), 48 (36.5%) and 7 (7.8%) in non-prisoners, respectively. Multiple logistic regression analysis revealed that independent factors related to co-infection of HCV and HIV infection were imprisonment (p<0.001. OR: 7.5) and using common syringe (p=0.03, OR: 4.5).

CONCLUSIONS

Our findings strongly suggest that drug injection inside prison carries is a risk for HIV infection and that HIV infection among IDUs is likely to be bridged to the broader population through sexual contact without using effective prevention programs.

Acute hepatitis C in HIV-infected men who have sex with men: an emerging sexually transmitted infection

Since 2000 outbreaks of acute hepatitis C virus (HCV) among HIV-positive men who have sex with men (MSM) who denied injecting drug use have been reported from Europe, the United States, Canada and Australia. Given the burden of liver disease, in particular HCV, on the morbidity and mortality in HIV patients in the era of combination antiretroviral therapy, the rapid and significant rise in the incidence of HCV in the HIV-infected MSM population in high-income countries is alarming. This relates to a significant change in the epidemiology of HCV that has occurred, with HCV emerging as a sexually transmitted infection within this population. Work to date suggests that this permucosal HCV transmission results from high-risk sexual and noninjecting drug use behaviours, reopening the discussion on the importance of sexual transmission. Given this occurs almost exclusively in HIV-infected MSM, HIV probably has a critical role mediated either through behavioural and/or biological factors. Finally, the management of acute HCV in HIV infection is complicated by concomitant HIV infection and combination antiretroviral therapy. This review will synthesize the most recent epidemiological, immunological and management issues that have emerged as a result of the epidemic of acute HCV among HIV-infected MSM.

Characteristics of HCV positive patients in an Italian urban psychiatric unit

OBJECTIVES

1) to assess the prevalence of hepatitis C virus (HCV) infection in a population of acute psychiatric in-patients; 2) to find out relationships between HCV comorbidity and clinical features of psychiatric patients.

METHODS

Prospective observational study in a 6-year period.

RESULTS

2396 cases (1492 patients) were admitted in the considered period. Forty-two patients (2.8%) were affected by HCV infection. HCV infection was more frequent in patients with less years of education, lower social class, lower last year best Global Assessment of Functioning score, more hostile or violent behavior in hospital, with a lifetime history of previous suicide attempt, and with substance-related disorders.

CONCLUSION

HCV infection in psychiatric patients constitutes a major threat to the health of psychiatric patients and is related with unfavorable social background, worse global functioning, hostile or violent behavior, substance-related disorders. It appears also to be a significant risk of suicidal behavior.

[Prevalences of hepatitis virus coinfection and indications for chronic hepatitis C virus treatment and liver transplantation in Spanish HIV-infected patients. The GESIDA 29/02 and FIPSE 12185/01 Multicenter Study]

INTRODUCTION

The aims of this study were to estimate the prevalence of HIV and hepatitis virus coinfection in the Spanish population and to determine the percentage of patients who are candidates for chronic hepatitis C virus (HCV) treatment and liver transplantation within this population.

METHODS

A cross-sectional study was performed in 2002 in two Spanish populations of HIV-infected patients: 1,260 patients from 39 centers throughout Spain (P1) and 1,560 patients from three tertiary teaching hospitals in Madrid (P2).

RESULTS

The following hepatitis A virus (HAV), hepatitis B virus (HBV) and HCV serological prevalence were found in the P1 and P2 groups, respectively: HAV-IgG antibodies: 74% and 78%; HBsAg1: 4.9% and 4.8%; HBsAg-, anti-HBc1, anti-HBs1: 39% and 39%; HBsAg-, anti-HBc1, anti-HBs-: 25% and 31%; HBsAg-, anti-HBc-, anti-HBs1: 7% and 8%; HBsAg-, anti-HBc-, anti-HBs-: 22% and 16%. Anti-HCV1: 61% and 65%, respectively. Of the patients with positive HCV serology, 88.8% and 84.6% of each group were positive for HCV-RNA by polymerase chain reaction. Multiple coinfections with hepatitis viruses were found in 3.2% and 2.8%, respectively; of these, 70% and 78% had coinfection with HBV, HCV and HDV. Liver cirrhosis was found in 5.8% and 9.6% of the patients coinfected with HIV and HCV, respectively. Liver transplant was indicated in approximately one out of every six coinfected patients with liver cirrhosis. The 43 and 37% of the HCV coinfected patients were good candidates for anti-HCV treatment, but only 14% and 15% of patients had initiated it.

CONCLUSIONS

A high percentage of HIV-infected patients in Spain were coinfected with hepatitis viruses, especially HCV. The number of possible candidates for liver transplantation is rising and could increase in the next few years. In the future, greater efforts to treat HIV-and hepatitis virus-coinfected patients will be required.

Consensus conference on chronic viral hepatitis and HIV infection: updated Spanish recommendations

Chronic hepatitis B and C represent a leading cause of morbidity and mortality among human immunodeficiency virus (HIV)-infected patients worldwide. New treatment options against both hepatitis B (HBV) and C (HCV) viruses have prompted us to update previous recommendations for the management of coinfected individuals. Fifteen topics (nine related to HCV, five to HBV and one to both viruses) were selected for this purpose. A panel of Spanish experts in the field was invited to review these areas and propose specific recommendations, which were scored according to the Infectious Disease Society of America (IDSA) grading system. These guidelines represent a comprehensive and updated overview on the management of hepatitis B and C in HIV-infected patients.

Hepatitis C: what every case manager should know

Over the next decade, case managers can anticipate encountering increasing numbers of clients with hepatitis C. This article provides a sociopolitical and medical overview of hepatitis C, diagnosis, risk and transmission factors, co-infection of HIV and hepatitis C treatment issues. The article identifies and analyzes policy and practice implications for case managers in health care.

A national survey of genitourinary medicine clinic attenders provides little evidence of sexual transmission of hepatitis C virus infection

OBJECTIVE

To determine the prevalence and genetic diversity of hepatitis C virus in genitourinary medicine clinic attenders and to assess the extent of sexual transmission of the virus.

METHODS

A cross sectional, unlinked, anonymous survey in 14 genitourinary medicine clinics situated in England, Wales, and Northern Ireland. Serum specimens from genitourinary medicine clinic attenders, retained as part of the Unlinked Anonymous Prevalence Monitoring Programme (UAPMP) serum archive, were tested in small pools, for the presence of antibody to hepatitis C virus (anti-HCV). The main outcome measures were prevalence of antibodies to hepatitis C virus and identification of hepatitis C virus genotypes.

RESULTS

Testing of 17,586 specimens from 1995 showed an adjusted prevalence of anti-HCV in genitourinary medicine clinic attenders of 1.03% (95% CI: 0.89 to 1.16) overall and 0.65% (95% CI: 0.51 to 0.78) among those who did not report injecting drug use. Prevalence in injecting drug users attending genitourinary medicine clinics was 36.9% in both 1995 and 1996. Heterosexual injecting drug users had a higher prevalence of anti-HCV than homosexual/bisexual injectors. The most common hepatitis C genotypes were types 3a and 1a. There was a high degree of concordance between genotype and serotype.

CONCLUSIONS

The low prevalence of anti-HCV in genitourinary medicine clinic attenders who deny injecting drugs suggests that the majority of hepatitis C infections have been acquired in adult life, mostly by injecting drug use, and that the hepatitis C virus is rarely transmitted sexually. The use of needle exchanges may explain the relatively low prevalence observed in the injecting drug users.

Hepatitis C virus viremia in HIV-infected individuals with negative HCV antibody tests

Hepatitis C virus (HCV) viremia may occur in persons without detectable HCV antibodies and has been reported in as many as 5.5% of HIV-positive persons. To better characterize serosilent HCV infection, the authors prospectively tested 131 HIV-positive persons and 102 HIV-negative control subjects with diabetes for the presence of HCV antibody (Ab) and HCV RNA. Thirty of 31 HCV Ab-positive (AbP) HIV-positive people tested positive for HCV RNA as did both HCV AbP, HIV-negative control subjects. Similarly, none of the 100 HIV-negative, HCV Ab-negative (AbN) control subjects was HCV RNA positive (p<.001). In contrast, 19 of 100 HIV-positive, HCV AbN persons met stringent criteria for HCV viremia, and 9 of these 19 people were HCV RNA positive when tested by a commercially available HCV RNA detection method. The mean duration of HCV viremia in HCV AbN people was 26.8 months (range, 1-99 months). None of the subjects developed HCV antibody during the study. The HIV-positive, HCV AbP, and RNA-positive group was significantly more likely to have acquired HIV parenterally (p<.001), have higher initial CD4 counts (p=.029), and have higher ALT values than the HCV AbN group (p<.002). In summary, HCV infection appears to occur more frequently among HIV-infected, HCV-seronegative persons than appreciated, especially if HIV acquisition was through sexual as opposed to parenteral risk factors and was associated with a lower initial CD4 count and lower ALT values.

HCV chronic hepatitis in patients with HIV: clinical management issues

HIV-hepatitis C virus (HCV) coinfection is common and affects more than one-third of all HIV infected persons worldwide. Prevalence among risk categories varies according to shared risk factors for transmission, mainly intravenous drug use (IDU) and hemophiliacs. Chronic HCV infection seems to accelerate the course of HIV disease, resulting in a worsened clinical and immunological progression. At the same time, several studies suggest that HIV disease modifies the natural history of HCV infection, leading to a faster course of progression from active hepatitis to cirrhosis, to end stage liver disease and death. HCV infection mimics opportunistic diseases because its natural history is significantly accelerated in HIV patients. Since highly active antiretroviral therapy (HAART) has slowed the progression of HIV disease and decreased the rate of HIV associated mortality, the prognosis of HIV disease has been modified, and the need to treat HCV coinfection become a significant issue. Because of the poor response rate obtained by either interferon alone or interferon thrice weekly plus ribavirin, the combination of pegylated interferon and ribavirin will probably become the standard of care, although the clinicians should be aware of the overlapping toxicity of nucleoside analogues and ribavirin. Many selected categories of patients pose particular challenges to physicians treating HCV infection: nonresponders to interferon, cirrhotic patients, and patients infected with both HCV and HBV. Liver transplantation in HIV patients is currently under evaluation, but should become the rescue therapy for HIV patients with end stage liver disease.

Management of hepatitis C in human immunodeficiency virus-infected patients

Hepatitis C virus-related liver disease and its associated complications are steadily emerging health concerns in persons co-infected with human immunodeficiency virus. The increasing number of liver-related deaths in human immunodeficiency virus-hepatitis C virus co-infected individuals supports the compelling argument for more aggressive treatment in these patients. The safety and efficacy of interferon/ribavirin in human immunodeficiency virus/hepatitis C virus co-infected patients is currently under evaluation. Despite well-documented concern over highly active antiretroviral therapy-associated hepatotoxicity human immunodeficiency virus/hepatitis C virus co-infected patients should be offered antiretroviral therapy. Since management of co-infected patients is complex a multidisciplinary approach is needed in order to facilitate care and help patients to achieve a positive outcome.

Seroprevalence of hepatitis C markers among intravenous drug users in western European countries: a systematic review

Currently, the most important risk factor for hepatitis C virus (HCV) infection in Europe is intravenous drug use. To establish a better insight into the epidemiology of hepatitis C among intravenous drug users (IVDUs) in western European countries a systematic review on the prevalence of hepatitis C markers and their determinants was performed. Reports were identified by searches on Medline and on the internet and by screening reference lists of selected papers. The prevalence rates of anti-HCV in western European IVDUs reported in the 66 studies selected for analysis, ranged between 37 and 98%. No relation was found between prevalence rates and mean age, mean duration of intravenous drug use, geographical area, setting of the study, method of recruitment or the year(s) of collection of samples. Eleven studies concerning the prevalence of HCV-RNA in hepatitis C-infected IVDUs were selected for analysis. Prevalence rates ranged from 26 to 86%. Based on five studies, a statistically significant positive linear relation was found between the mean age of study population and the prevalence of HCV-RNA. Our analysis revealed considerable variation in prevalence rates of hepatitis C markers among IVDUs in western Europe. We found no conclusive explanation for this variability. Further research investigating the dynamics of the hepatitis C epidemic in IVDUs is necessary.

Hepatitis C virus infection in young, low-income women: the role of sexually transmitted infection as a potential cofactor for HCV infection

OBJECTIVES

We evaluated risk for hepatitis C virus (HCV) infection in women residing in low-income neighborhoods of northern California.

METHODS

A population-based sample of 1707 women, aged 18 to 29, were surveyed and screened for sexually transmitted infections and HCV.

RESULTS

Women infected with HCV (2.5%) were more likely to have a history of injection and noninjection drug use, to exchange sex for money or drugs, and to have sexually transmitted infections. HCV was independently associated with history of injection drug use, herpes simplex virus type 2 (HSV-2) infection, and heroin and cocaine use.

CONCLUSIONS

Injection drug use is the highest risk exposure for HCV, but HSV-2 and noninjection drug use contribute significantly to increased risk. HCV prevention programs in impoverished areas should integrate drug treatment and sexually transmitted infection control.

Hepatitis C: an epidemiological review

The aim of the study was to analyse the current literature regarding the mode of transmission of HCV and its global prevalence in different groups of people. A systematic review of the literature on the epidemiology of hepatitis C from 1991 to 2000 using computerized bibliographic databases which include Medline, Current Content and Embase. The prevalence of hepatitis C virus (HCV) varies tremendously in different parts of the world, with the highest incidence in the Eastern parts of the globe compared with the Western parts. Furthermore, certain groups of individuals such as intravenous drug users are at increased risk of acquiring this disease irrespective of the geographical location. Although the main route of transmission is via contaminated blood, curiously enough in up to 50% of the cases no recognizable transmission factor/route could be identified. Therefore, a number of other routes of transmission such as sexual or household exposure to infected contacts have been investigated with conflicting results. Hepatitis C infection is an important public health issue globally. Better understanding of routes of transmission will help to combat the spread of disease. In order to prevent a world wide epidemic of this disease, urgent measures are required to (i) develop a strategy to inform and educate the public regarding this disease and (ii) expedite the efforts to develop a vaccine.

Risk factors for hepatitis C virus infection among homeless adults

OBJECTIVE

To describe the prevalence of hepatitis C virus (HCV) infection in a sample of homeless and impoverished adults and examine risk factors for HCV infection in the overall sample and as a function of injection drug use.

DESIGN

Assays were conducted on stored sera. Sociodemographic characteristics and risky sexual activity were measured by content-specific items. Substance use was measured by a structured questionnaire. HCV antibodies were tested by enzyme-linked immunosorbent assay; a confirmatory level was defined by recombinant immunoblot assay.

SETTINGS

Shelters ( N = 36) and outdoor locations in Los Angeles.

PARTICIPANTS

Eight hundred eighty-four homeless women and/or partners or friends.

RESULTS

Among this sample of 884 homeless and impoverished adults, 22% were found to be HCV infected. Lifetime injection drug users (IDUs) (cocaine, crack, and methamphetamine) and recent daily users of crack were more likely than nonusers or less-frequent users of these drugs to be HCV-infected. Similar results were found for those who had been hospitalized for a mental health problem. Among non-injection drug users and persons in the total sample, those who reported lifetime alcohol abuse were more likely than those who did not to be HCV infected. Controlling for sociodemographic characteristics, multiple logistic regression analyses revealed IDUs have over 25 times greater odds of having HCV infection than non-IDUs. HCV infection was also predicted by older age, having started living on one's own before the age of 18, and recent chronic alcohol use. Males and recent crack users had about one and a half times greater odds of HCV infection when compared to females and non-chronic crack users.

CONCLUSIONS

Targeted outreach for homeless women and their partners, including HCV testing coupled with referrals to HCV and substance abuse treatments, may be helpful.

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.

Commercial tattooing as a potentially important source of hepatitis C infection. Clinical epidemiology of 626 consecutive patients unaware of their hepatitis C serologic status

Tattooing in commercial tattoo parlors is known to transmit blood-borne viral infections, including hepatitis C virus (HCV), in other countries, but its contribution to the high population prevalence of HCV infection in the United States has been incompletely evaluated. Risk factors for blood-borne infection were assessed by physician's interview of 626 consecutive patients undergoing medical evaluation for spinal problems in 1991 and 1992 while unaware of their HCV status. Later all were screened for HCV infection with enzyme-linked immunosorbent assay (EIA-1 and EIA-2), and positives were confirmed with second-generation recombinant immunoblot assay (RIBA). Forty-three patients were seropositive for HCV (sample prevalence 6.9%, population-standardized prevalence 2.8%). Logistic regression analysis identified 4 independent risk factors for HCV infection: injection-drug use (adjusted prevalence odds ratio [OR] = 23.0; 95% confidence intervals [CI] = 7.5-70.6), ancillary hospital jobs held by men (OR = 9.6; 95% CI = 3.8-24.3), tattoos from commercial tattoo parlors (OR = 6.5; 95% CI = 2.9-14.8), and drinking > or = 3 6-packs of beer per month (OR = 4.0; 95% CI = 1.8-8.7). If causal, these 4 risk factors account for 91% of HCV infections, with tattooing explaining 41%, heavy beer drinking 23%, injection-drug use 17%, and ancillary health care jobs for men 8%. Transfusions, promiscuous sexual activity, bone grafts, acupuncture, perinatal or intimate transmission in families, and other modes were not independently associated with serologic evidence of HCV infection. Unlikely to be explained by confounding or incomplete disclosure of other risk factors, tattooing in commercial tattoo parlors may have been responsible for more HCV infections than injection-drug use.

Heterosexual transmission of hepatitis C, hepatitis B, and HIV-1 in a sample of inner city women

BACKGROUND

To clarify the role of heterosexual transmission of hepatitis C virus (HCV) and to identify associated risk factors.

GOAL

To compare risk factors with infection among women with HCV, HIV-1, and hepatitis B virus (HBV).

STUDY DESIGN

A cross-sectional study of the prevalence of HCV, HIV-1, and HBV in a sample of 599 sexually active, nontransfused, inner-city women with no evidence of intravenous drug use.

RESULTS

The prevalence of HCV was 1.6%, compared with 2.0% for HIV-1 and 18.8% for HBV; 75% of women infected with HCV were also infected with HIV-1 or HBV (P < 0.001). Women engaging in very high-risk sexual behavior were 14.2 times more likely to have HCV than other women (95% CI, 1.8-642.5).

CONCLUSIONS

The epidemic of HCV may be facilitated by high-risk sexual behavior. The relatively high prevalence of HCV suggests the need for more widespread screening among inner-city females.

HCV status knowledge and risk behaviours amongst intravenous drug users

The aim of this study was to identify relationships between injecting and sexual risk behaviours and hepatitis C virus (HCV) status knowledge in intravenous drug users (IDUs). It was a cross-sectional survey (March 1994-June 1995) in 10 drug abuse treatment or psychosocial centres in Paris, France. We used a structured questionnaire about sexual, injecting, HIV and HCV antibody testing practices and results during the previous 6 months. Six hundred and twelve sexually active IDUs aged 18 or older who were current injecting drug users were interviewed. Of 592 respondent IDUs, 37% did not report consistent HCV testing and 34% reported being HCV-positive. HCV-positive IDUs were older than HCV-negatives and HCV-unknowns. HCV-unknowns and HCV-positives had a lower educational level than HCV-negatives. After adjusting for demographic characteristics and HIV status, the factors associated with being HCV-unknown were not using condoms (OR: 2.9; 95% CI: 1.9-4.6) as well as clean equipment (OR: 1.8; 95% CI: 1.2-3.0). Not using new equipment was negatively associated with being HCV-unknown (OR: 0.4; 95% CI: 0.2-0.6) and with being HCV-positive (OR: 0.5; 95% CI: 0.3-0.8). Our study suggests that particular sexual and injecting risk-behaviours are associated with not knowing HCV status. As HCV-unknown IDUs are likely to be at the risk of transmitting HCV or acquiring other infections. HCV testing should be encouraged and associated with sexual counselling. Special attention should be paid to disinfecting practices for HCV-positives and use of new injecting equipment should be recommended for HCV-negatives.

Risk factors for hepatitis C virus infection in United States blood donors. NHLBI Retrovirus Epidemiology Donor Study (REDS)

Injection drug use (IDU) is a known risk factor for hepatitis C virus (HCV) infection, but the strength of other parenteral and sexual risk factors is unclear. In 1997, we performed a case-control study of 2,316 HCV-seropositive blood donors and 2,316 seronegative donors matched on age, sex, race/ethnicity, blood center, and first-time versus repeat-donor status. Odds ratios (OR) and 95% confidence intervals (CIs) were calculated using conditional logistic regression. Questionnaires were returned by 758 (33%) HCV(+) and 1,039 (45%) control subjects (P =.001). The final multivariate model included only the following independent HCV risk factors: IDU (OR = 49.6; 95% CI: 20.3-121.1), blood transfusion in non-IDU (OR = 10.9; 95% CI: 6.5-18.2), sex with an IDU (OR = 6.3; 95% CI: 3.3-12.0), having been in jail more than 3 days (OR = 2.9; 95% CI: 1.3-6.6), religious scarification (OR = 2.8; 95% CI: 1.2-7. 0), having been stuck or cut with a bloody object (OR = 2.1; 95% CI: 1.1-4.1), pierced ears or body parts (OR = 2.0; 95% CI: 1.1-3.7), and immunoglobulin injection (OR = 1.6; 95% CI: 1.0-2.6). Although drug inhalation and a high number of lifetime sex partners were significantly more common among HCV seropositives, they were not associated with HCV after controlling for IDU and other risk factors. IDU, blood transfusion among non-IDU, and sex with an IDU are strong risk factors for HCV among United States blood donors. Weaker associations with incarceration, religious scarification, being stuck or cut with a bloody object, pierced ears or body parts, and immunoglobulin injection must be interpreted with caution.

Hepatitis C: public health strategies

Hepatitis C virus (HCV) is a major global public health problem. As with many recently discovered diseases, there is still considerable controversy within the scientific community regarding the prevalence, incidence and socio-economic burden of acute and chronic hepatitis C. New infections continue to occur. Given the substantial morbidity and mortality attributable to HCV-related chronic liver disease, each country, irrespective of its economic status, should develop an HCV-related public health plan for the prevention of new HCV infections. The source of HCV infection includes transfusion of blood or blood products from unscreened donors, transfusion of blood products that have not undergone viral inactivation, parenteral exposure to blood through the use of contaminated and inadequately sterilized instruments and needles used in medical, dental and "traditional" medicine, individuals undergoing procedures such as haemodialysis, persons who participate in high risk sexual practices, household or sexual contacts with HCV-infected persons and infants of HCV-infected mothers. In many countries, the relative contribution of the various sources of infection has not been defined with population-based epidemiological studies. Wherever possible, such studies should be performed to enable countries to prioritise their preventive measures and to make the most appropriate use of available resources.

Sexual transmission of hepatitis C virus infection

BACKGROUND

Hepatitis C virus (HCV) is the cause of almost all cases of parenterally transmitted non-A, non-B viral hepatitis (NANBH). HCV is an RNA virus, unrelated to the hepatitis viruses, A, B, D, or E; it was first identified in 1989. Although most infections become chronic, and it may lead to chronic liver disease, most patients with HCV infection are asymptomatic. The predominant modes of transmission are by blood, blood products, or other parenteral exposure, particularly injecting drug use. More contentious is the role of sexual transmission, although evidence for this was provided by studies of NANBH.

OBJECTIVE

This review considers the evidence for sexual transmission, and the types of studies used to estimate the rate of transmission and the factors that may influence it.

METHOD

A Medline search using the keywords hepatitis C, sex, transmission, and prevalence in MeSH and free text. References in papers were searched, and some unpublished data identified. References were further selected to illustrate different methodologies.

FINDINGS

Evidence for sexual transmission is provided by several types of study including prevalence studies in groups at risk of other STDs, investigation of cases identified from surveillance reports, and cross sectional and longitudinal partner studies. Many studies are limited by their small size, the sensitivity and specificity of early assays, lack of controls, or the difficulty of excluding other routes of transmission. One prospective cohort study reported an incidence of 12 per 1000 person years in the sexual partners of HCV infected patients. 1-3% of partners of HCV infected patients are found to be infected in cross sectional studies. Co-infection with HIV, duration of the relationship, or chronic liver disease may be independent cofactors increasing the risk of transmission. A meta-analysis of selected studies may be informative, and further larger prospective studies are required. There is a small but definite risk of sexual transmission of hepatitis C.

Hepatitis C virus infection in Chicago women with or at risk for HIV infection: evidence for sexual transmission

BACKGROUND AND OBJECTIVES

The importance of sexual transmission of hepatitis C virus (HCV) infection is unclear. We attempted to define its role in women with or at risk for HIV infection.

GOAL OF THIS STUDY

To ascertain if high-risk sexual behavior was independently associated with HCV infection.

STUDY DESIGN

Risk factors were assessed cross-sectionally in Chicago women newly enrolled in the Women's Interagency HIV Study. Women who had (n = 243) or were at risk for HIV infection (n = 53) were tested for HCV antibodies (Ab).

RESULTS

Of 296 women, 123 (42%) were HCV Ab positive; prevalence was 90% in women who injected drugs (IDU) compared with 12% in noninjectors (odds ratio [OR], 64.0, 95% confidence interval [CI], 29.9 to 137.0). A multivariate model showed associations with IDU (OR, 110.3, 95% CI, 33.3 to 365.8), prior gonorrhea (OR, 3.6, 95% CI, 1.4 to 8.9), and sex with a male IDU (OR, 2.7, 95% CI, 1.1 to 7.0).

CONCLUSION

Injection drug use is the strongest predictor of HCV infection, but sexual risk factors are also independently associated.

Factors associated with serum HCV RNA positivity in anti-HCV antibody positive intravenous drug users

Serum hepatitis C virus (HCV) RNA, HCV genotypes and liver function tests were evaluated in a series of 189 unselected, consecutive anti-HCV positive intravenous drug users (IVDUs). Serum HCV RNA was detected in 106/189 patients. Abnormal liver function tests were associated with alcohol abuse, but not with the presence of serum HCV RNA. Among 109 patients retested after a mean follow-up of 21 months, 41 were intermittently serum HCV RNA positive. Patients persistently negative had more commonly a past history of acute hepatitis. A history of prostitution and/or a pattern of abuse involving >30 injections per week were related to infection by genotype 3a. In conclusion, serum HCV RNA is either transiently or persistently detectable in most anti-HCV positive IVDUs, but bears no association with abnormal liver biochemistry. Infection by HCV-3a is more common in IVDUs with more deviant life styles. In those cases where serum HCV RNA is found repeatedly negative, HCV infection may have been cleared, possibly through an episode of acute hepatitis.

Hepatitis C

Hepatitis C virus (HCV) infection afflicts millions of people in the United States and worldwide. We examine the epidemiology of HCV infection, the molecular biology of the virus, the pathophysiology of infection, the clinical diagnosis and manifestations of infection, and the treatment of HCV infection.

Oral sex and the transmission of viral STIs

OBJECTIVE

To review the literature on the role of oral sex in the transmission of viral sexually transmitted infections (STIs).

METHOD

A Medline search was performed using the keywords oro-genital sex, and those specific to each infection. Further references from each article identified by Medline were also included, as were relevant references from "Current contents".

CONCLUSIONS

Oral sex is a common sexual practice among both heterosexual and homosexual couples. The evidence suggests that HIV transmission can take place through oro-genital sex from penis to mouth and vagina to mouth. Case reports describe apparent transmission from mouth to penis although this appears less likely. The risk of oro-genital transmission of HIV is substantially less than from vaginal and anal intercourse. Receptive oro-genital sex carries a small risk of human papillomavirus infection and possibly hepatitis C, while insertive oro-genital contact is an important risk factor for acquisition of HSV 1. Oro-anal transmission can occur with hepatitis A and B. The transmission of other viruses may occur but is unproved. The relative importance of oral sex as a route for the transmission of viruses is likely to increase as other, higher risk sexual practices are avoided for fear of acquiring HIV infection.

Heterosexual transmission of hepatitis C virus among married couples in southwestern Japan

The heterosexual transmission of hepatitis C virus (HCV) remains controversial, and data from general populations are scanty. In this cross-sectional study, we assessed the seroprevalence of antibodies to hepatitis C virus (anti-HCV) and the presence and genotype of HCV-RNA among 109 married couples within an endemic, community-based Japanese population. Overall, 25% of the husbands and 32% of the wives had anti-HCV. Spouses with anti-HCV-positive partners were around 2 times more likely to have anti-HCV than spouses with anti-HCV-negative partners (p = 0.01). Of 6 couples in which both spouses had HCV-RNA, however, 3 presented discordant HCV genotypes (type 1b vs. 2b). The couples' anti-HCV concordance status was not significantly influenced by the presence or absence of HCV-RNA among anti-HCV-positive partners (odds ratio [OR]: 0.8 for wives, 0.6 for husbands), nor by the length of marriage, the number of pregnancies or the use of contraceptives. No significant associations with anti-HCV were observed for serum markers of sexually transmitted agents, including human T-lymphotropic virus (OR = 1.1, 95% confidence interval [CI] 0.5-2.3), Treponema pallidum (OR = 0.7; CI 0.1-6.1) and hepatitis B virus (OR = 1.6; CI 0.9-3.0). Our results suggest that the clustering of HCV infection among specific couples within this endemic population may not be attributable to heterosexual transmission. Follow-up studies are necessary to determine the risk of heterosexual transmission of HCV in endemic areas.

Hepatitis C transmission on the north coast of New South Wales: explaining the unexplained

OBJECTIVE

To determine the routes of hepatitis C virus (HCV) transmission in an Australian community.

DESIGN

Questionnaire-based, cross-sectional survey of notified HCV cases.

SUBJECTS AND SETTING

All cases notified to the New South Wales North Coast Public Health Unit between 1 January 1993 and 30 September 1994.

OUTCOME MEASURES

Frequency of potential transmission exposures (parenteral and sexual); most likely primary exposure; HCV infection rates in sexual partners and offspring.

RESULTS

467 subjects responded (47% of resident cases). Of these, all but one reported actual or potential blood exposures (injecting drug user [IDU], 85%; IDU with sharing of injection equipment, 76%; pre-1990 blood transfusions, 6%; other blood exposures, 8%). Most subjects reported multiple exposures and none reported sexual contact as the only potential exposure. Of 233 sexual partners tested for HCV, 83 were positive; 54 of these were questioned and all had other parenteral exposures. Only three children out of 91 children tested were positive for HCV (two expressing maternal antibodies).

CONCLUSIONS

In contrast with previous studies, possible HCV transmission modes were identified for almost all respondents. Most respondents in this community were IDUs. Non-parenteral transmission appeared minimal. Novel approaches to preventing HCV transmission in IDUs are needed.

Sexual behaviour and multiple infections in drug abusers

We have studied the prevalence and the serological profile of HBV, HCV, HDV and HIV infections in 137 Italian subjects addicted to the intravenous use of heroine and correlated the virological findings with sexual behaviour. HBV and HCV viremia were also measured in 114 patients. Anti-HCV was detected in 81% of the addicts, and one or more markers of HBV infection were detected in 62.8% (4.4% were carriers of HBsAg, 58.4% had evidence of past HBV infection and 13.1% of the latter also had HDV markers). Anti-HIV was positive in 23.4%; 26% of those positive for anti-HCV and 4.6% of those positive for HBV markers had no other viral marker: none had only anti-HIV. HBV-DNA was negative in the carriers of HBsAg, and HCV-RNA was not detected in any of the HBsAg carriers who also had circulating anti-HCV. Overall, 34% of the anti-HCV positive addicts had HCV-RNA in their blood. The prevalence of the virus infection correlated with the duration of drug addiction but not with sexual behaviour, and sexual behaviour did not influence the acquisition of any virus. HCV infection was most frequent and probably the first infection to occur, but exposure to HBV was also common despite a low rate of HBsAg carriage. The prevalence of HDV infection was high (50%) in the HBsAg carriers, while the overall prevalence of HIV was lower (23%) than expected. Lack of HBV-DNA and HCV-RNA in carriers of HBV with anti-HCV in serum may indicate that HBV and HCV mutually inhibit their own replication.

Anti-HCV seroprevalence and risk factors of hepatitis C virus infection in Moroccan population groups

Hepatitis C virus (HCV) seroprevalence and transmission routes were investigated in several groups of the Moroccan population. This study showed a low HCV seroprevalence in the Moroccan general population. However, haemodialysis patients and haemophiliacs were at higher risk of having HCV infection, since the prevalences were, respectively, 35.1 and 42.4% in comparison with the blood donors' prevalence (1.1%). These results indicated that parenteral exposure is the transmission pathway of HCV. To investigate the possibility of vertical HCV transmission, a cohort of healthy, unselected pregnant women were included in the study. A prevalence of 1% was found among them. Seven newborns were anti-HCV-positive, although, when RT-PCR was used to search for HCV RNA in their sera, none of them was viraemic. These data indicated that anti-HCV antibodies were passively acquired in these cases. We concluded that vertical transmission is absent when mothers are at low risk of contracting other parenterally or sexually transmitted diseases. Three percent of a group of patients of a centre for sexually transmitted diseases were repeatedly anti-HCV-positive, suggesting the possible sexual transmission of HCV. When screening 116 sera of anti-HIV-positive subjects, 19.8% were anti-HCV-positive. Furthermore, 17.9% of the sixty-seven patients who were proven to have sexually contracted HIV were also anti-HCV-positive. These data might reflect a likely cotransmission of these two viruses, hence suggesting HIV is a cofacter for HCV sexual transmission, as previously reported.

Sexual transmission of hepatitis C virus infection

The role of sexual transmission in the diffusion of HCV infection, was studied through the seroprevalence of anti-HCV antibodies in the heterosexual habitual partners of 83 anti-HCV positive subjects. The index cases were represented by 10 dialysed subjects, 31 patients with chronic liver disease and 42 healthy carriers. Seroprevalence of anti-HCV positivity reported in partners was 8.43%, with a higher rate in cohabitants of patients with chronic liver disease (16.12% vs 4.76% of carriers); no case was found among partners of dialysed subjects Laboratory and ultrasonograph signs of chronic hepatitis were reported in 3 cases (3.61%). Control on 70% of the cohabitants' relatives, was negative for HCV infections. These data suggest a possible sexual transmission of HCV infection, even if its prevalence resulted modest, undoubtedly lower than in other disease sexually transmitted.

Hepatitis C virus infection in a large cohort of homosexually active men: independent associations with HIV-1 infection and injecting drug use but not sexual behaviour

OBJECTIVE

To determine the prevalence and risk factors for hepatitis C virus (HCV) infection in a cohort of homosexually active men, with particular reference to assessing sexual transmission.

DESIGN

Prevalence based on cross-sectional testing for HCV (c100 protein) antibody in a cohort using sera stored between 1984 and 1989, and assessment of risk factors using a case-control analysis based on questionnaire data from HCV positive and negative subjects.

SUBJECTS/SETTING

1038 homosexually active men who were participating in a prospective study established to identify risk factors for AIDS. They had been recruited through private and public primary care and sexually transmissible disease (STD) services in central Sydney.

MAIN OUTCOME MEASURES

Prevalence of HCV antibody and its association with human immunodeficiency virus type 1 (HIV-1) infection and other STDs, number of sexual partners, sexual practices and recreational drug use.

RESULTS

Overall, 7.6% of subjects tested were seropositive for HCV antibody. In univariate analysis, HCV infection was significantly associated with injecting drug use (IDU) (OR = 8.18, p < 0.0001) and HIV infection (OR = 3.14, p < 0.0001) and with self reported history of syphilis (OR = 1.88, p = 0.016), anogenital herpes (OR = 1.93, p = 0.017), gonorrhoea (OR = 2.43, p = 0.009) and hepatitis B (OR = 1.92, p = 0.010). In case control analysis, similar sexual behaviours (partner numbers and practices) were reported by HCV positive and HCV negative subjects except that HCV negative subjects more frequently reported engaging than HCV positive subject in unprotected receptive anal intercourse without ejaculation (OR = 0.61, p = 0.034), unprotected insertive (OR = 0.59, p = 0.039) and receptive (OR = 0.56, p = 0.016) oro-anal intercourse (rimming) and insertive fisting (OR = 0.48, p = 0.034). In multiple logistic regression analyses, only HIV-1 infection (OR = 3.18, p < 0.0001) and IDU in the previous six months (OR = 7.24, p < 0.0001) remained significantly associated with the presence of HCV antibody.

CONCLUSIONS

IDU was the major behavioural risk factor for HCV infection. If sexual or another from of transmission did occur, it may have been facilitated by concurrent HIV-1 infection.

HCV transmission in family members of subjects with HCV related chronic liver disease

To investigate the risk of sexual and intrafamilial transmission of HCV, 220 family members of 76 patients (index cases) with chronic type C viral liver disease were tested for serological markers of HCV. Of the family members, 129 were offspring, 64 sexual partners, 15 parents and 12 siblings of the index cases. Anti-HCV was tested in all the household contacts; HCV-RNA was tested in antibody positive samples. The serologic markers of HCV were tested in a control group of 168 family members of 81 patients with chronic hepatitis unrelated to HCV. The overall prevalence of anti-HCV was 8.2% compared to 0.6% in the control group (p < 0.001). Sexual partners were anti-HCV positive more frequently than the other contacts (20% vs 2.2%; p < 0.001), without any difference in males or females. No correlation was observed between the occurrence of HCV infection in contacts and age, severity of liver disease or risk factor for the acquisition of HCV in the index cases. Seven of the 18 (39%) anti-HCV positive family contacts had bio-chemical evidence of chronic liver disease, histologically confirmed in the 6 patients who underwent a liver biopsy. Liver chemistry was normal in all the HCV-negative contacts. Ten of the 18 anti-HCV positive contacts (55%) were HCV-RNA positive, Genotypes were the same (1b) in 4 of the 7 viremic couples of subjects: in 3 of the 6 couples of sexual partners and in the only mother/son couple. These data suggest the occurrence of intraspousal transmission of HCV, while intrafamiliar acquisition of HCV in non-sexual contacts seems to be rare.

Hepatitis C in Lithuania: incidence, prevalence, risk factors and viral genotypes

BACKGROUND

The epidemiology of hepatitis C virus (HCV) infection has been studied in many countries. However, little is known about HCV infection in Lithuania, a Baltic country, that was part of the former Soviet Union.

OBJECTIVES

The aim of this study was to determine and evaluate the etiology of acute viral hepatitis, the risk factors for acquiring HCV in comparison to hepatitis B virus (HBV), seroprevalence of anti-HCV among blood donors and risk groups of the population in Lithuania. The distribution of HCV genotypes from Lithuanian first-time blood donors was also assessed.

STUDY DESIGN

Sera taken from clinical viral hepatitis patients, blood donors, risk groups of population were investigated serologically. Patients with acute viral hepatitis were interviewed to determine their risk factors for HCV and HBV. HCV genotyping was done by PCR using type specific primers.

RESULTS

Acute hepatitis C accounted for 5.0-8.5% of reported viral hepatitis cases in adults in Vilnius. Of the acute hepatitis C cases, 37.0% was associated with blood transfusions before the implementation of screening of blood donors for anti-HCV and only 15.4% (2/13) after the screening was started. Anti-HCV was found in 2.2% of first-time blood donors, in 7.9% of commercial blood donors, in 13.9% of commercial blood plasma donors, in 48.3% of hemodialysis patients, in 29.4% of prisoners, in 9.4% of elderly nursing home residents, and in 7.9% of hemodialysis staff. The following distribution in genotypes were found: genotype 1b (54.3%), 3a (23.9%), 2a (10.9%) 2b (4.3%), 1a (0%), and double infection (6.5%).

CONCLUSIONS

Lithuania is a country with a considerable hepatitis C problem.

Detection of HCV RNA in serum and seminal fluid from HIV-1 co-infected intravenous drug addicts

The presence of hepatitis C virus (HCV) RNA in serum and seminal fluid was investigated in eleven drug addicts coinfected with HIV-1 and HCV. Serum and seminal fluid were taken from each patient at the same time point. HCV RNA was found in ten of the eleven serum samples tested, but only in one of the semen samples. No relationship was observed between CD4 cell counts, the stage of HIV infection, extent of liver damage and the presence of HCV RNA in serum and semen. The results indicate that HCV is not usually present in the semen and provide further evidence against sexual transmission as an important mode of transmission of HCV infection.

Efficacy and safety of alpha-interferon treatment for chronic hepatitis C in HIV-infected patients. HIV-Hepatitis Spanish Study Group

The efficacy and safety of recombinant alpha-interferon (IFN) therapy for chronic hepatitis C (CHC) was assessed in 57 HIV-infected individuals with CD4+ T cells above 200/mm3 and compared to the response obtained in 21 HIV-negative patients with CHC. IFN 5 megaU was given three times a week subcutaneously for 3 months. In responding patients, IFN 3 megaU three times a week was additionally administered for 9 months. After 8 months follow-up in HIV-infected patients, 38% (22/57) achieved normal (complete response, CR) alanine aminotransferase (ALT) values. Partial response (PR) was seen in 21% (12/57), and 40% (23/57) did not respond. Patients with CD4+ cells above 500/mm3 achieved CR in 58% (14/24) of cases compared to 24% (8/33) among those having a lower CD4+ count (P < 0.01). Females attained CR in 60% (9/15) of cases, and men in only 30.9% (13/42) (P < 0.01). No serious side effects or opportunistic infections were observed during the study period. However, three (5.2%) patients showed a dramatic fall in total CD4+ T cell count after beginning IFN therapy. Among 21 HIV-negative patients, after 8 months follow-up, CR was achieved in 10 (47%), PR in four (19%), and seven (33%) did not respond. We concluded that IFN therapy seems to be well tolerated and useful in HIV-infected patients suffering CHC. The rate of CR was not significantly different compared to that observed in HIV-negative patients (38% vs. 47%), relative risk (RR) = 0.67 (0.19-2.37).(ABSTRACT TRUNCATED AT 250 WORDS)

Association between hepatitis C virus seroreactivity and HIV infection in non-intravenous drug abusing prostitutes

Two hundred and ninety-four non-transfused prostitutes from Spain, who denied intravenous drug abuse, were tested for hepatitis C virus (HCV) antibodies. Seventeen (5.78%) of them were seropositive. Both in univariate and correspondence analyses, serological results for hepatitis C were associated with the HIV-1 serostatus (p < 0.001), number of sex partners (p < 0.05) and a history of genital ulcers (p < 0.05). In logistic regression analysis, hepatitis C seropositivity was associated only with HIV-1 infection (adjusted odds ratio = 13.6; 95% confidence interval = 3.3-55.2). These results show that hepatitis C seropositivity is associated with HIV-1 infection in female non-intravenous drug abusing prostitutes. These findings are also consistent with the hypothesis that HCV can be sexually transmitted with low efficiency.

Methods of transmission of hepatitis C

The route of transmission of hepatitis C virus is still controversial. Parenteral exposure via blood or blood products leads to infection in the majority of cases, and the majority of intravenous drug users become infected by repetitive exposure to contaminated injection equipment. The risk of infection from a single needlestick injury is 5-15% and may depend on the size of the innoculum. Other parenteral routes of transmission may include traditional healing practices and the use of contaminated medical equipment. Transmission is less common within a family but the prevalence of hepatitis C viral antibodies is higher in family members and sexual partners of carriers than in the general population. There are some well-documented instances of acute hepatitis C occurring after a defined sexual exposure. Vertical transmission is rare unless the mother has high levels of circulating HCV RNA as may occur in those also infected with HIV. The detection of hepatitis C in saliva and the higher than expected prevalence of infection in dentists may point to the possibility of transmission by salivary contamination. There remain large numbers of hepatitis C carriers in whom no route of infection can be identified.

Hepatitis C: an overview

Hepatitis C virus (HCV) has been associated with acute and chronic posttransfusion and with sporadic non-A non-B (NANB) hepatitis, cirrhosis, and hepatocellular carcinoma (HCC). Cloning of the sequence encoding an antigenic component of HCV in 1989 led to the development of tests to detect antibody to HCV in serum. Viral HCV RNA can be detected and estimated with polymerase chain reaction (PCR) and branched-chain DNA (bDNA) signal amplification tests. The entire viral genome has been sequenced. The HCV envelope region varies considerably, and infections with mutant HCV have been described. Approximately 0.5-1.5% of healthy blood donors test positive, and HCV infection can be acquired by blood transfusion or i.v. drug abuse. Vertical and sexual transmission of the virus is rare, and the transmission mode remains obscure in a large group of patients. Acute hepatitis C is mild and often asymptomatic. Chronic hepatitis C has an indolent course but may progress to cirrhosis and HCC. Recombinant alpha interferon (IF) is used to treat chronic HCV disease, but no consensus has been reached on patient selection, dose, and duration of treatment. Approximately 50% of treated patients respond, but 50-80% of responders relapse over time. Liver transplantation in patients with end-stage, HCV-related liver disease is often followed by allograft infection. Short-term survival with reinfection is good, but the long-term consequences remain to be defined.

Acute hepatitis C infection after sexual exposure

A case is described of a woman with acute hepatitis C infection whose partner had chronic hepatitis C infection and where heterosexual contact was the only major risk factor. Infection of both partners was confirmed serologically and by the finding of virus RNA by reverse transcription and polymerase chain reaction amplification. Nucleotide sequence analysis of the NS5 region (RNA polymerase) was used to show that both partners were infected with virus of the same genotype (1a). The nucleotide sequence of virus RNA found in the female patient is closest to variants cocirculating in the male contact, consistent with transmission having occurred between the two.

Molecular detection of hepatitis C virus: impact of detection methodology on clinical and laboratory correlations

The clinical manifestations of hepatitis C virus (HCV) infection are generally indistinguishable from other causes of viral hepatitis. HCV infections are usually anicteric, asymptomatic, and rarely cause acute fulminant liver failure. Serological testing for HCV in conjunction with epidemiological studies have verified that HCV was the major cause of parenterally transmitted non-A, non-B hepatitis (NANBH). With the widespread introduction of serological screening of blood products for HCV antibody, the risk of transfusion-associated HCV infection has been dramatically reduced (to < 3 cases per 10,000 units transfused). Despite the virtual elimination of transfusion-associated infections, the diagnosis of HCV remains important because > 50% of infections are sporadic in origin, 50 to 70% of infected individuals develop chronic hepatitis, and these individuals are at risk of developing cirrhosis (> 20%) as well as hepatocellular carcinoma. Although currently available anti-HCV immunoassays function well as blood-donor screening assays, they are poor at detecting acute infection because of the prolonged lag time between infection and detection of seroconversion (approximately 10 to 26 weeks for second-generation immunoassays). In contrast, polymerase chain reaction (PCR)-based detection of HCV RNA in serum can detect infection in as little as 1 to 2 weeks after exposure. This review focuses on the impact of modern serologic and nucleic acid-based HCV detection methodology on the clinical understanding of HCV infection, its associated illnesses, and its transmissability. Quantitative and reproducible nucleic acid-based detection assays will be required to provide additional insights into the clinical spectrum of HCV infections as well as to assess the efficacy of antiviral agents.