Durban World AIDS Conference
July 9-14, Durban, South Africa

REPORT45

HCV/HIV Coinfection Prevalence & Sexual Transmission

This report is comprised mostly of studies presented in Durban (but also includes information from other sources) and details the prevalence of HCV in HIV infected individuals from various backgrounds on a worlwide basis from Boston to Italy to Spain to San Francisco. From IVDUs to the potential for sexual transmission. These reports and previous ones are piecing together a picture of the prevalence of coinfection. A number of prevalence studies reported from various cities in the USA estimate that 60-90% of individuals with HIV due to IVDU have HCV as well. Based on these studies it appears that there is a risk for contracting HCV from sexual contact. The question remains --how much risk?

HCV and Breastmilk

There have been doubts about that HCV could be transmitted sexually or that it could be transmitted sexually at more than a very low rate. A recently published study found HCV in breastmilk, and a second recently published study found HCV in male semen. A Spanish research group reported breast milk HCV-RNA was negative in

nonviremic mothers and positive in 20% of the viremic mothers. The rate of HCV transmission was higher for infants of mothers with higher HCV viremia (P < 0.01) and also for infants whose mothers were HCV-RNA-positive in breast milk (P < 0.05). The authors said larger studies are needed before advising avoidance of maternal breast feeding (Pediatr Infect Dis J 2000 Jun;19(6):511-6: Ruiz-Extremera A et al).

HCV in Male Semen

Using a sensitive testing method (PCR), French research group Eight seminal plasma samples of 21 (38%) were found to contain HCV-RNA (6/8 were HIV+, 2/8 were HIV-). HCV viral loads detected in semen were low, which suggests that the risk of HCV sexual transmission is probably also low. We are aware that only further studies using experimental infection in a cell culture system or an animal model would prove that HCV-RNA positivity in semen reflects the presence of infectious virus (Lancet 2000; 356: 42 - 43, Marianne Leruez-Ville et al). 

Sexual Transmission of HCV & Transmission from Mother-to-Child

An Italian study reported recently that HCV was transmitted from mother to newborn 5% when HIV was not present but 17% when the mother had HIV. At the Feb. 2000 HIV Retrovirus Conference, Craib and others from British Vancouver reported on a study to determine HCV prevalence and identify risk factors in a group of sexually active homosexual men. In a random sample of 232 men, 120 were HIV+ (112 were HIV-). Of the 232 men 20 (8.6%) had HCV and HCV prevalence was significantly higher (6-fold) among HIV+ than HIV- men (17/120 14% vs 3/112  2.7%). They reported the risk factors for the HCV+ men. HCV+ men had more sexual partners in the past year (>= 20 partners: 80% vs 40%), and in their lifetime (>=100 partners: 90% vs 61%). They also had greater incidence of receptive fisting (30% vs12%; p=0.40), insertive fisting (55% vs 25%; p=0.004), more often reported receptive oral-anal contact (100% vs 85%; p=0.067), more often reported injection drug use (21% vs 2%; p<0.001), cocaine use (50% vs 24%; p=0.013), MDA use (70% vs 36%; p=0.003), and amphetamine use (30% vs 13%; p=0.056). Multivariate analysis showed injection drug use (p=0.024), being HIV+ (p=0.056), low education level (p=0.031) and insertive fisting (p=0.032) to be independent risk factors for being HCV+.

Death Due to End-Stage Liver disease in Brescia, Italy Before & After Introduction of HAARTÖincreased from 12% to 33%

Three hundred and eight in-hospital deaths were observed  from 1987 to December 1995 in a prospectively followed cohort  of 1894 with HIV. Forty six deaths were observed  from 1998 to 1999 in the same cohort.Among the 308 in-hospital deaths occurred from 1987  to 1995, liver failure was defined as the cause of death in 35  patients (12%). Among the 46 in-hospital death observed from 1998 to 1999 liver failure was defined as the cause of death in 15  (33% p>0.01 vs. 1987-95). Multivariate analysis showed that  in-hospital liver related mortality was independently associated  with hepatitis B surface antigen reactivity (Odds Ratio, 9), antibody HCV reactivity (OR 5) and history of alcohol abuse(OR 2.3).

End stage liver disease is a growing cause of mortality  in Italian HIV seropositives and it caused one third of in-hospital  deaths in the last two years. Prevention and treatment of hepatitis  viruses co-infection and reduction of alcohol intake are management  priorities in Italian HIV seropositives. (Reported by A Spinetti, Clinica di Malattie Infettive, Spedali Civili, P.zzale Spedali Civili 1, 25123 Brescia, Italy)

16% Sexual Exposure to HCV in Spain

In a study designed to evaluate the prevalence, route of transmission  and clinical significance that current co-infection with TT virus  (TTV), hepatitis C virus (HCV), and hepatitis G virus (HGV) in HIV-1 infected patients, M Martinez from Barcelona, Spain analyzed the presence of HCV in plasma samples from 160 infected patients with parenteral (38 intravenous  drug users 'IVDU's' and 41 patients with hemophilia) or sexual  (39 homosexuals and 42 heterosexuals) risk of exposure, and in  168 volunteer blood donors. Alanine aminotransferase (ALT) levels  and CD4+ T cell counts were also analyzed. Prevalences of  HCV infection was  higher among patients with parenteral (needles by drug abuse) (62% and 68%) than in those with sexual (17% and 16%) risk of exposure. But the study authors report 16% risk of sexual transmission. Some of this 16% could be due to unidentified drug use or an unwillingness to admit drug abuse.

Impact of HCV infection on HIV progression and survival in the Swiss HIV cohort studies

To assess the impact of HCV infection on clinical  progression and on survival of HIV+ subjects in the era of potent  antiretroviral therapy (ART), G Greub of the ID Dept. at University Hospital in Lausanne Switzerland looked at 2766 individuals followed in the Swiss HIV Cohort Studies. They started potent ART between 01/01/95 and 03/31/99.

1011/2766 (36.6%) HIV+ subjects were HCV co-infected.  511/537 (95.2%) active drug user were HCV+ as compared to 22.4% in other groups.

17% Prevalence of HCV and HIV co-infection in a patient population with low IV drug useÖin Boston, Mass

M. Desyatnik from Beth Israel Deaconess Medical Center reported on a study was to determine the prevalence of HCV co-infection in a  population comprised of homosexual and heterosexual patients  with a low rate of IV drug use.

Through a retrospective chart review of 138 patients, the number of co-infections was established. HCV infection was determined by either newly positive HCV serology or by documented history of hepatitis C infection.

One hundred thirty eight (138) charts were reviewed.  Subjects were 21-63 yrs of age (40.7 +/- 7.4, mean +/-SD) with CD4 counts of 10-1341 cells/mm3 (439 +/- 277), HIV-I  RNA of 50-309,000 (14,076 +/- 51,200), and weight of 56-115  kg (76 +/- 13). For 46/138 patients, only pre-HAART data was available. Of the rest, 90 patients were receiving HAART and 2 patients chose not to receive antiretroviral therapy. The overall  prevalence of HCV co-infection was 17.4%. Bear in mind the overall HCV infection rate in the USA is about 1.8%.

HIV is associated with sexual risk and HCV with injection risk among young injection drug users in San FranciscoÖ312 Young IVDUsÖ29% had HBV, 45% had HCVÖ93% with HIV also had HCV

K.A. Page-Shafe from the University of California San Francisco reported on this study examining HCV prevalence and risk factors for  HIV hepatitis B (HBV) and C (HCV) among young injection drug  users (YIDU) in San Francisco. YIDU (>30 years) recruited in 4 neighborhoods were questioned about injection and sexual behaviors, sources of clean needles, knowledge and use of needle hygiene, history of STD  and overdose experience. Blood was drawn for HIV, HBV and HCV antibody testing.

312 YIDU participated, 193 (68%) males and 87 (31%) females.  Median age was 22 (range: 15-29), and median number of years  injecting was 5 (range 0-19). Prevalence of HIV, HBV (core antibody  or surface antigen), and HCV was 6%, 29%, and 45%, respectively.  93% of those with HIV infection were co-infected with HCV or HBV.  Variables independently associated 'OR ;(95% CI)' with HCV seropositivity  were: age (per 5 yr. increase) '2.2;(1.3-43.7)', years injecting  (per 5 yr. increase) '2.1;(1-3.5)', injected by a sex partner  at initiation '3.9;(1.5-9.9)', ever injected with someone else's  used needle '2.5;(1.2-5.2)', bleached last time injected with  borrowed needle '0.5;(0.2-0.98)', snorted or smoked cocaine,  methamphetamine, or heroin in the prior year '0.4; (0.2-0.8)',  injected daily '4.4;(2.4-8.5)', and HBV '3.0;(1.5-6.0)'.

27/39 (69%) with HIV had HCV in Patients Presented in Emergency Room, Alberta, Canada

S. Houston at the University of Alberta, in Edmonton, Albetra Canada reported on 3057 subjects were entered in database. Subjects were younger, presented  more frequently with trauma and more often went on to admission  than the general ED population (all p>0.05). 71% presented with medical illnesses, 21% with trauma. 7% self-identified as aboriginal.  37(1.2%, 95%CI = 1-2) were HIV-seropositive; 2 others demonstrated  a banding pattern characteristic of acute seroconversion. HIV  infection was associated in multivariate analysis with aboriginal  status, age and HCV infection. 27 of all 39 (69%) HIV-infected subjects and both seroconverters were HCV co-infected.