Researchers in New York City are reporting their work uncovering a new epidemic of hepatitis C virus (HCV) infection among men-who-have-sex-with-men (MSM) who have HIV infection. These authors have previously reported unusually rapid fibrosis progression due to new HCV in MSM who have HIV infection and now expand on their findings, demonstrating that sexual transmission rather than injection drug use is the route of infection. Treatment is highly successful if started early in the course of infection, however, they report ominous news about liver disease progression. “This epidemic represents a new clinical syndrome for HCV infection that turns much of our knowledge on its ear: a new risk group becoming infected through a previously rare route of transmission resulting in unprecedented progression of liver fibrosis,” said Daniel Fierer, MD, principal investigator on this study.

In an analysis of 21 HCV-infected patients matched with uninfected controls, unprotected receptive anal and oral sex were significantly associated with new HCV infection. Neither current nor prior injection drug use was associated with HCV infection. In addition, treatment with pegylated interferon and ribavirin, initiated within 6 months of diagnosis, was completed in 16 patients with genotype 1 HCV infection; 12 (75%) achieved sustained viral response (SVR), compared to the 15-30% SVR rate expected with chronic genotype 1 HCV infection. Of significant concern, however, 30 patients underwent liver biopsy during the early infection period and 23 (77%) already had moderate fibrosis, making early curative treatment even more important to prevent further progression of liver fibrosis.

Because of these findings, study authors recommend routine screening for acute HCV for all MSM patients with HIV, using a simple and inexpensive algorithm of ALT measurement every 3 months and HCV antibody measurement every 6 to 12 months. “Changing the perception and behavior of physicians and patients is difficult,” said Dr. Fierer, “One of the main barriers to early detection is the lack of recognition by physicians and patients alike that HIV-infected MSM are at risk for HCV infection. This lack of perception of the problem results in lack of screening of HIV-infected MSM and therefore lack of timely diagnosis and treatment.”

Dr. Fierer thinks the next steps in battling this epidemic are educating HIV providers about the existence of this world-wide epidemic, educating patients at risk that unprotected sex among HIV-infected men is a significant risk for HCV infection, and changing the official recommendations by the US national authorities such as the CDC, HIVMA, etc, as has already been done in Europe and more recently at the state level in New York.

Abstract title:

Characterization of an epidemic of sexually-transmitted acute hepatitis C infection in HIV-infected men in New York City

About the AASLD

AASLD is the leading medical society focused solely on advancing the science and practice of hepatology and represents more than 3,300 practitioners, researchers, and allied health professionals worldwide. Founded by physicians in 1950, AASLD has upheld the standards of the profession and fostered research that generates treatment options for the millions of patients with liver diseases.

Source: American Association for the Study of Liver Diseases

A U.S.-backed vaccine experiment in Thailand has for the first time demonstrated a “small but measurable” benefit in preventing HIV infection, the Washington Post reports (Brown, Washington Post, 9/24). Col. Jerome Kim, a physician involved with the trial who is manager of the army’s HIV vaccine program, said that although the reduction in transmission was small, it is statistically significant and means the vaccine was 31.2% effective (McNeil, New York Times, 9/25). According to the Post, the “chief usefulness” of the vaccine is “likely to be what it can teach virologists about what is happening in the immune system when a person is even somewhat protected from HIV.” The vaccine is not expected to be licensed or produced in large amounts, and it is unlikely that countries would consider it effective enough to be used as a public health measure to reduce the spread of HIV. Nonetheless, the findings are considered a milestone, as they mark the first positive results of an HIV vaccine after two decades of experiments (Washington Post, 9/24).

The vaccine combines Sanofi-Pasteur’s ALVAC canary pox vaccine and AIDSVAX, a failed HIV vaccine made by VaxGen, which is owned by the not-for-profit Global Solutions for Infectious Diseases (Fox, Reuters, 9/24). The six-year study involved 16,000 Thai men and women and was run by the U.S. Army, NIH and Thailand’s Ministry of Public Health. According to the Post, about 40% of the participants were women, and many were employed in shipping and manufacturing enterprises along the Thai coast. A few were injection drug users and men who have sex with men — two groups considered at high risk for HIV transmission. Researchers randomly assigned participants to receive the vaccine or a placebo. Participants were counseled on methods of HIV prevention and advised to use condoms (Washington Post, 9/24).

The participants received six immunizations over six months, two with AIDSVAX and four with ALVAC (Reuters, 9/24). Fifty-one of the 8,197 vaccinated people became infected with HIV in the three years after the shots, compared with 74 of the 8,198 people who received placebos (Washington Post, 9/24). Further details of the study, which cost $105 million, will be presented at a vaccine conference in Paris in October (Marchione, AP/San Francisco Chronicle, 9/24).

Researchers said the vaccine, known as RV 144, “protected too few people to be declared an unqualified success,” and they were also “puzzled” by the trial’s results because the vaccine did not change the amount of HIV in a person’s blood compared with someone who received a placebo, the New York Times reports. A vaccine that offers partial protection typically lowers the viral load. However, this did not occur in the trial, which suggests that the vaccine does not produce neutralizing antibodies — which attack virus cells — like most vaccines, according to Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, which paid for most of the trial. He said the vaccine may produce “binding antibodies,” which attach themselves to and empower effector cells, a type of white blood cell attacking the virus (McNeil, New York Times, 9/25).

Fauci said, “Conceptually, we know a vaccine is possible,” adding, “Whether the vaccine is going to look anything like this one, I don’t know. But at least we know it can be done” (Washington Post, 9/24). Mitchell Warren, executive director of AVAC, the AIDS Vaccine Advocacy Coalition, said that the results of the study are “hugely exciting and, frankly, unexpected,” adding that although RV 144 “is not the vaccine that ends the epidemic,” it is “a fabulous new step that takes us in a new direction” (New York Times, 9/25).

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