Issue:  Vol. 48 / No. 8 / 22 February 2018

Hep C in HIVers may cause rapid liver disease


Dr. Daniel Fierer spoke about HIV-hepatitis C coinfection at a forum in San Francisco last week. Photo: Liz Highleyman
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While HIV continues to garner the lion's share of attention regarding gay men's health, a second forum in as many months focused on the growing epidemic of hepatitis C among HIV-positive men who have sex with men – and presenters noted that rapid liver disease could be a result.

The March 17 forum – provocatively titled "Could you survive HIV only to die from hepatitis C?" – featured Dr. Daniel Fierer of Mt. Sinai School of Medicine in New York City, one of the leading American experts on HIV and hepatitis C virus (HCV) coinfection.

Dr. Marcus Conant, whose Conant Foundation sponsored the meeting in conjunction with Project Inform and the Black Coalition on AIDS, noted that while nearly 4 million people in the U.S. have hepatitis C, the rate of new infections in the general population has fallen dramatically in recent decades.

But such is not the case for HIV-positive gay and bisexual men. Outbreaks of apparently sexually transmitted acute hepatitis C started cropping up among gay men in London and continental European cities around 2002. The first similar U.S. report, by researchers from the University of California at San Francisco, was published in 2006. Dr. Brad Hare, a member of that team, said that today 42 percent of HIV-infected men in UCSF's Positive Health Program also have HCV.

Fierer said these recent acute HCV coinfections in HIV-positive men appear to represent "a new 21st century clinical syndrome," since they depart in some important ways from the prevailing consensus about hepatitis C.

Traditionally, experts have maintained that HCV is rarely spread through sex, a claim based on studies of monogamous HIV-negative heterosexual men and women, who have a sexual transmission rate under 5 percent.

Though specific risk factors have varied from study to study, the recent acute hepatitis C outbreaks among gay men have been linked to fisting, unprotected anal intercourse, group sex, sharing sex toys, having other sexually transmitted diseases, and use of non-injected recreational drugs.

Based on an analysis of a small but growing group of coinfected gay men in New York, Fierer said that acute HCV infection in a person who already has HIV may lead to unusually rapid liver disease progression.

Over time, hepatitis C infection can lead to liver fibrosis, or buildup of scar tissue; ultimately, this can progress to cirrhosis, liver cancer, and end-stage liver failure. Typically, this process takes years or even decades.

But as Fierer first reported at the 2007 retrovirus conference, several HIV-positive men with acute hepatitis C at Mt. Sinai already showed evidence of moderate – and in some cases, severe – liver fibrosis, despite having had HCV for only weeks or months; this cohort has now expanded to 45 men.

Fierer suggested that HIV-related immunocompromise may predispose people to accelerated fibrosis if they are subsequently infected with HCV. In contrast, injection drug users who become infected with both viruses usually get HCV first, since it is more easily transmitted than HIV, and do not show this type of unusually rapid progression.

However, most coinfected men in the Mt. Sinai cohort were in "terrific shape" with regard to their HIV disease, Fierer said. Overall, they had well-preserved immune function, with an average CD4 cell count of 525, and many had never started antiretroviral therapy because their CD4 counts were still high.

Fierer's findings have proved controversial, since they go against conventional wisdom about the normal course of hepatitis C. Researchers studying the coinfection outbreaks in the U.K. and Europe have not reported similar rapid progression, but they usually estimate liver damage using non-invasive methods that are not as accurate as the "gold standard" liver biopsies used by Fierer's team.

"I would love to be completely wrong about this," Fierer said, "but somebody's got to look."

The good news is that if hepatitis C treatment is started early, during the acute phase of infection, there is a very good chance of a cure. In addition to eliminating HCV, treatment also has the potential to improve existing liver damage. Fierer described one patient who achieved a sustained response after 24 weeks of pegylated interferon plus ribavirin, and a repeat liver biopsy showed that his liver inflammation and fibrosis were almost completely resolved.

Fierer recommended HCV antibody tests every six to 12 months. Dr. Marion Peters from UCSF, also speaking at the forum, said the standard HCV antibody test is almost always accurate in HIV-positive people unless they have very low CD4 counts (below 100).

After the acute stage of hepatitis C, when to start treatment is an open debate. Treatment should begin when liver disease starts to progress, but since it's generally been assumed that this takes a long time, doctors do not routinely recommend biopsies for people without long-standing infection. "We haven't been routinely biopsying patients with new HCV infection," Hare said, "but [Fierer's] data are making us rethink this."

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