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Fisting, drug use, syphilis; risk factors for hepatitis C transmission in HIV-positive gay men
  Source: Robert Fieldhouse (http://www.natap.org)
There has been a recent increase in the incidence of hepatitis C (HCV) among HIV-positive gay men in London. Studies from three of London's leading HIV clinics presented at the 9th Conference of the British HIV Association in Manchester last weekend have highlighted the contribution other sexually transmitted infections, non-injection recreational drug use and specific sex acts such as fisting are having on hepatitis C transmission among HIV-positive gay men in the capital.
Researchers from the Royal Free Hospital identified an association between acute hepatitis C infection and having a concomitant sexually transmitted infection. Twenty cases of acute hepatitis C were identified between October 2002 and January 2003. In total eight of the men had syphilis, two had recently acquired HIV infection, two had gonorrhoea and two had herpes simplex virus.
The mean age of the men was 30.5 years and the median CD4 count was 576 cells. Over half of the men (55%) were on HAART at the time of their hepatitis C diagnosis.
Researchers also questioned men about their sexual practices; all of them reported unprotected anal intercourse and 17 of the 20 reported fisting and group sex. Whilst only two of the 20 reported ever having shared injecting equipment for drug use, 70% (14/20) had shared notes or straws to snort cocaine or ketamine. The researchers suggested that the predominance of genotype 1 infections found among the men suggests a common pool of infection.
The men were treated as soon as possible (within six months of documented seroconversion) with PEG-Interferon and ribavirin. Preliminary results suggest a high rate of spontaneous HCV clearance, with treatment in acute infection being a viable option, said the researchers.
Meanwhile researchers from the Mortimer Market Centre and the Department of STDs at the Royal Free and University College Medical School presented the results of a small observational study of HIV-positive patients diagnosed with hepatitis C during January 2002 - January 2003.
The researchers found that four of the fifteen individuals cleared HCV RNA spontaneously after exposure, but in all cases reactivation of hepatitis C occurred. All patients were offered treatment with PEG-Interferon with the addition of ribavirin for 12 weeks if they were still HCV RNA positive. In total ten patients started interferon therapy, but only two of the eight who have so far completed the treatment course responded to therapy. Six of those for whom treatment failed had genotype 1 infection.
The researchers also identified concomitant syphilis and unsafe sex as risk factors for HCV acquisition, but failed to elucidate specifically which sex acts the men had been engaging in. None of the men had ever injected drugs but all had snorted cocaine in the past six months. The researchers underlined the role non-injection recreational drug use may be playing in facilitating HCV transmission.
Finally, researchers from the Chelsea and Westminster Hospital identified 36 HIV-positive gay men who seroconverted for HCV between January 1997 and March 2003. The majority 32/36 were white, 2 were Asian, 1 South American and 1 African In total 31 of the 36 men reported recent unprotected anal sex. Eleven individuals had been diagnosed with infectious syphilis in the year preceding HCV seroconversion, including those who were diagnosed with HCV and syphilis concurrently. The researchers concluded the high number of individuals reporting unsafe sex, low documented injecting drug use (only four individuals) and the high rate of concomitant syphilis infection suggests that sexual transmission is fuelling a significant increase in HCV seroconversion. One limitation of this study is that it failed to explore the role of intranasal cocaine use on HCV transmission.
These studies, taken as a whole begin to provide more detailed insight into the emerging pattern of new hepatitis C cases among HIV-positive gay men in London. A more consistent, joined up research effort would help to further elucidate which specific sex acts, sexually transmitted infections or kinds of recreational drug use are elevating HIV-positive gay men's risk of HCV acquisition.
Aizen, K et al. Acute hepatitis C (HCV) in a cohort of HIV-positive homosexual men- patient characteristics, risk factors and outcomes. Ninth Annual Meeting of the British HIV Association, Manchester, Abstract P45, 2003.
Browne RE et al. Increasing incidence of acute hepatitis C in HIV-positive men secondary to sexual transmission: a new epidemic? Ninth Annual Meeting of the British HIV Association, Manchester, Abstract 016, 2003.
Lascar RM et al. Outcome of acute hepatitis C in HIV-positive homosexual men.Ninth Annual Meeting of the British HIV Association, Manchester, Abstract 017, 2003.
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