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Acute hepatitis C in HIV-infected individuals - recommendations from the NEAT consensus conference ('screen every 6 months after initial screening') - publication pdf attached
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Published Ahead-of-Print
AIDS: POST ACCEPTANCE, 6 December 2010
doi: 10.1097/QAD.0b013e328343443b

Hepatitis C virus (HCV) infection is a transmissible disease with potentially severe consequences on morbidity and mortality. Although there is increasing awareness of an ongoing epidemic of acute HCV infection in HIV-infected men who have sex with men (MSM), there exists no guidance on the best management of acute HCV infection in HIV-infected individuals. As data from clinical trials and cohort studies has become available, evidence based guidelines are timely to permit best management of these individuals. To address this issue, the European AIDS Treatment Network (NEAT) invited members of the European AIDS Clinical Society (EACS) Hepatitis Group, the European Association for the Study of the Liver (EASL), the European Study Group on Viral Hepatitis (ESGVH) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), the European AIDS Treatment group (EATG) and other experts to attend a consensus conference on acute HCV infection in HIV-infected individuals in Paris, France, on May 21st, 2010. This review reports the results of the conference and recommendations issued on the diagnosis, epidemiology, natural course and treatment of HIV-infected patients with acute hepatitis C infection.
Consensus recommendation Screening for acute HCV infection
(Grade A, Level II, MGrade C, Level II)
(1) All newly diagnosed HIV individuals should be screened for anti-HCV antibody [42].
(2) HIV-infected MSM at risk for contracting acute hepatitis C infection should be screened six monthly with ALT and annually with anti-HCV antibody.
(3) HIV-infected patients with newly diagnosed sexually transmitted infection or continued intravenous drug use should be screened 3 months after diagnosis/ last exposure
(4) A NAT test for HCV RNA should be performed if a diagnosis of acute HCV infection is suspected.
"treatment has been recommended in those with persistent HCV RNA reactivity 12 weeks after onset of symptoms or 12 weeks after putative exposure, though there may be as much as 8 weeks difference between these time points. Low level viraemia and viral load fluctuations are common in acute HCV and are incorporated in standard diagnostic criteria"
Consensus recommendation: case definition acute HCV infection
Preferred criteria (Grade A, Level II)

(1) Positive anti-HCV IgG in the presence or absence of a positive HCV RNA and a documented negative anti- HCV IgG in the previous 12 months or
(2) Positive HCV RNA and a documented negative HCV RNA and negative anti-HCV IgG in the previous 12 months
Alternative criteria (Grade B, Level III)
If historical data is lacking and relevant test results within the past year unavailable, acute hepatitis C may be diagnosed if the following criteria are met
Positive HCV RNA regardless of anti-HCV IgG with:
(1) A) an acute rise in ALT greater than 10 times the upper limits of normal (ULN) B) an acute rise in ALT greater than five times the ULN, with documented normal ALT within twelve months. In individuals with a previously high ALT, an acute rise to 3.5 x their previous ALT is acceptable [14] and
(2) anti-hepatitis A virus IgM negative and anti-hepatitis B core IgM antibody negative, and exclusion of other causes of acute hepatitis.
No consensus (20 in favour, 6 against with 3 abstentions) was reached to include a history of transmission risk factors for acute HCV in the alternative case definition.
HCV transmission in MSM
Studies in MSM have shown HIV infection and intravenous drug use to be independently associated with the presence of HCV antibodies [29,33 35]. In early reports, evidence for sexual transmission was weak with conflicting evidence of an association with sexual risk behaviour [33 39].
Recent studies investigating factors underlying HCV transmission in HIV-infected MSM have provided further evidence for an association with certain sexual practices including fisting, using sex toys, and group sex [29,36,37]. Non-injecting drug use is also associated, probably because of the influence on sexual behaviour but transmission through sharing contaminated devices may also contribute. There is an association with bacterial sexually transmitted infections notably syphilis and lymphogranuloma venereum. The mechanism of sexual transmission remains uncertain but the association with traumatic sexual practices and ulcerative STIs affecting the mucosa of the rectum provides some clues. HCV RNA has been detected in semen and more often in the HIV-infected [38], although one study failed to detect HCV RNA in the semen of most HIV-infected men even during acute HCV infection [39]. Group sex may facilitate transfer of infected material [36]. Other causes of disruption of the ano-rectal mucosa, including surgery, may contribute to the risk [Schmidt]. There is no evidence that HIV-infected men are more susceptible to HCV infection due to immunological deficits, or that a more virulent HCV strain is being selected. Phylogenetic analyses of transmitted HCV strains show clustering consistent with transmission among a social and sexual network of HIV-infected MSM, which extends nation- ally and internationally [40]. Although the majority of patients present with two or more risk factors described above, cases of acute HCV infection are seen in MSM who report only unprotected anal intercourse. Although current outbreaks have been largely confined to HIV- infected MSM, cases have also been reported in HIV- uninfected individuals.
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