Coinfection Fell along with Injection Drug Use among Men in
HOPS; WIHS Women Appear Prone to HCV Sexual Transmission
Two recently published studies looked at the epidemiology
coinfection in large, long-term cohort studies.
Among men in the HIV Outpatient Study (HOPS), the
HIV/HCV coinfection rate declined between 1996 and
2007, corresponding to a drop in the proportion of
new HIV infections attributable to injection drug
use. In the Women's Interagency HIV Study (WIHS),
however, a considerable number of women who acquired
hepatitis C virus (HCV)
did not inject drugs but had partners who did, suggesting
that sexual transmission occurs more often than previously
thefirst study, described in the March
1, 2010 Journal of Acquired Immune Deficiency Syndromes,
Philip Spradling from the Centers for Disease Control and Prevention
(CDC) assessed HCV screening practices and determined trends
in the prevalence of hepatitis C coinfection among 7618 HOPS
participants -- mostly gay/bisexual men -- enrolled at 10 clinics
in 8 U.S. cities.
The researchers calculated the proportion of study participants
eligible to be tested for HCV -- that is, those who had never
been tested before or were previously found to be HCV negative
-- and looked at the annual prevalence of HCV infection from
1996 through 2007 according to socio-demographic, clinical,
and HIV risk category characteristics.
proportion of eligible cohort participants tested for HCV
infection rose from 10.7% in 1996 to 76.6% in 2007, with
increases seen in all demographic and risk groups.
HCV prevalence decreased from 36.7% in 1996 to 19.7% in
in prevalence occurred among all groups except injection
a multivariate analysis, the following factors were independently
associated with an increased likelihood of having received
an HCV test:
older than 35 years;
least 3 years of participation in the HOPS cohort;
in the high-risk heterosexual or injection drug user
for HCV infection in the HOPS has improved, although a sizable
fraction of patients remain unscreened," the study authors
They explained that the decline in overall HCV infection prevalence
between 1996 and 2007 resulted primarily from a decline in the
fraction of all prevalent infections in the cohort attributable
to injection drug users.
the second study, published in the November
20, 2009 issue of AIDS Patient Care and STDs, Toni
Frederick and colleagues attempted to determine whether sexual
transmission was a significant route of HCV transmission among
women in the U.S. WIHS cohort.
have traditionally thought that sexual transmission of HCV is
uncommon overall, and studies of HIV negative monogamous heterosexual
couples typically find transmission rates below 5%. Since around
2000, however, researchers have been reporting clusters of acute
or recent HCV infection among mostly HIV positive gay/bisexual
men, first in large European cities then in the U.S. and Australia.
While there has been some variation among studies, commonly
reported risk factors include "rough sex" (e.g., fisting),
sex in group settings, sex while using non-injection club drugs,
and concurrent sexually transmitted diseases (STDs).
men, having HIV seems to increases like likelihood that an individual
will become infected with HCV, develop chronic infection (rather
than spontaneous clearance), experience more rapid liver disease
progression, and respond less well to interferon-based therapy.
But these effects have not been extensively studied in women.
present study included more than 3600 HIV positive and at-risk
HIV negative women enrolled in WIHS from October 1994 to November
1995 and from October 2001 to November 2002. Demographic and
clinical factors associated with HCV infection were assessed
in a multivariate analysis controlling for history of injection
drug use or blood transfusions.
3636 women with available HCV test results, 31.5% were found
to be HCV antibody positive.
group included 13.5% who had no reported history of injection
drug use or blood transfusions.
prevalence of HCV infection among women with no reported
history of injection drug use or blood transfusion was 6.5%
-- 7.7% for HIV positive women and 3.6% for HIV negative
multivariate analysis showed that among women with no history
of injection drug use themselves, having sex with a man
who was an injection drug user was an independent risk factor
for HCV infection, after controlling for other factors including
blood transfusions, age, HIV status, and hepatitis B infection
(odds ratio [OR] 2.8).
stratification according to HIV status showed that the association
was significant only for HIV positive women (OR 1.9) compared
to HIV negative women (OR 1.1), although these odds ratios
did not differ significantly.
on these findings, the WIHS investigators concluded, "For
HIV positive women with no reported history of [injection drug
use], sex with an [injection drug user] male was independently
associated with HCV, suggesting that sexual transmission may
be an important mode of HCV transmission for these high-risk
this study is cross-sectional, it is possible that HIV infection
may play a role in increasing the likelihood of HCV sexual transmission
because of a compromised immune system in the setting of continued
high-risk sexual behaviors," they suggested in their discussion.
study of the sexual practices of women with HIV and at risk
for HIV may shed light on potential mechanisms of sexual transmission
of HCV," the authors continued. "Like HIV, STDs may
increase the risk of HCV transmission through ulcerative lesions,
providing a portal of entry for HCV. Anal sex, intercourse during
menstruation, and sex with physical trauma may also provide
avenues for enhanced sexual transmission of HCV through exposure
HIV-infected MSM [men who have sex with men], it has been suggested
that high-risk sexual practices including anal fisting and sex
in the presence of ulcerative coinfections are associated with
HCV acquisition and may have fueled recent HCV outbreaks in
this subgroup of MSM," they added. "These same mechanisms
may be important for HCV transmission among HIV-infected women
engaging in high-risk sexual practices."
HOPS: Division of Viral Hepatitis, National Center for HIV,
Hepatitis, STD, and TB Prevention, Centers for Disease Control
and Prevention, Atlanta, GA.
WIHS: Maternal-Child and Adolescent Center for Infectious
Diseases and Virology, Division of Hematology & Department
of Preventive Medicine, Keck School of Medicine, University
of Southern California, Los Angeles, CA; Division of Gastroenterology,
University of California at San Francisco, San Francisco, CA;
Cook County Medical Center, Chicago, IL; State University at
Downstate Medical Center, Brooklyn, NY; Georgetown University
School of Medicine, Washington, DC; Johns Hopkins School of
Public Health, Baltimore, MD; Bronx-Lebanon Hospital Center,
Spradling, JT Richardson, K Buchacz, and others. Trends in Hepatitis
C Virus Infection Among Patients in the HIV Outpatient Study,
1996-2007. Journal of Acquired Immune Deficiency Syndromes
53(3): 388-396 (Abstract).
March 1, 2010.
Frederick, P Burian, N Terrault, and others. Factors Associated
with Prevalent Hepatitis C Infection Among HIV-Infected Women
with No Reported History of Injection Drug Use: The Women's
Interagency HIV Study (WIHS). AIDS Patient Care and STDs
23(11): 915-923 (Abstract).
November 20, 2010.