EPIDEMIOLOGY, CLINICAL FEATURES AND OUTCOME OF ACUTE HEPATITIS C IN HIV-POSITIVE PATIENTS: PRESENTATION OF OUR EXPERIENCE E. Angeli, A. Mainini, C. Atzori, G. Gubertini and G. Rizzardini II Dept. Infectious Diseases L. Sacco Hospital, Milan - Italy 7 th International Workshop of HIV and Hepatitis Co-infection Milan, June 1-3, 2011
BACKGROUND (1) Acute hepatitis C is a quite rare event, usually difficult to recognize due to the paucity of clinical symptoms. In HIV-HCV co-infected patients, spontaneous clearance is significantly lower than in HCVmonoinfection (5-24% vs 25%).
BACKGROUND (2) Spontaneous clearance of acute HCV in HIV+ patients has been associated to (NEAT Acute Hepatitis C Infection Consensus Panel, AIDS 2011): host genetic factors (IL28B CC genotype using the rs12979860) adaptive immune responses female sex, exposure group (sex vs IVDU) HBs Ag positivity, jaundice, higher peak ALT early decline of HCV-RNA at 4-8 weeks
BACKGROUND (3) Treatment of acute HCV infection is recommended in HIV+ patients, for the higher rates of virological response (around 60-80%) compared to chronic hepatitis C (EACS guidelines, HIV Med 2008; NEAT Acute Hepatitis C Infection Consensus Panel, AIDS 2011) However, timing of diagnosis and antiviral therapy might be quite difficult to achieve
PATIENTS AND METHODS (1) Retrospective analysis of all the episodes of acute hepatitis C occurred since 2002 in HIV-positive outpatients followed at the II Department of Infectious Diseases of L. Sacco Hospital in Milan, Italy.
PATIENTS AND METHODS (2) For each patient we recorded epidemiological data (age, gender, risk factors for HIV), immune-virological and biochemical parameters (CD4+ cells count, HIV-RNA, ALT, AST, ggt), duration and CDC stage of HIV infection, HCVrelated parameters (HCV-RNA, genotype, appearance of anti-hcv antibodies) and outcome (spontaneous HCV clearance or treatment). IL28B polymorphism was retrospectively analyzed.
RESULTS (1) 12 cases of acute hepatitis C occurred in our department during the period 2002-2011. They were all men, who acquired HIV infection through sexual exposition (MSM). In 11 subjects acute hepatitis C was diagnosed by detection of positive anti-hcv antibodies, while one had positive HCV-RNA. Only one patient had clinical symptoms and developed jaundice.
Characteristics of 12 pts with acute HCV infection Mean age (ys) 38±7 (range 26-48) Mean duration of HIV infection (ys) 5±5 (range 0-12) CDC stage A 10/12 (83.3%) Patients on HAART 7/12 (58.3%) Mean CD4+ at nadir (cells/mmc) 319±202 (range 28-716) Mean CD4+ at diagnosis (cells/mmc) 642±288 (range 212-1155) Mean ALT (IU/l) 539±416 (range 112-1469) Mean AST (IU/l) 248±198 (range 75-745) Mean HCV-RNA (IU/ml) 702167±837195 (range 1783-2599186) HCV genotype: 1 2 3 4 n.a. 7/12 (58.3%) 1/12 (8.3%) 2/12 (16.7%) 1/12 (8.3%) 1/12 (8.3%) Concomitant STDs 6/12 (50%)
RESULTS (2) Only one patient spontaneously cleared HCV within 24 weeks, while 9 (82%) underwent antiviral treatment (8 PEG- IFN + RBV, 1 PEG-IFN mono-therapy). 6 patients were treated during acute infection (range 4-20 weeks), while 3 received antiviral therapy for a recently acquired chronic infection (range 76-120 weeks) Treatment duration for acute HCV was 24 (4), 36 (1) and 48 weeks (1). 2 recently infected patients are at the moment under observation.
RESULTS OF ANTIVIRAL TREATMENT SVR* 5/9 (55.5%) Relapse 2/9 (22.2%) EOT 2/9 (22.2%) *4 pts treated during acute infection Both pts with genotype 1 treated for acute infection for 24 weeks
IL28B POLYMORPHISM pt genotype rs12979860 C>T rs12980275 A>G rs80999917 T>G outcome 1 n.a. absent absent absent clearance 2 1 absent absent absent SVR 3 4 present present present SVR 4 1 present present present relapse 5 3 absent absent absent EOT 6 3 present present present SVR 7 1 absent absent absent follow up 8 1 absent absent absent relapse 9 1 present present present SVR 10 1 present present present EOT 11 1 absent absent absent follow up
RESULTS (3) Concomitant sexually transmitted diseases were diagnosed in 6/12 patients (50%), i.e. 5 cases of syphilis and 2 Chlamydia infections. One patient had previously HBV coinfection. One patient showed a second episode of acute hepatitis C two years after successful treatment of the first one, due to re-infection.
CONCLUSIONS (1) Even in our experience, acute hepatitis C is not a common event in HIV+ patients, but spontaneous clearance is extremely rare. However, in our cases, treatment of acute HCV infection was applied in 6/12 pts, underlining the complexity of the problem (timing of diagnosis and therapy, confidence of physicians, adherence, contraindications).
CONCLUSIONS (2) Subjects at high risk should undergo close screening and monitoring in order to detect early infection and to consider the option of antiviral therapy in relation to several parameters (viral kinetics, pt characteristics, genetics) In this subset of population, clinical evaluation should also include other STDs, and appropriate counseling continuously provided.