Acute hepatitis C outbreak among HIV-infected men, Madrid, Spain.
|Article Type:||Letter to the editor|
HIV patients (Care and treatment)
HIV patients (Diagnosis)
Hepatitis C (Diagnosis)
Hepatitis C (Care and treatment)
Hepatitis C (Demographic aspects)
Fierer, Daniel Seth
de Gorgolas, Miguel
Fernandez-Guerrero, Manuel L.
|Publication:||Name: Emerging Infectious Diseases Publisher: U.S. National Center for Infectious Diseases Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 U.S. National Center for Infectious Diseases ISSN: 1080-6040|
|Issue:||Date: August, 2011 Source Volume: 17 Source Issue: 8|
|Topic:||Event Code: 310 Science & research|
|Geographic:||Geographic Scope: Spain Geographic Name: Madrid, Spain (City) Geographic Code: 4EUSP Spain|
To the Editor: In the past decade, hepatitis C virus (HCV) has
emerged as a sexually transmitted infection (STI) among HIV-infected men
who have sex with men (MSM). The epidemic was originally reported in
several northern European countries (England, France, Germany, and the
Netherlands) (1) and soon after in Australia (2) and the United States
(3). Acute HCV acquisition was associated with group sex, unprotected
receptive anal intercourse, and according to some studies, concomitant
STI (4). Molecular phylogenetic studies suggested evidence of an
international transmission network of MSM within northern Europe (1).
However, expansion of the HCV epidemic among MSM to Spain (5) or to
other countries of the Mediterranean area had not previously been
We report 4 cases of acute HCV in HIV-infected MSM in Madrid, Spain, 2010. These patients were monitored at a university-affiliated hospital in downtown Madrid, which provides health care to a large MSM community in the Chueca District. Diagnosis of acute HCV was made by using the following criteria of the European AIDS Treatment Network (6): 1) positive HCV RNA; 2) an acute rise in alanine aminotransferase level >5x the normal upper limit, with documented normal alanine aminotransferase level within 12 months; and 3) negative results for anti-hepatitis A virus immunoglobulin M and anti-hepatitis B core immunoglobulin M (when other causes of acute hepatitis were excluded). An HCV RNA load fluctuation of >1 log10 IU/mL, if present, was considered further evidence of acute HCV infection (7).
All 4 patients were MSM with well-controlled HIV infection who were receiving antiretroviral treatment. During routine medical screening, they were found to have newly elevated liver transaminase levels, and further assessment confirmed the diagnosis of acute HCV infection (Table). Three patients had received a diagnosis of STI in the previous 6 months, but only 1 patient acknowledged having unprotected anal intercourse. In addition, only 1 patient acknowledged using any recreational drugs (amyl nitrate); all denied using injection drugs (Table). All patients had lived in Madrid for at least 5 years before receiving a diagnosis of acute HCV. No patients reported having sex during international travel, using sex toys, or fisting.
The patients described here lived in the Chueca District of Madrid, the largest MSM community in Spain, which is frequented by MSM traveling from smaller cities in Spain and other countries. Two of the 3 patients were infected with HCV genotype 4, which is unusual in patients from outside the Middle East and Africa (8) yet unexpectedly common in northern European HCV outbreaks (1), which suggests that the patients reported here may have been part of the social network originating in the north. Further sequencing of these isolates is under way to address this issue. The third patient with an identifiable HCV genotype was infected with HCV genotype 1, the most common genotype among HIV-infected MSM in northern Europe (1). These findings suggest that a larger, undetected outbreak of HCV infection is taking place in Madrid.
Although the patients reported here described fewer risks for sexual acquisition of HCV than patients from northern Europe or the United States, 3 had recent STI, which suggests that they underreported their risks for HCV acquisition. This temporal association between STI and acute HCV in these patients suggests that the pattern of emergence of sexually transmitted HCV among MSM in Spain might be similar to that seen in northern Europe, following regional epidemics of syphilis (starting in 2000) (9,10). We therefore encourage HIV specialists and general practitioners, when investigating an STI, to perform HCV testing on MSM as well as on persons with newly elevated liver aminotransferase levels.
(1.) van de Laar T, Pybus O, Bruisten S, Brown D, Nelson M, Bhagani S, et al. Evidence of a large, international network of HCV transmission in HIV-positive men who have sex with men. Gastroenterology. 2009;136:1609-17. doi:10.1053/j. gastro.2009.02.006
(2.) Matthews GV, Hellard M, Kaldor J, Lloyd A, Dore GJ. Further evidence of HCV sexual transmission among HIV-positive men who have sex with men: response to Danta et al. AIDS. 2007;21:2112-3. doi:10.1097/QAD.0b013e3282ef3873
(3.) Fierer DS, Uriel AJ, Carriero DC, Klepper A, Dieterich DT, Mullen MP, et al. Liver fibrosis during an outbreak of acute hepatitis C virus infection in HIV-infected men: a prospective cohort study. J Infect Dis. 2008;198:683-6. doi:10.1086/590430
(4.) van de Laar TJ, Matthews GV, Prins M, Danta M. Acute hepatitis C in HIV-infected men who have sex with men: an emerging sexually transmitted infection. AIDS. 2010;24:1799-812. doi:10.1097/ QAD.0b013e32833c11a5
(5.) Ruiz-Sancho A, Barreiro P, Castellares C, Labarga P, Ramos B, Garcia-Samaniego J, et al. Outbreak of syphilis, but not of acute hepatitis C, among HIV-infected homosexual men in Madrid. HIV Clin Trials. 2007;8:98-101. doi:10.1310/hct0802-98
(6.) European AIDS Treatment Network (NEAT) Acute Hepatitis C Infection Consensus Panel. Acute hepatitis C in HIV-infected individuals: recommendations from the European AIDS Treatment Network (NEAT) consensus conference. AIDS. 2011;25:399-409.
(7.) Heller T, Rehermann B. Acute hepatitis C: a multifaceted disease. Se min Liver Dis. 2005;25:7-17. doi:10.1055/s-2005-864778
(8.) Kamal SM, Nasser IA. Hepatitis C genotype 4: what we know and what we don't yet know. Hepatology. 2008;47:1371-83. doi:10.1002/hep.22127
(9.) Diaz A, Junquera ML, Esteban V, Martinez B, Pueyo I, Suarez J, et al. HIV/ STI co-infection among men who have sex with men in Spain. Euro Surveill. 2009;14: pii: 19426.
(10.) Gonzalez-Lopez JJ, Guerrero ML, Lujan R, Tostado SF, de Gorgolas M, Requena L. Factors determining serologic response to treatment in patients with syphilis. Clin Infect Dis. 2009;49:1505-11. doi:10.1086/644618
Address for correspondence: Ana MontoyaFerrer, Fundacion Jimenez Diaz, Avenida Reyes Catolicos, 2, Madrid 28040, Spain; email: email@example.com
Table. Description of 4 HIV-infected men with HCV infection, Madrid, Spain, 2010 * Characteristic Patient 1 Age, y 31 Country of origin Italy Date of HIV diagnosis 2006 Jun Year ART initiated 2008 Prior negative HCV test 2006 Date AHC diagnosed May 2010 CD4 count, cells/[micro]L 562 HIV viral load Undetectable Symptoms at diagnosis No ALT/AST levels at AHC 564/331 diagnosis, U/L HCV genotype 4 HCV RNA load, IU/mL ([log.sub.10] 950,556 (5.98) IU/mL) HCV RNA load fluctuation 4.32 within 3 mo, [log.sub.10] IU/mL Unprotected anal intercourse No STI in previous 6 mo Proctitis Group sex (>2 persons) Yes Drug use Amyl nitrate only Characteristic Patient 2 Patient 3 Age, y 41 39 Country of origin Ecuador Spain Date of HIV diagnosis 2000 Jul 1998 Year ART initiated 2000 2006 Prior negative HCV test Nonet Nonet Date AHC diagnosed May 2010 May 2010 CD4 count, cells/[micro]L 327 787 HIV viral load Undetectable Undetectable Symptoms at diagnosis Mild asthenia only No ALT/AST levels at AHC 304/216 222/114 diagnosis, U/L HCV genotype 4 1a HCV RNA load, IU/mL ([log.sub.10] 629,875 (5.80) 11,827 (4.07) IU/mL) HCV RNA load fluctuation <1.00 1.33 within 3 mo, [log.sub.10] IU/mL Unprotected anal intercourse No No STI in previous 6 mo Syphilis No Group sex (>2 persons) No No Drug use No No Characteristic Patient 4 Age, y 39 Country of origin Spain Date of HIV diagnosis 2001 Year ART initiated 2006 Prior negative HCV test 2008 Date AHC diagnosed May 2010 CD4 count, cells/[micro]L 750 HIV viral load Undetectable Symptoms at diagnosis No ALT/AST levels at AHC 261/125 diagnosis, U/L HCV genotype Indeterminate HCV RNA load, IU/mL ([log.sub.10] 2,254,258 (6.35) IU/mL) HCV RNA load fluctuation <1.00 within 3 mo, [log.sub.10] IU/mL Unprotected anal intercourse Serosorting ([double dagger]) STI in previous 6 mo Proctitis Group sex (>2 persons) No Drug use No * HCV, hepatitis C virus; ART: antiretroviral therapy; AHC, acute hepatitis C infection; ALT, alanine aminotransferase; AST, aspartate aminotransferase; STI, sexually transmitted infection. ([dagger]) Both patients had normal transaminase levels in the 4 y before AHC diagnosis. ([double dagger]) Unprotected sex between seroconcordant partners (HIV positive).
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