Sexual HCV reinfection of HIV-positive gay man while receiving PEG-interferon plus ribavirin

Although sexual transmission of HCV occurs in <1% of monogamous heterosexual couples who do not use condoms, an increasing number of cases of transmission to HIV-positive gay men has been reported in the UK over the last two years. Transmission in these cases is linked to anal intercourse without using condoms, multiple partners, active and receptive fisting, and recreational drug use. [1]

Sexual transmission of HCV to HIV-negative men has not been reported, but it has not been established whether HIV plays a role in these cases of transmission or whether transmission related to a highly infectious pathogen being exposed during higher risk activities to groups of men who already decide to only have sex with other HIV-positive partners.

A letter in the 8 April issue of AIDS from den Hollander and colleagues from the South Rijnmond Medical Centre in Rotterdam describes the case of patient who was sexually reinfected with a different HCV strain while receiving pegylated-interferon plus ribavirin treatment for his initial acute HCV infection. [2]

This patient, diagnosed with HIV since 1998, seroconverted to HCV genotype-1 between January and May 2003, with a HCV-RNA load up to 1.92 x 109 copies/ml. HCV testing was prompted after elevated AST failed to normalize after switching nevirapine to lopinavir/r, and he mentioned participation in group sex parties where one of the other participants was HCV-positive. From 1998 to 2004 he was treated for several sexually transmitted diseases (gonorrhoea, syphilis, rectal lymphogranuloma venereum).

Treatment with PEG-IFN-alpha 2a, 180 ug/week and ribavirin 1000 mg/day was started, and lopinavir/r/3TC/tenofovir was continued. HCV RNA was cleared after 12 weeks and AST levels normalised. At month 13, still on PEG-IFN/ribavirin therapy, AST levels increased and HCV RNA became detectable. Genotyping showed HCV genotype-2. The patient admitted he had participated in one more ‘fist-fucking’ party at month 11 in Berlin. The patient denied IVDU at any time.

The letter reports that this is the first case of reinfection during HCV treatment, and that PEG-IFN and ribavirin did not prevent infection with HCV.

Comment

There are a number of comments to this study that are worth making in addition to the conclusions of the authors.

Firstly, there was a good response to PegIFN and RBV despite HIV co-infection and genotype-1 infection

Secondly, re-infection was the most likely cause of the second surge of HCV viraemia (different genotype) and that pegIFN did not protect against this, reflecting the patient’s susceptibility to HCV infection probably related to HIV induced immune suppression.

Finally, the important conclusion must be to spread the ‘safe sex’ message and increase awareness with regard to mucosal traumatic ‘sexual’ transmission of HCV in this group of patients and the importance of continuing to offer early treatment to prevent long-term progression to end-stage liver disease and HCC.