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Health Spotlight


HIV and Hepatitis C: Common Co-Infection

blood sample

HIV (human immunodeficiency virus) is the virus that causes AIDS (acquired immunodeficiency syndrome), which progressively destroys the body's ability to fight infections and certain cancers by destroying the immune system. Hepatitis C virus (HCV) is a contagious viral disease that causes inflammation of the liver, and is spread primarily through contact with infected blood. One out of every four persons diagnosed with HIV is co-infected with HCV.1

Prevalence

  • More than one million people in the United Sates are currently living with HIV, and it is estimated that about 40,000 Americans become infected with HIV each year.2
  • In 2002, 19,346 patients received HIV care in the Veterans Health Administration (VHA). This makes the VHA the largest single provider of HIV care in the U.S.1
  • Three percent of the world's population,3 and as many as four million Americans are infected with HCV.4
  • HCV is a major health concern for veterans, with an estimated prevalence of 7% to 35% compared to 1.8% of the general population.5

Transmission

The HIV virus is passed from one person to another through blood-to-blood and sexual contact. It can occur when blood, semen, pre-seminal fluid, vaginal fluid, or breast milk is passed from an infected person to an uninfected person.

Injection drug use is the primary way in which HCV is spread. It also may be spread by using razors, toothbrushes, tattooing equipment, or body piercing needles that are contaminated with the blood of an infected individual. HCV is not spread through kissing or casual contact.

Screening Tests

Many people with HIV do not experience symptoms for years. The only way to know whether or not you have HIV is to undergo appropriate HIV screening. Commonly used screening tests look for antibodies produced by the body's immune system when they are exposed to HIV. Most people will develop detectable antibodies about 25 days after exposure, but in rare cases in can take up to six months to develop antibodies to HIV. Standard screening tests for HIV include:

  • The EIA (enzyme immunoassay) - performed on blood drawn from a vein, or using oral fluid (not saliva) or urine rather than blood;
  • Home testing kits (collection of small blood sample sent to manufacturer for EIA test); and
  • Rapid tests (produce results in 10-30 minutes but must be confirmed with a follow-up test before final diagnosis).6

For more information about HIV testing, go to the National HIV Testing Resources web site at http://www.hivtest.org.

HCV can be detected through blood tests that show elevated liver enzymes. Further testing for HCV antibodies using the EIA test and a supplemental test (HCV-RNA detection) can positively identify the infection.7

Treatment

The U.S. Food and Drug Administration (FDA) have approved several drugs for the treatment of HIV, such as nucleoside reverse transcriptase (RT) inhibitors and protease inhibitors. When RT inhibitors and protease inhibitors are used in combination, it is referred to as highly active antiretroviral therapy, or HAART. This therapy can be used by those who are newly infected, as well as by people with AIDS.2

Presently, there is no vaccine to prevent HCV. Interferon and ribavirin are two drugs licensed for the treatment of persons with chronic hepatitis C. Interferon can be taken alone or in combination with ribavirin. Combination therapy is currently the treatment of choice.8

HSR&D Research

Following are a few examples of recent and ongoing work by HSR&D investigators in the areas of HIV and HCV. In addition to these studies, VA's HIV/Hepatitis Quality Enhancement Research Initiative (HIV/Hepatitis QUERI) works to improve the quality of care and outcomes of veterans with HIV and/or HCV.

Improving HIV Screening with Rapid Testing
Testing for HIV is cost-effective, yet testing rates remain low. Standard screening test results are unavailable on the same day and many do not return for their results, but rapid HIV testing results can be available in 20 minutes. Funded through HIV/Hepatitis QUERI, this study shows that administering the rapid HIV test with streamlined counseling to veterans greatly increased both HIV testing and receipt of results. Rapid HIV testing has been implemented in one VISN, and if cost-effectiveness and increased testing turn out as expected, rapid testing will be implemented in VA facilities across the country. 9

Study Examines Effect of Hepatitis C and HIV Co-Infection
Injection drug users make up the largest group of people with HCV, and due to shared routes of transmission, co-infection with HCV and HIV is prevalent. Among HIV-positive injection drug users, 50%-70% are co-infected with HCV. This study sought to determine whether HIV is associated with spontaneously resolved HCV infection and levels of hepatitis C viremia (presence of virus in the bloodstream). Participants were recruited from the San Francisco VA Medical Center and San Francisco General Hospital between 2/97 and 7/03, and included injection drug users who had HCV alone (n=165) or who had co-infection with HIV (n=186). Findings show that there was no significant difference in spontaneously resolved HCV between participants with HCV and HIV compared to those with HCV only (11% vs. 15%). Higher viral levels were independently associated with both HIV status and longer duration of HCV infection.4

History of Injection Drug Use Not Associated with Hepatitis Treatment or Outcomes
The most recent VA guidelines recommend a case-by-case approach to treatment for veterans with HCV, who also are injection drug users. This study sought to determine the impact of a history of injection drug use on HCV treatment and outcomes. Investigators identified more than 4000 veterans with HCV who were seen and evaluated for treatment at 24 geographically diverse VA medical centers between 1999 and 2001. After analyzing study data, findings show that injection drug use was not associated with being a candidate for HCV treatment, acceptance into treatment, early discontinuation of therapy, or response to treatment. However, reduced HCV treatment candidacy and discontinuation of therapy were both independently associated with veterans having a low income and consuming three or more alcoholic drinks per day.5

Hepatitis C Infection Significantly Increases Risk for Non-Hodgkin Lymphoma
Hepatitis C virus (HCV) causes chronic hepatitis, cirrhosis, and hepatocellular carcinoma. Studies also have found an increased prevalence of HCV among persons with non-Hodgkin lymphoma (NHL). This study sought to determine if HCV infection is associated with malignant lymphoproliferative disorders, such as NHL and Waldenström's macroglobulinemia. Investigators compared VA data for 146,394 HCV-infected veterans with 572,293 veterans who were not infected with HCV. Data from VA administrative records for FY1989 through FY2004 were analyzed, and included information about patient demographics and all hospitalizations at more than 150 VA hospitals. In addition, outpatient data and death records were examined. Findings show that among HCV-infected veterans there was a 20% to 30% increased risk of non-Hodgkin lymphoma, and an almost three-fold risk of Waldenström's macroglobulinemia. Investigators suggest that screening HCV-infected individuals could identify early-stage lymphoproliferative conditions for early intervention.10

Resources

For those who test positive for HIV or have personal concerns and want more information, there is a CDC National AIDS Hotline at 1-800-342-AIDS (2437).

References

  1. VA's HIV/Hepatitis Quality Enhancement Research Initiative Fact Sheet. June 2007.
  2. A Glance at the HIV/AIDS Epidemic. Centers for Disease Control and Prevention (CDC).
  3. The ABC's of Hepatitis. Hepatitis Foundation International.
  4. Seal K, Monto A, Dove L, et al. The association of HIV and HIV-related factors with resolved hepatitis C virus infection and levels of viremia among injection drug users. Digestive Diseases and Sciences December 2007;52(12):3423-3430.
  5. Seal K, Currie S, Shen H, et al. Hepatitis C treatment candidacy and outcomes among 4318 U.S. veterans with chronic hepatitis C virus infection: Does a history of injection use matter? Journal of Clinical Gastroenterology February 2007;41(2):199-205.
  6. What are the different HIV screening tests available in the U.S.? Centers for Disease Control and Prevention.
  7. Hepatitis C: New treatment helps some, but cure remains elusive. U.S. Food and Drug Administration.
  8. Hepatitis C Fact Sheet. Centers for Disease Control and Prevention.
  9. Anaya H, Asch S, Hoang T, et al. Improving HIV screening with rapid testing and streamlined counseling. Presented at the XVI International AIDS Conference, Toronto, Canada, August 13-18, 2006.
  10. Giordano T, Henderson L, Landgren O, et al. Risk of Non-Hodgkin Lymphoma and Lymphoproliferative Precursor Diseases among 146,394 Hepatitis C Virus Infected U.S. Veterans. JAMA May 2007;297(18):2010-2017.