European recommendations issued on acute hepatitis C infection in patients with HIV

European investigators and activists have developed recommendations for the management of acute hepatitis C infection in patients with HIV.

Published in the online edition of AIDS, they cover the diagnosis, epidemiology, natural history and treatment of the infection.

It is estimated that approximately a third of HIV-positive patients in Europe are co-infected with hepatitis C. The epidemic of sexually transmitted hepatitis C among HIV-positive gay men has lead to a renewed focus on the infection. Therefore in May 2010 doctors, researchers and activists from a number of European-wide bodies met in Paris to develop consensus guidelines about the management of acute hepatitis C infection.

Their recommendations concerned:

• Definition of acute hepatitis C infection.

• Screening for hepatitis C.

• Risk reduction advice.

• Natural history.

• Treatment during acute infection.

Acute hepatitis C is defined as the first six months after infection with the virus. Many people do not develop symptoms when they first contract the virus, and delayed antibody responses have been seen in a minority of HIV-positive patients.

Preferred European criteria for the diagnosis of acute infection are:

1.     Positive anti-hepatitis C IgG with or without detectable hepatitis C viral load and a negative hepatitis C antibody test in the previous twelve months.

Or:

2.     Positive hepatitis C viral load and a documented hepatitis C negative viral load and negative anti-hepatitis C IgG in the previous year.

However, in circumstances where previous test results are unavailable, acute hepatitis C can be diagnosed if a patient has detectable hepatitis C viral load, with:

1.     An increase in ALT levels greater than ten times the upper limit of normal, or five times the upper limit if liver function was normal within the previous twelve months.

2.     Negative for both hepatitis A and hepatitis B and all other causes of liver disease have been excluded.

Recommendations are also made concerning the screening of individuals for acute infection. These are:

1.     All patients newly diagnosed with HIV should have a hepatitis C antibody test.

2.     HIV-positive gay men at risk of hepatitis C should have their ALTs measured every six months and should also have an annual hepatitis C antibody test.

3.     Patients with an incident sexually transmitted infection (STI), as well as those who inject drugs, should be screened for acute hepatitis C three months after the diagnosis of the STI  or the last possible exposure to the virus.

4.     Individuals with suspected acute infection are recommended to have a their hepatitis C viral load monitored using nucleic acid testing.

There is currently some uncertainty about the exact mode of hepatitis C transmission in HIV-positive gay men. However, the following risk-reduction recommendations are made:

1.     Advice should include discussions of hepatitis C transmission and fisting, recreational drug use, group sex, use of sex toys, unprotected sex, traumatic sex, sharing injecting equipment, and risks from blood-to-blood contact.

2.     Information about hepatitis C risk reduction should be given to all HIV-positive individuals after their diagnosis and then at regular intervals. Patients with newly diagnosed hepatitis C should also be counselled about risk reduction.

A proportion of individuals naturally clear hepatitis C infection without the need for treatment. The consensus recommendations made the following observations about the natural history of the infection:

1.     HIV-positive patients are at greater risk of developing chronic hepatitis C infection.

2.     Studies suggest that between 0% and 40% of HIV-positive patients spontaneously clear hepatitis C during the acute phase.

3.     Factors associated with spontaneous clearance include female sex; sexual transmission; infection with hepatitis B; jaundice; and higher peak ALT levels.

4.     An early decline in hepatitis C viral load, four to eight weeks after infection is also associated with spontaneous clearance.

Good response rates to hepatitis C therapy have been seen in HIV-positive patients who start such treatment within a year of contracting the virus. Therefore recommendations are offered regarding the monitoring of the infection and test results that should act as a prompt to initiate treatment.

1.     Hepatitis C viral load should be measured when a patient is first diagnosed and then four weeks later.

2.     Treatment should be offered if viral load has not fallen by 2 log₁₀ copies/ml at the four week monitoring interval, or if a patient still has a detectable hepatitis viral load twelve weeks after acute infection was diagnosed.

3.     In circumstances where patients spontaneously clear the virus, a repeat measurement of viral load should be made after 48 weeks.