Good news on UK hepatitis C rates
About 9% of people with HIV in the UK are co-infected with hepatitis C virus (HCV), a study has found.1 This is a far lower rate than in other countries, and reflects the fact that, because of the early adoption of needle-exchange programmes in the UK, only a minority of injecting drug users have acquired HIV.
The study, in contrast with a number of European and American studies, found that treatment outcomes for people co-infected with HCV were no worse than for other people with HIV.
It also found, however, that about one-in-five people diagnosed with HIV in the UK have never been tested for HCV, despite guidance that all patients should be screened annually.
Researchers looked at HCV status and treatment outcomes in 31,765 patients attending ten HIV clinics between 1996 and 2007.
Overall, 64% of patients had been tested for hepatitis C at least once. The proportion of patients screened for the virus increased from 9% in 1996 to 80% in 2007.
HCV infection was much higher in patients whose HIV risk factor was injecting drug use. Eighty-four per cent of current or former injecting drug users had hepatitis C compared with 7% of gay men. The investigators suggested some of the infections in gay men may be due to injecting drugs but that patients had either concealed this or they or their doctors had assumed they caught HIV sexually.
Nonetheless, HCV infection was more common in all groups than in the general population, where HCV prevalence is just 0.44%.
Low HDL cholesterol is biggest modifiable risk for CVD
High-density lipoprotein (HDL) is sometimes called ‘good’ cholesterol as it protects against heart disease. It consists of particles in the blood, which carry fats back from the blood vessels to the liver, where they are stored. In contrast LDL (low-density lipoprotein) is called ‘bad’ cholesterol as it distributes fats to the blood vessels and raises heart disease risk.
Researchers calculated that the biggest single risk factor for cardiovascular disease in a group of 110 HIV patients was age, which accounted for 41% of the risk, but low HDL cholesterol was responsible for 18% of the risk. This exceeded the amount of risk attributed to smoking (7%), total cholesterol (4%), and male gender (2%).
The average age of this patient group was 37; two-thirds were on HIV therapy, two-thirds were men, and nearly 40% were smokers.
Cholesterol monitoring showed that 3% of individuals had elevated total cholesterol, 5% had high LDL cholesterol and 53% had low HDL cholesterol.
The limitation of this study was that, apart from being small, it was only a snapshot of heart disease risks at one timepoint. A longitudinal study would be needed to follow a larger group of patients and see how many developed heart disease to confirm the low-HDL connection. A number of HIV drugs have been associated with increased risk of strokes and heart attacks and with rises in total and LDL cholesterol. So far the only one that seems to improve HDL levels is the NNRTI drug nevirapine (Viramune).3
Lubricants may not be safe
The study4 follows on from two studies presented at last year’s International Microbicides Conference (see Are lubricants safe? in HTU 198). In one, six out of nine lubricants tested were found to damage rectal-lining cells5 and in the other, people taking part in a microbicide trial who used water-based lubes for anal sex were found to be more likely to acquire chlamydia, gonorrhoea or syphilis than people who did not use them.6
Water-based lubes are recommended for use with condoms because oil-based ones weaken the rubber and make them break.
In the latest study, researchers tested 41 commercially available lubes for their toxicity to cells. All were found to be toxic, to a greater or lesser extent, to rectal and colonic cells in the test tube.
Furthermore, four lubes out of the six with the brand name Astroglide appeared actively to enhance HIV infection of cultured cells. The researchers found that this was because they contained a substance called polyquaternium-15, which helps HIV attach itself to cells. The least toxic lubricant was the vaginal moisturiser Replens.
Condoms are still far more protective against HIV than lubricants are damaging, and not using lube can cause condoms to split. So for the moment, if condoms are your main HIV prevention method, using a water-based lubricant with them is still the safest thing to do. However people who for one reason or another do not use condoms might be safer to use non-water-based lubricants. A good compromise is the silicone-based lubricants which, while more expensive, are also condom-friendly.
Gardasil vaccine is effective in young men
This study may increase the pressure for Gardasil or the other HPV vaccine Cervarix to be licensed for use in the EU and given to young men in the UK.
Strains of HPV cause genital and anal warts and the vast majority of cervical and anal cancers, conditions far more common in people with HIV. Gardasil provides protection against infection by the two most common wart-causing strains of the virus (HPV 6 and 11) and the two most common cancer-causing strains (16 and 18). In contrast, Cervarix, which is currently given to young women in the UK, only protects against types 16 and 18 but may offer significant protection against other cancer-causing types of HPV too.
The study gave Gardasil or placebo to 4065 sexually experienced men aged 16 to 26. Fifteen per cent of them were men who had sex with men.
The recommended protective dose of Gardasil is three shots over one year. In the 69% of men who took all three shots, only six patients developed genital or anal warts or pre-cancerous conditions. This corresponds to an efficacy against HPV disease of 84%. The efficacy was higher in heterosexual men (92%) than in gay men (79%), possibly reflecting a higher variety of minority strains of HPV circulating amongst gay men.
Dr Jane Kim, author of an editorial that accompanied the study, said that its results “affirm the potential for HPV vaccines to prevent related disease in boys and men”.
Do these results mean that boys should routinely receive a vaccine against human papillomavirus? The data from this study persuaded the US Food and Drug Agency to license Cervarix for use in men as well as women. However, anal cancer is much rarer than cervical cancer and only a significant health risk in people with HIV. Some European regulators think that the money spent on vaccinating boys against HPV could be better spent elsewhere, a view echoed by an editorial in the New England Journal of Medicine, which published the study.8
- Turner J et al. The prevalence of hepatitis C virus (HCV) infection in HIV-positive individuals in the UK – trends in HCV testing and the impact of HCV on HIV treatment outcomes. J Viral Hepat, 17: 569-77, 2010.
- Cotter AG et al. High-density lipoprotein levels and 10-year cardiovascular risk in HIV-infected patients. AIDS 25: online edition, 2011.
- Van Leth F et al. Nevirapine and efavirenz elicit different changes in lipid profiles in antiretroviral-therapy-naïve patients infected with HIV-1. PLoS Med 1: e19, 2004.
- Begay O et al. Identification of personal lubricants that can cause rectal epithelial cell damage and enhance HIV-1 replication in vitro. AIDS Research and Human Retroviruses, early online edition, February 2011.
- Russo J et al. Safety and anti-HIV activity of over-the-counter lubricant gels. International Microbicides Conference, Pittsburgh, abstract 347, 2010.
- Gorbach PM et al. Rectal lubricant use and risk for rectal STI. International Microbicides Conference, Pittsburgh, abstract 348, 2010.
- Giuliano AR et al. Efficacy of quadrivalent HPV vaccine against HPV infection and disease in males. N Engl J Med 364: 401-11, 2011.
- Kim JJ Weighing the benefits and costs of HPV vaccination in young men. N Engl J Med 364: 393-5, 2011.