High-risk lifestyle

[Guest guest]

High-risk lifestyle

By Jane ElliottHealth reporter, BBC NewsWhen hepatitis C was first discovered 21 years ago, Nafeica Wafaquani was herself just 21.She knew nothing of the virus and was by her own admission living a high-risk lifestyle – injecting drugs and not practising safe sex."Although we did not know much about hep C," she said. "We did know about HIV so I should have been taking precautions."I liked to be pretty rebellious. I was part of a whole subculture who felt that personal was political, squatting was a social statement, drug use was personal choice and sex was as and when a woman wanted it.Risky lifestyle"I took a lot of risks, of STDs, unwanted pregnancies, and putting myself in dangerous situations."Of course my attitude has changed. I’m now horrified at how many risks I took.""I have been very lucky as I have a strong liver, which has not degenerated

much"Nafeica WafaquaniNafeica does not know exactly how and when she became infected, but believes it could have been through her ex-partner’s habit of sharing needles.Eight years ago, after learning more about the disease, Nafeica decided to get herself tested."I knew I had put myself at risk when younger so it did not come as a huge surprise to be honest, but I had not shown any symptoms," she said."I had a lot of fatigue and depression and achy bones, but did not realise it was the hep C."Future looks promisingDr Kosh Agarwal, consultant hepatologist at King’s College Hospital, London, said the future is far from bleak for people like Nafeica.He says doctors can now cure 50% of cases, rising to 80% for some of those with certain genome types."Hepatitis C is a disease that we can treat effectively," said Dr Agarwal."The key issue is awareness, as most people will

not have symptoms for many years."Hep C can be cured and the treatments are much better. We can cure 50% of people who come through the door with hep C, but the treatments last between six months to a year."I believe very strongly in the next two to three years that we are going to have a whole new batch of antiviral drugs that are going to change the way we treat hep C."We are very positive – so get tested and get treated. It is not a death sentence unless you come too late," he said.Dr Agarwal urged everyone at risk to come for testing, whether or not they had symptoms.HEPATITIS C TRANSMISSION ROUTESSharing drug-taking equipmentBlood transfusions and blood products – if you received a blood transfusion before September 1991 or blood products before 1986 in the UKFrom infected mother to baby, before or during birthMedical and dental treatment abroad, where unsterile equipment may have been

usedTattooing, ear or body piercing, acupuncture, electrolysis and semi-permanent make-up where unsterile equipment may have been usedBy sharing razors or toothbrushes that may have been contaminated with blood from someone who is infected"Most people who get hep C are unlikely to have much in the way of symptoms so therefore don’t really know that they have hep C it is a sneaky virus that can sit in the background of the liver and cause damage over time."If untreated over a significant period of time, hep C can cause end-stage liver disease," he said.Professor , professor of medicine at Imperial College, London, and director of the liver and anti-viral centre at St ’s Hospital, agreed: "Hepatitis C remains a serious public health threat but it has very quickly become manageable, now being curable in the majority of cases."The biggest barrier to successful recovery is not lack of effective

antiviral treatment, but the fact that so many people don’t know they have it. I’d urge all those who may be at risk to get tested and treated."Nafeica, from Wiltshire, said she is very hopeful for her future."I have been very lucky as I have a strong liver, which has not degenerated much."I have started now on the treatment and have the genome type which responds well to it," she said.

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How common is sexual transmission of hepatitis C?AnswerHepatitis C is transmitted primarily by exposure to blood infected with the hepatitis C virus. Transmission rarely occurs from exposure to other infected body fluids, such as semen.If you're in a long-term, monogamous relationship with a partner who has hepatitis C, your risk of sexual transmission is 0 percent to 0.6 percent per year. For monogamous couples, the Centers for Disease Control and Prevention (CDC) doesn't recommend routine condom use to prevent transmission. But couples should avoid sharing razors, toothbrushes and nail clippers.The risk of transmission is slightly higher — about 1 percent per year — if you're involved in a short-term sexual relationship with someone who has hepatitis C. This risk increases if your partner is also infected with HIV. Under these circumstances, the

CDC recommends routine condom use to reduce your risk of transmission.If you're concerned about hepatitis C, talk to your doctor. Hepatitis C can be diagnosed by a blood test. Treatment may include medications to help clear the virus from your bloodstream.Mayo Clinic infectious disease specialist Steckelberg, M.D.,

HCV Sexual Transmission Revisited: A Look at the Latest ResearchLiz HighleymanSexual activity has traditionally been regarded as a rare route of hepatitis C virus (HCV) transmission. In the past few years, however, clusters of apparently sexually transmitted HCV – mostly among HIV positive gay men – have cast doubt on this assumption.Transmission Among Monogamous CouplesMost studies indicate that sexual transmission of HCV is very uncommon among long-term, monogamous, HIV negative heterosexual couples, with rates in the range of 0%-3%. As reported in the May 2004 American Journal of Gastroenterology, for example, Carmen Vandelli and colleagues followed 895 HCV negative individuals who had monogamous sexual relationships with HCV positive

partners.

Over 10 years of follow-up, just three new HCV infections occurred, for an incidence rate of 0.37 per 1,000 person-years (PY).

The authors concluded that “the risk of sexual transmission of HCV within heterosexual monogamous couples is extremely low or even null.†Likewise, V. Tahan and colleagues reported in the April 2005 American Journal of Gastroenterology that none of 216 HCV negative individuals with opposite-sex HCV positive spouses seroconverted during an average follow-up period of about three years.Transmission Among HIV Positive Gay MenBut the picture is different for HIV positive individuals. At the 13th Conference on Retroviruses and Opportunistic Infections (CROI) this past February, two research teams presented the latest data on clusters of acute hepatitis among gay men in England and the Netherlands, while a French team reported on apparent sexually transmitted HCV in heterosexual women.Since 2002, more than 200 cases of acute hepatitis C have

been reported among men who have sex with men (MSM) in London and Brighton in the UK. Mark Danta from London’s Royal Free Hospital gave an update on a cohort of 111 HIV positive men diagnosed with HCV between October 2002 and August 2005 (CROI abstract 86). The men who contracted HCV had three times more sex partners (30 vs 10) in the past year than men who remained HCV negative. Other significant risk factors included unprotected receptive and insertive anal intercourse, fisting, use of sex toys, group sex, and sexual activity under the influence of recreational drugs (92% vs 62%). What’s more, these factors appeared to interact: individuals who engaged in three or four of these practices in group sex settings had 23 times the risk of HCV infection. In addition, the men who contracted HCV were more likely to meet partners in sex clubs or bathhouses or over the Internet, and most (92%) had concurrent sexually transmitted diseases (STDs).

“High-risk and mucosally traumatic sexual factors are significantly associated with the recent transmission of HCV,†Danta concluded.Roel Coutinho and Thijs van de Laar reported on a retrospective study of sexual transmission of HCV among 1,836 HIV positive and HIV negative gay men in the Amsterdam Cohort Study (CROI abstract 87). A total of 29 cases of acute HCV have been detected in Amsterdam since 2000, all but one in HIV positive men. The post-2000 HCV incidence rate among men with HIV was 0.87 per 100 PY – a 10-fold increase over the pre-2000 rate. The largest cluster of cases had HCV genotype 4, which is uncommon in Europe. Like Danta, the Dutch researchers found that among the 20 men interviewed about sex and drug use, HCV infection was associated with fisting (practiced by 50%) and STDs that cause genital ulcers (e.g., syphilis, genital herpes simplex, lymphogranuloma venereum)(reported by 65%). The researchers concluded that

“HIV infection and/or mucosal trauma caused by extreme sexual techniques and concurrent STD might facilitate sexual transmission of HCV.â€Evidence from North AmericaClusters of apparently sexually transmitted HCV among MSM have also been seen in France, but, interestingly, not in North America. In the March 2005 American Journal of Public Health, M. Alary and colleagues reported that in a cohort of 1,085 MSM in Montreal, only one new HCV infection was detected during eight months of follow-up (in a man who shared needles), despite the fact that 63% reported unprotected anal sex. After controlling for injection drug use, the researchers concluded that sexual behavior was not significantly linked to HCV infection (although this was not an HIV positive cohort). In the U.S., Srigayatri Bollepalli and colleagues found that injection drug use was the only risk factor significantly associated

with HCV infection among HIV positive MSM in Arizona, concluding that “exual transmission of HCV among HIV [positive] patients is extremely rare†(56th AASLD, 2005; abstract 65573).But such cases aren’t unknown. In the January 1, 2006 Journal of AIDS, Annie Luetkemeyer and colleagues reported on a series of nine cases of acute HCV infection in HIV positive men seen at the University of California in San Francisco. Sex with men was the only risk factor reported by six of these individuals, while two reported unprotected sex with women, and three had concurrent STDs. The authors suggested that “MSM sexual activity as well as sexually transmitted infections may play an important role in HCV transmission in HIV-infected patients.â€What About Women with HIV?A new development at this year’s Retrovirus conference was a report of acute HCV infections in HIV positive

heterosexual women. J. Ghosn and colleagues analyzed data from 402 patients recently infected with HIV in the French PRIMO Cohort (abstract 843). They detected acute hepatitis C in two women and three men, for an incidence rate of 3.56 per 1000 PY (7.81 per 1000 PY for the women; 2.61 per 1000 PY for the men). As in Amsterdam, the incidence of acute hepatitis C increased in the early 2000s, from 1.81 per 1000 PY before January 2002 to 4.69 per 1000 PY after that date (all but one of the five new HCV infections were detected since 2002). Because none of the five reported “classical risk factors,†such as injection drug use or blood transfusions, the researchers concluded that “[t]he only identified risk factor for HCV acquisition was unsafe sex,†and suggested that “women are also at risk of acquiring HCV via the sexual route.â€Ghosn’s results conflict with a study from the U.S. Women’s Interagency HIV Study (WIHS), reported in the

November 15, 2003 issue of Clinical Infectious Diseases, showing no evidence of sexual HCV transmission in this cohort of 2,059 HIV positive and 569 HIV negative women. On the other hand, as reported in the May 1, 2003 Journal of Infectious Diseases, data from the HIV Epidemiology Research Study (HERS), looking at 871 HIV positive and 439 HIV negative women, suggested that 10.5% of the women coinfected with HCV had sex as their only risk factor (some also had genital herpes simplex).Better Safe than SorryTwo other recent studies indicate that sexual HCV transmission is biologically plausible, since HCV is present in semen and female genital fluid. As reported in the November 4, 2005 issue of AIDS, Aureliea Briat and colleagues from Paris analyzed HCV RNA levels in the semen of 82 HIV/HCV coinfected and 38 HCV monoinfected men. They detected HCV genetic material more often in the seminal

fluid of coinfected men than men with HCV alone (38% vs 18%). Similarly, as reported in the November 1, 2005 Journal of Infectious Diseases, M.J. Nowicki and colleagues measured HCV RNA levels in the cervicovaginal lavage fluid from 58 HIV/HCV coinfected and 13 HCV monoinfected women enrolled in WIHS. HCV RNA was detected in the genital fluid of 29% of the coinfected women, but none of the HCV monoinfected women.While studies have yielded conflicting data, there is increasing evidence that sexual transmission of HCV may be more common than previously thought – and that it appears to be occurring more frequently in recent years. Until more is known, it is prudent for people with any of the risk factors seen in these studies (e.g., HIV positive, multiple sexual partners, fisting, STDs) to practice safer sex, including the use of latex condoms and gloves.http://www.hcvadvocate.org/news/newsLett

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