SUMMARY
Objective:
to determine the prevalence and epidemiological factors associated with hepatitis (HCV) coinfection in human immunodeficiency virus (HIV) patients from Curitiba and the metropolitan region.
Methods:
a study with 303 HIV+ patients, mean age 41.2 years (18-73); 50.5% men, followed at the Hospital de Clínicas, Universidade Federal do Paraná, between April 2008 and March 2009. Clinical and epidemiological data were obtained through questionnaires and retrospective analysis of medical records. Anti-HCV antibodies were detected by chemiluminescence immunoassay.
Results:
a total of 12.9% of HIV+ patients were positive for anti-HCV antibodies, 64.1% were men and 35.9% women, with mean age of 44.5 years (24-66). The frequency of HCV among men was 16.7% and among women 9.1% (p=0.06). HCV prevalence was associated to HIV infection when compared to the general population (p<10-6, OR=100.4; 95CI=13.7-734.9). The parenteral route of transmission was the most frequent among coinfected patients (46.1%), and the sexual transmission among HIV+/HCV- (71.8%) (p=0.02, OR=0.2; 95CI=0.1-0.7). The frequency of intravenous drug users was higher among the coinfected patients (61.5%) compared to the non coinfected (12.6%) (p<10-6, OR=11.1; 95CI=4.5-27.7).
Conclusion:
the prevalence of coinfection with HCV in HIV+ patients is 12.9%, 88 times higher than in the general population in Curitiba. The most frequent route of transmission in the coinfected patients is parenteral, but the sexual route is also representative (34.6%).
Keywords:
HIV; acquired immunodeficiency syndrome; coinfection; hepatitis C
RESUMO
Soroprevalência de marcadores do vírus da hepatite C (HCV) em pacientes infectados com HIV de Curitiba e Região Metropolitana
Objetivo:
verificar a prevalência e caracterizar fatores epidemiológicos associados à coinfecção por HCV em pacientes HIV+ de Curitiba e Região Metropolitana.
Métodos:
estudo envolvendo 303 pacientes HIV+, com idade média de 41,2 anos (18-73); 50,5% homens; acompanhados no Hospital de Clínicas da Universidade Federal do Paraná, entre abril de 2008 e março de 2009. Os dados clínico-epidemiológicos foram obtidos por meio de questionários e análise retrospectiva dos prontuários. Os anticorpos anti-HCV foram detectados por ensaio imunoenzimático quimioluminescente.
Resultados:
dos pacientes HIV+, 12,9% apresentaram sorologia positiva para o HCV, sendo 64,1% homens e 35,9% mulheres, com idade média de 44,5 anos (24-66). A frequência nos homens foi de 16,7%, e nas mulheres, 9,1% (p=0,06). A prevalência do HCV foi significativamente associada à infecção por HIV quando comparada à população geral (p<10-6, OR=100,4; IC95%=13,7-734,9). A via de transmissão parenteral foi a mais frequente entre os coinfectados (46,1%), e a sexual, a mais frequente entre os não coinfectados (71,8%) (p=0,02, OR=0,2; IC95%=0,1-0,7). A frequência de usuários de drogas injetáveis foi maior entre os coinfectados (61,5%) do que entre os não coinfectados (12,6%) (p<10-6, OR=11,1; IC95%=4,5-27,7).
Conclusões:
a prevalência da infecção por HCV nos pacientes HIV+ é de 12,9%, 88 vezes maior que a infecção na população geral de Curitiba. A via de transmissão mais frequente entre os coinfectados foi a parenteral, porém, a via sexual também é representativa para a transmissão do HCV (34,6%).
Palavras-chave:
HIV; síndrome de imunodeficiência adquirida; coinfecção; hepatite C
INTRODUCTION
Infection with the human immunodeficiency virus (HIV), which causes Acquired Immune Deficiency Syndrome (AIDS), and hepatitis C virus (HCV) are among the major challenges to public health in the world. Both are RNA viruses and share common transmission routes, including parenteral, sexual and vertical. This epidemiological similarity results in a high prevalence of HIV/HCV co-infection and represents an important factor of morbidity and mortality for the individuals affected.11 Laskus T, Kibler K V, Chmielewski M, Wilkinson J, Adair D, Horban A, et al. Effect of hepatitis C infection on HIV-induced apoptosis. PLoS One. 2013; 8(10):e75921.
2 Soriano V, Vispo E, Labarga P, Medrano J, Barreiro P. Viral hepatitis and HIV co-infection. Antiviral Res. 2010; 85(1):303-15.
3 Kim AY, Onofrey S, Church DR. An epidemiologic update on hepatitis C infection in persons living with or at risk of HIV infection. J Infect Dis. 2013; 207(Suppl 1):S1-6.-44 Operskalski E a, Kovacs A. HIV/HCV co-infection: pathogenesis, clinical complications, treatment, and new therapeutic technologies. Curr HIV/AIDS Rep. 2011; 8(1):12-22.
Liver diseases are one of the most frequent causes (9%) of hospitalization and death in HIV infected patients, with co-infection with HCV an important cofactor for worsening the clinical picture.33 Kim AY, Onofrey S, Church DR. An epidemiologic update on hepatitis C infection in persons living with or at risk of HIV infection. J Infect Dis. 2013; 207(Suppl 1):S1-6.,55 Soriano V, Vispo E, Fernandez-Montero JV, Labarga P, Barreiro P. Update on HIV/HCV coinfection. Curr HIV/AIDS Rep. 2013; 10(3):226-34. The prevalence of HIV/HCV co-infection varies widely in different populations, according to the associated risk factors, distinct epidemiological characteristics and methodological differences.
HIV/HCV co-infection significantly alters the clinical course of these infections and is associated with unfavorable outcomes. In addition to liver damage, HCV enhances the activation of the immune system, chronic inflammation, and increased cardiovascular risk, kidney diseases and cancer. Furthermore, it can slow down the reconstitution of the immune system after highly active anti-retroviral treatment (HAART), and increase the risk of progression to AIDS.33 Kim AY, Onofrey S, Church DR. An epidemiologic update on hepatitis C infection in persons living with or at risk of HIV infection. J Infect Dis. 2013; 207(Suppl 1):S1-6.,55 Soriano V, Vispo E, Fernandez-Montero JV, Labarga P, Barreiro P. Update on HIV/HCV coinfection. Curr HIV/AIDS Rep. 2013; 10(3):226-34.,66 Zeremski M, Martinez AD, Talal AH. Management of hepatitis C virus in HIV-infected patients in the era of direct-acting antivirals. Clin Infect Dis 2013; 58(6):880-2. Concomitant treatment of these viruses may cause drug interaction between HAART and direct-acting antiviral agents (DAA), used in the treatment of HCV, increasing liver damage by up to three times.55 Soriano V, Vispo E, Fernandez-Montero JV, Labarga P, Barreiro P. Update on HIV/HCV coinfection. Curr HIV/AIDS Rep. 2013; 10(3):226-34.,77 Greub G, Ledergerber B, Battegay M, Grob P, Perrin L, Furrer H, et al. Clinical progression, survival, and immune recovery during antiretroviral therapy in patients with HIV-1 and hepatitis C virus coinfection: the Swiss HIV Cohort Study. Lancet. 2000; 356(9244):1800-5.,88 Mendes-Corrêa MCJ, Barone AA, Cavalheiro NP, Tengan FM, Guastini C. Prevalence of hepatitis B and C in the sera of patients with HIV infection in São Paulo, Brazil. Rev Inst Med Trop São Paulo. 2000; 42(2):81-5. Furthermore, co-infected patients have lower HCV clearance and greater viral load, and thus more rapid progression of liver disease compared to HIV patients that are not co-infected.11 Laskus T, Kibler K V, Chmielewski M, Wilkinson J, Adair D, Horban A, et al. Effect of hepatitis C infection on HIV-induced apoptosis. PLoS One. 2013; 8(10):e75921.,44 Operskalski E a, Kovacs A. HIV/HCV co-infection: pathogenesis, clinical complications, treatment, and new therapeutic technologies. Curr HIV/AIDS Rep. 2011; 8(1):12-22.,99 Aranzabal L, Casado JL, Moya J, Quereda C, Diz S, Moreno A, et al. Influence of liver fibrosis on highly active antiretroviral therapy-associated hepatotoxicity in patients with HIV and hepatitis C virus coinfection. Clin Infect Dis. 2005; 40(4):588-93.
10 Martín-Carbonero L, Benhamou Y, Puoti M, Berenguer J, Mallolas J, Quereda C, et al. Incidence and predictors of severe liver fibrosis in human immunodeficiency virus-infected patients with chronic hepatitis C: a European collaborative study. Clin Infect Dis. 2004; 38(1):128-33.-1111 Sulkowski MS. Viral hepatitis and HIV coinfection. J Hepatol. 2008; 48(2):353-67. HIV patients classified as rapid progressors have a higher HCV viral load than long-term progressors, suggesting that immunological and/or genetic factors also contribute to control of viremia in both viruses.1212 Thibault V, Candotti D, Autran B, Cahour A, Agut H; French ALT Study Group. Hepatitis C virus infection in long-term nonprogressor HIV-1-infected subjects. J Acquir Immune Defic Syndr. 2002; 29(2):204-6.
Given the complexity of treatment in co-infected patients, it is necessary to identify HCV co-infection in individuals with HIV early in order to establish therapeutic measures and even primary prevention that alters the progression to chronicity. In such patients, treatment for HCV with DAA should be prioritized.55 Soriano V, Vispo E, Fernandez-Montero JV, Labarga P, Barreiro P. Update on HIV/HCV coinfection. Curr HIV/AIDS Rep. 2013; 10(3):226-34.,1313 Labarga P, Soriano V, Vispo ME, Pinilla J, Martin-Carbonero L, Castellares C, et al. Hepatotoxicity of antiretroviral drugs is reduced after successful treatment of chronic hepatitis C in HIV-infected patients. J Infect Dis. 2007; 196(5):670-6.
The present study analyzed some epidemiological factors involved in the co-infection of HIV/HCV in patients from Curitiba and the metropolitan region under monitoring at the Infectious and Parasitic Diseases Outpatient Clinic of the Hospital de Clínicas da Universidade Federal do paraná (HC/UFPR) in order to determine the prevalence and associated risk factors.
METHODS
Patients and clinical data
303 HIV positive individuals of both sexes were analyzed during monitoring at the Infectious and Parasitic Diseases Outpatient Clinic of the HC/UFPR from April 2008 to March 2009.
The clinical and epidemiological data were obtained during medical visits by filling in a questionnaire on the risk factors associated with HIV acquisition, and through a retrospective analysis of medical records. The following variables were analyzed: age, sex, date of first positive serology for HIV, possible form of acquisition of the virus and associated risk factors such as use of injectable drugs, number of sexual relations and history of blood transfusion and/or blood products.
This study was approved by the Ethics Committee for Research on Human Beings (CEP) at the HC/UFPR under nº CEP/HC 1409.074/2007-04.
Collection of blood and laboratory analysis
The patients treated at the Infectious and Parasitic Diseases Outpatient Clinic of the HC/UFPR in Curitiba, with HIV positivity determined according to the protocol of the National Coordination of STD/AIDS of the Ministry of Health (CNDST/AIDS-MS), were contacted and, after proper clarification and signing of the informed consent (IC) form, 5 mL of venous blood with anticoagulant was collected from each patient. After centrifugation, the serum was suitably separated, aliquoted and stored at -80°C until tested for the presence of anti-HCV antibodies.
Anti-HCV antibodies were determined by enzyme immunoassay with micro chemiluminescence (MCL), using the Architect® (Abbott, USA) commercial systems of the clinical analyses service of the HC/UFPR, according to manufacturer's instructions.
Statistical analysis
The data collected and results obtained were tabulated in an Excel spreadsheet and comparisons between groups were performed using the two-tailed Fisher's exact test, Student's t-test or chi-square test. The odds ratio value and confidence interval of 95% were calculated when appropriate. P-values <0.05 were considered significant.
RESULTS
The results of the characterization of the sample are presented in Table 1. Among the 303 HIV patients studied, 153 (50.5%) were male and 150 patients (49.5%) were female, with a mean age of 41.2 years (18 to 73 years). In relation to the predominant ancestry, 289 (95.4%) were Euro-Brazilians and 14 (4.6%) were Afro-Brazilians.
39/303 patients were identified (12.9%) as seropositive for HCV, a total of 25/39 (64.1%) of whom were male and 14/39 patients (35.9%) female, with a mean age of 44.5 (24-66 years); 37 (94.9%) were Euro-Brazilians and 2 (5.1%) Afro-Brazilians. Among the remaining 264 (87.1%) HIV patients, 139/264 (52.7%) were female and 125/264 (47.3%) were male, with a mean age of 40.7 years and variation of 18 to 73 years. The prevalence of HCV infection was significantly higher in HIV patients (12.9%) than in the general population of Curitiba (0.15%)1414 De Moraes Braga AC, Reason IJM, Maluf ECP, Vieira ER. Leprosy and confinement due to leprosy show high association with hepatitis C in Southern Brazil. Acta Trop. 2006; 97(1):88-93. (p<10-6, OR=100.4; 95CI=13.7-734.9).
The age and descent were similar in the two groups of HIV and HIV/HCV patients. In relation to sex, women represented 52.7% of cases in patients not co-infected and 35.9% in co-infected patients, suggesting a trend, albeit not significant (p=0.059), towards a higher frequency of co-infected males.
Only 193 (63.7%) of the 303 patients analyzed informed their supposed route of HIV infection. Therefore, in 110 (36.3%) of patients it was not possible to trace the route of infection of the virus. The co-infected patients differed from those not co-infected in relation to the frequency of sexual transmission and parenteral routes (p=0.02, OR=0.2, 95%CI =0.1-0.7), with the sexual route most frequent among HIV/HCV- and parenteral among those with HIV/HCV. Regarding injectable drug use (p<10-6, OR=11.1, 95CI=4.5-27.7), this was significantly higher among co-infected patients (61.5%) than those not co-infected (12.6%) and also in relation to the number of transmission routes to which they reported being exposed (p=0.01, OR=0.3, 95CI=0.1-0.7).
Among patients not co-infected, 167/264 (63.3%) informed the supposed route of infection. 15/167 (9.0%) of these cases had two or more overlapping transmission routes, 120/167 (71.9%) reported sexual contact only, 19/167 (11.4%) reported the parenteral route by blood transfusion, and 13/167 (7.8%) intravenous injectable drug use (IDU). Among individuals with overlapping routes, the sexual route was reported in 14/15 and the parenteral route was involved in all cases.
Among HIV patients co-infected with HCV, 26/39 (66.7%) informed the supposed route of infection. 7/26 of these presented overlapping routes, 10/26 (38.5%) reported only IDU and 9/26 (34.6%) only the sexual route. No cases of isolated infection via transfusion were reported. Among individuals with overlapping routes, the sexual route was reported in 5/7 and the parenteral was involved in 7 cases. Therefore, the parenteral route was the most frequent among patients co-infected with HIV/HCV 12/26 (46.1%), while the sexual transmission route was more frequent among HIV patients without co-infection 120/167 (71.9%).
There was no difference between the route of infection between men and women and between age groups, both in the co-infected group and the group with HIV alone. In relation to the time for progression to AIDS, among co-infected patients, the analyses were not conclusive because the majority of the patients were unable to inform the approximate date of the start of infection.
DISCUSSION
The prevalence indexes for HIV infection remain alarming. According to the World Health Organization (WHO), approximately 3% of the world population is infected with HIV and Brazil has one of the highest rates in South America, from 2.5 to 10%.1515 Martins T, Narciso-Schiavon JL, Schiavon LL. Epidemiologia da infecção pelo vírus da hepatite C. Rev Assoc Med Bras. 2011; 57(1):107-12.
With the introduction of HAART therapy in 1996 there was a significant decrease in mortality of individuals infected with HIV. However, in the last 10 years, despite the efficiency of this therapy, we have seen a worsening of the clinical condition of these patients in relation to liver disease, such as decompensated cirrhosis and hepatocellular carcinoma, mainly due to co-infection with HBV and HCV. These clinical symptoms have been the main cause of hospitalization, accounting for 9% of deaths among HIV infected individuals.16RuppiK M, Ledergerber B, Richenbach M. Changing patterns of cause of death in the Swiss HIV Cohort Study (SHCS) 2005-2009. 18th CROL. Boston, 2011.,1717 Puoti M, Moioli M, Travi G, Rossotti R. The burden of liver disease in HIV infected patients. Semin Liver Dis. 2012; 32(2):103-13. Various strategies have been proposed for the reduction of mortality in these individuals, such as vaccination against HBV and optimization of HIV and HCV therapies; screening for alcohol abuse; and diagnosis and treatment of underlying diseases, such as diabetes.1818 Puoti M, Rossotti R, Travi G, Panzeri C, Morreale M, Chiari E, et al. Optimizing treatment in HIV/HCV coinfection. Dig Liver Dis. 2013; 45(Suppl 5):S355-62.
The prevalence of HCV infection was significantly associated with HIV infection compared with the prevalence of HCV in the general population of Curitiba, which justifies screening for HCV in HIV patients. Co-infection with HCV is a major etiological cause of liver disease in HIV-infected individuals, with a negative impact on these patients. Liver damage induced by the immunosuppression caused by the presence of HIV is boosted by the presence of HCV, which also causes chronic inflammation in the liver, leading to an increased risk of cardiovascular and kidney diseases.44 Operskalski E a, Kovacs A. HIV/HCV co-infection: pathogenesis, clinical complications, treatment, and new therapeutic technologies. Curr HIV/AIDS Rep. 2011; 8(1):12-22.,1919 Chen T-Y, Ding EL, Seage Iii GR, Kim AY. Meta-analysis: increased mortality associated with hepatitis C in HIV-infected persons is unrelated to HIV disease progression. Clin Infect Dis. 2009; 49(10):1605-15.
The co-infection rates vary widely in different populations, probably due to differences in the population groups and methodologies used (Table 2). The prevalence of co-infection varies in different populations, from 10% and possibly reaching 85% in IDU.11 Laskus T, Kibler K V, Chmielewski M, Wilkinson J, Adair D, Horban A, et al. Effect of hepatitis C infection on HIV-induced apoptosis. PLoS One. 2013; 8(10):e75921. In the United States and Europe, it is estimated that approximately 30% of HIV patients are co-infected with HCV,1717 Puoti M, Moioli M, Travi G, Rossotti R. The burden of liver disease in HIV infected patients. Semin Liver Dis. 2012; 32(2):103-13. which may reach up to 95% if one considers blood as the route of transmission, both IDU as well as blood transfusion.2020 Alter MJ. Epidemiology of viral hepatitis and HIV co-infection. J Hepatol. 2006; 44(1 Suppl ):S6-9. In Brazil, the prevalence varies from 5 to 54% depending on the region investigated and the study design,2121 Segurado AC, Braga P, Etzel A, Cardoso MR. Hepatitis C virus coinfection in a cohort of HIV-infected individuals from Santos, Brazil: seroprevalence and associated factors. AIDS Patient Care STDS. 2004; 18(3):135-43.
22 Morimoto HK, Caterino-De-Araujo A, Morimoto AA, Reiche EM V, Ueda LT, Matsuo T, et al. Seroprevalence and risk factors for human T cell lymphotropic virus type 1 and 2 infection in human immunodeficiency virus-infected patients attending AIDS referral center health units in Londrina and other communities in Paraná, Brazil. AIDS Res Hum Retroviruses. 2005; 21(4):256-62.
23 Braga WSM, da Costa Castilho M, dos Santos IC, Moura MA, Segurado AC, et al. Low prevalence of hepatitis B virus, hepatitis D virus and hepatitis C virus among patients with human immunodeficiency virus or acquired immunodeficiency syndrome in the Brazilian Amazon basin. Rev Soc Bras Med Trop. 2006; 39(6):519-22.
24 Silva ACM, Barone AA. Risk factors for HIV infection among patients infected with hepatitis C. Rev Saúde Pública. 2006; 40(3):482-8.
25 Tovo CV, Santos DE, Mattos AZ, Almeida PRL, Mattos AA, Santos BR. Prevalência ambulatorial em um hospital geral de marcadores para hepatites B e C em pacientes com infecção pelo vírus da imunodeficiência humana. Arq Gastroenterol. 2006; 43(2):73-6.-2626 Mussi AD, Pereira RA, Corrêa e Silva VA, Martins RM, Souto FJ. Epidemiological aspects of hepatitis C virus infection among HIV-infected individuals in Mato Grosso State, Central Brazil. Acta Trop. 2007; 104(2-3):116-21. and may reach 84% in IDU.2121 Segurado AC, Braga P, Etzel A, Cardoso MR. Hepatitis C virus coinfection in a cohort of HIV-infected individuals from Santos, Brazil: seroprevalence and associated factors. AIDS Patient Care STDS. 2004; 18(3):135-43.,2727 Marchesini AM, Prá-Baldi ZP, Mesquita F, Bueno R, Buchalla CM. Hepatitis B and C among injecting drug users living with HIV in São Paulo, Brazil. Rev Saúde Pública. 2007; 41(Suppl 2):57-63. In this study, we observed a prevalence of 12.9% co-infection with HCV among patients monitored at the Infectious and Parasitic Diseases Outpatient Clinic at the HC/UFPR in Curitiba. This rate was similar to that found in São Paulo by Farias et al.,28Farias N, Tancredi MV, Wolffenbüttel K, Tayra A. Characteristics from persons and factors associated to HIV-seropositivity at the São Paulo State testing & counseling sites, 2000 to 2007. Bol Epidemiológico Paulista. 2008; 5(60). Available at: http://www.cve.saude.sp.gov.br/agencia/bepa60_hiv.htm.
http://www.cve.saude.sp.gov.br/agencia/b...
but lower than that observed in patients in Londrina (PR) by Reich et al.2929 Reiche EMV, Bonametti AM, Morimoto HK, Morimoto AA, Wiechemann SL, Matsuo T, et al. Epidemiological, immunological and virological characteristics, and disease progression of HIV-1/HCV-co-infected patients from a southern Brazilian population. Int J Mol Med. 2008; 21(3):387-95. (21%) and in Santa Maria (RS) by Santos et al.3030 Santos KF, Vieira TB, Beck ST, Leal DBR. Alterações laboratoriais encontradas em indivíduos co-infectados pelo vírus da imunodeficiência humana (HIV) e pelo vírus da hepatite C (HCV). Rev Bras Análises Clínicas. 2010; 42(1):21-4. (31.2%). The prevalence of co-infection with HCV observed in Curitiba was lower than those reported in Eastern European countries and the United States, which ranges from 20-40%.55 Soriano V, Vispo E, Fernandez-Montero JV, Labarga P, Barreiro P. Update on HIV/HCV coinfection. Curr HIV/AIDS Rep. 2013; 10(3):226-34.,1818 Puoti M, Rossotti R, Travi G, Panzeri C, Morreale M, Chiari E, et al. Optimizing treatment in HIV/HCV coinfection. Dig Liver Dis. 2013; 45(Suppl 5):S355-62.
Although some authors, such as Greub et al.77 Greub G, Ledergerber B, Battegay M, Grob P, Perrin L, Furrer H, et al. Clinical progression, survival, and immune recovery during antiretroviral therapy in patients with HIV-1 and hepatitis C virus coinfection: the Swiss HIV Cohort Study. Lancet. 2000; 356(9244):1800-5.and Lakus et al.11 Laskus T, Kibler K V, Chmielewski M, Wilkinson J, Adair D, Horban A, et al. Effect of hepatitis C infection on HIV-induced apoptosis. PLoS One. 2013; 8(10):e75921. report rapid progression to AIDS in the presence of co-infection with HIV/HCV, this evidence was not found in our study, possibly due to the limited number of sampling of co-infected cases (39 cases). However, a meta-analysis by Chen et al. characterized that the increased mortality in these patients was not associated with AIDS defining events.1919 Chen T-Y, Ding EL, Seage Iii GR, Kim AY. Meta-analysis: increased mortality associated with hepatitis C in HIV-infected persons is unrelated to HIV disease progression. Clin Infect Dis. 2009; 49(10):1605-15.
According to the Ministry of Health, the Brazilian profile of HIV infection in 2012 was 1.7 cases of men for every case in women,31Ministério da Saúde. Boletim Epidemiológico HIV AIDS; 2013. Available at: http://www.aids.gov.br/sites/default/files/anexos/publicacao/2013/55559/_p_boletim_2013_internet_pdf_p__51315.pdf
http://www.aids.gov.br/sites/default/fil...
while in the present study the proportion found was 1:1. In relation to the frequency of HIV/HCV co-infection with regard to sex, there was a greater proportion of men (64.1%) compared to women (35.9%) among co-infected patients. Although the difference is not significant (p=0.06), these data are similar to those reported by Távora et al.3232 Távora LG, Hyppolito EB, Cruz JN, Portela NM, Pereira SM, Veras CM. Hepatitis B, C and HIV co-infections seroprevalence in a northeast Brazilian center. Arq Gastroenterol. 2013; 50(4):277-80. in northeastern Brazil (77.8 and 22.2%, respectively) and Reiche et al.2929 Reiche EMV, Bonametti AM, Morimoto HK, Morimoto AA, Wiechemann SL, Matsuo T, et al. Epidemiological, immunological and virological characteristics, and disease progression of HIV-1/HCV-co-infected patients from a southern Brazilian population. Int J Mol Med. 2008; 21(3):387-95. (71.1 and 28.9%, respectively) in Londrina (PR).
The descent profile characterized in our study is directly related to the profile of the population of the metropolitan region of Curitiba, according to the last census by the Brazilian Census Bureau (IBGE - Instituto Brasileiro de Geografia e Estatística),33IBGE. Instituto Brasileiro de Geografia e Estatística. Censo Demográfico; 2010. with a higher frequency of Euro-Brazilian individuals.
Considering the risk factors associated with HCV transmission, the parenteral route was reported in 46.1% of co-infected patients HIV/HCV who reported a single route of infection. This frequency increased significantly (65.4%) when considering reports involving this associated with other routes of transmission. These findings corroborate the results obtained in other studies in Brazil3434 Treitinger A, Spada C, Silva EL, Miranda AF, Oliveira OV, Silveira MV, et al. Prevalence of serologic markers of HBV and HCV Infection in HIV-1 Seropositive Patients in Florianópolis, Brazil. Braz J Infect Dis. 1999; 3(1):1-5.,3535 Pavan MHP, Aoki FH, Monteiro DT, Gonçales NSL, Escanhoela CAF, Gonçales Júnior FL. Viral hepatitis in patients infected with human immunodeficiency virus. Braz J Infect Dis. 2003; 7(4):253-61. and other countries, with data indicating a frequency up to 75%.44 Operskalski E a, Kovacs A. HIV/HCV co-infection: pathogenesis, clinical complications, treatment, and new therapeutic technologies. Curr HIV/AIDS Rep. 2011; 8(1):12-22.,55 Soriano V, Vispo E, Fernandez-Montero JV, Labarga P, Barreiro P. Update on HIV/HCV coinfection. Curr HIV/AIDS Rep. 2013; 10(3):226-34. This is due to the fact that it is often not possible to state which of the routes was responsible for transmission since these individuals also had sexual contact as an associated risk factor. Although the parenteral route is the most frequent in co-infection, in 34.6% (9/26) of the cases the sexual route was the only route of infection reported. When multiple transmission routes were considered, the sexual route was involved in 53.8% (14/26) of cases. These data indicate that the sexual route is indeed an important route of transmission for HCV, a fact corroborated by other authors in Brazil and the United States.66 Zeremski M, Martinez AD, Talal AH. Management of hepatitis C virus in HIV-infected patients in the era of direct-acting antivirals. Clin Infect Dis 2013; 58(6):880-2.,1515 Martins T, Narciso-Schiavon JL, Schiavon LL. Epidemiologia da infecção pelo vírus da hepatite C. Rev Assoc Med Bras. 2011; 57(1):107-12. Some studies, such as those by Vandelli et al., Bradshaw et al. and Witt et al.,3636 Vandelli C, Renzo F, Romanò L, Tisminetzky S, De Palma M, Stroffolini T, et al. Lack of evidence of sexual transmission of hepatitis C among monogamous couples: results of a 10-year prospective follow-up study. Am J Gastroenterol. 2004; 99(5):855-9.
37 Bradshaw D, Matthews G, Danta M. Sexually transmitted hepatitis C infection: the new epidemic in MSM? Curr Opin Infect Dis. 2013; 26(1):66-72.-3838 Witt MD, Seaberg EC, Darilay A, Young S, Badri S, Rinaldo CR, et al. Incident hepatitis C virus infection in men who have sex with men: a prospective cohort analysis, 1984-2011. Clin Infect Dis. 2013; 57(1):77-84. also reported the importance of this route. This fact has been the subject of discussion in the literature, with studies indicating the importance of this route mainly among men who have sex with men that do not use drugs.55 Soriano V, Vispo E, Fernandez-Montero JV, Labarga P, Barreiro P. Update on HIV/HCV coinfection. Curr HIV/AIDS Rep. 2013; 10(3):226-34.,3838 Witt MD, Seaberg EC, Darilay A, Young S, Badri S, Rinaldo CR, et al. Incident hepatitis C virus infection in men who have sex with men: a prospective cohort analysis, 1984-2011. Clin Infect Dis. 2013; 57(1):77-84.,3939 Zocratto KBF, Caiaffa WT, Proietti FA, Proietti ABC, Mingoti SA, Ribeiro GJC, et al. HCV and HIV infection and co-infection: injecting drug use and sexual behavior, AjUDE-Brasil I Project. Cad Saúde Pública. 2006; 22(4):839-48.
The successful treatment of co-infection has reduced the morbidity and mortality of these patients, whose priority treatment should be for HCV.1818 Puoti M, Rossotti R, Travi G, Panzeri C, Morreale M, Chiari E, et al. Optimizing treatment in HIV/HCV coinfection. Dig Liver Dis. 2013; 45(Suppl 5):S355-62. However, reports from different regions of the world have shown that only 30% of co-infected patients are eligible for standard therapy with pegylated interferon and ribavirin for treatment of HCV4040 Mendes-Corrêa MC, Martins LG, Tenore S, Leite OH, Leite AG, Cavalcante AJ, et al. Barriers to treatment of hepatitis C in HIV/HCV coinfected adults in Brazil. Braz J Infect Dis. 2010; 14(3):237-41. and, in some cases, the choice of HAART therapy for the treatment of HIV and DAA therapy for HCV treatment will depend on the patient's response and the possible interactions between the drugs. This fact justifies the need for screening of co-infection with the HCV virus in HIV patients. The presence or absence of co-infection with HCV is crucial to the definition of treatment strategies, the choice of drugs and initiation of therapy that will directly impact the clinical progression and prognosis.
CONCLUSION
The prevalence of HCV infection in HIV patients in Curitiba is 12.9%, significantly higher than that found in the general population, which justifies the need for HCV screening in HIV patients . The parenteral route of transmission is the most prevalent in co-infected patients (46.1%), but the sexual route is also an important portion of the cases (34.6%). In HIV patients not co-infected with HCV, the most prevalent route was sexual, in 71.9% of the cases.
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Financial support: Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) and Fundação Araucária/PPSUS
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FUNDING AGENCY Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) and Fundação Araucária/PPSUS.
ACKNOWLEDGMENTS
The authors gratefully acknowledge the participation and collaboration of patients and the staff at Hospital de Clínicas, Universidade Federal do Paraná.
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Publication Dates
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Publication in this collection
Jan-Feb 2016
History
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Received
03 July 2014 -
Accepted
08 July 2014