Reinfection after hepatitis C cure: prevention may require long-term support for people who have injected drugs

Reinfection rates after hepatitis C cure among people who inject drug users, as well as past drug users, are relatively low, according to findings from studies from Norway and Canada presented at the International Liver Congress in Vienna in April.

The findings suggest that current and former injecting drug users who have been cured of hepatitis C require ongoing support to remain free of hepatitis C, but also indicate that fears of a high rate of reinfection should not be used as a reason to withhold hepatitis C treatment from people who inject drugs.

A meta-analysis of studies of hepatitis C treatment outcomes in people who inject drugs, published in 2013, found an incidence of between 2.4 and 6.4 per 100 person-years of follow-up, but a subsequent meta-analysis found that the reinfection rate could be as high as 8%. (Aspinall 2013, Hill 2014)

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Re-infection due to ongoing risk probably the cause of HCV recurrence after SVR

Rates of hepatitis C virus (HCV) reoccurrence after successful therapy differ markedly between risk groups, according to the results of a meta-analysis presented at the recent Conference on Retroviruses and Opportunistic Infections. 

At one end of the spectrum, over a fifth of patients with HIV co-infection who cleared HCV infection with treatment experienced a recurrence of the infection. This compared to a rate just 1% in patients with no HCV risk factors. The UK investigators leading the study believe these large differences point to re-infection rather than relapse being the cause of the re-emergence of HCV after treatment response.

HCV infection is an increasingly important cause of liver-related illness and death around the world. Diagnosing and treating HCV is therefore a global health priority, especially as therapy with combinations of new direct-acting anti-HCV drugs can achieve a cure or sustained virological response (SVR) – absence of HCV RNA 24 weeks after the completion of therapy – in up to 90% of patients.    

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Snapshots —Alan Franciscus, Editor-in-Chief

Abstract: Low Risk of Liver Decompensation among Human Immunodeficiency Virus/Hepatitis C Virus-Coinfected Patients with Mild Fibrosis in the Short-Term.
  Authors: J Macias et al.  Hepatology. 2014 Dec 24. doi: 10.1002/hep.27674. [Epub ahead of print]

Results and Conclusions: The authors of this study wanted to find out which HIV/HCV patients can safely wait, or wait in the short term for treatment.  This study was conducted during the time that pegylated interferon was part of the treatment regime.  A total of 1729 patients were evaluated (683 patients by liver biopsy; 1046 by liver stiffness measurement) and followed over time. The authors concluded that patients who did not have advanced fibrosis were at “very low risk” of decompensated cirrhosis, at least in the short term.  In this population, a careful watchful waiting is appropriate—in the author’s opinion.

Editorial Comments: I find this study interesting and valuable.  But I think it is a dangerous game to play.  This is a population of patients who typically have faster disease progression—faster than people who are monoinfected.  It may be safe if people are followed very carefully.  But wouldn’t it be easier and safer to treat now and not take the chance of putting people at undue risk?

Abstract: Hepatitis C Virus (HCV) Antibody Dynamics Following Acute HCV Infection and Reinfection among HIV-Infected Men Who Have Sex with Men.
  Authors:  J. Vanhommerig et al. Clin Infect Dis. 2014 Dec 15;59(12):1678-85. doi: 10.1093/cid/ciu695. Epub 2014 Sep 3.

Results and Conclusions: This study identified 63 HIV/HCV coinfected patients who had tested positive for HCV antibodies and HCV RNA (viral load).  The patients were followed for 4 years.  Five of the patients spontaneously cleared HCV and 31 of 43 patients were treated and cured.  In 36 (5 spontaneously cleared; 31 cured) the antibody titers (the measurements) declined.  In 8 of the 31 patients the HCV antibody titers disappeared. 

Eighteen of the patients were re-infected with a dif­ferent strain than the initial one and devel­oped a surge in both antibodies and HCV RNA.  The researchers believed that one patient was re-infected three separate times after the first successful treatment. 

Editorial Comments:  I couldn’t find the entire journal article to find out what type of counseling efforts were offered to the study participants.  This study, however, should remind us we need to educate people about prevention measures.  But what was interesting is that 8 people had undetectable antibody titers in this small study.  On a personal note, I did a demonstration of an HCV antibody test.  I was cured of hepatitis C more than 10 years ago.  The results showed very low reactive results.  I wonder if my antibody titers will become undetectable after time.  This study made me wonder how many ‘Baby Boomers’ became infected many years ago, naturally cleared the virus, and when tested recently had antibody titers too low to register.

http://hcvadvocate.org/news/newsLetter/2015/advocate0115_mid.html#3