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Liz Highleyman
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In This Issue:
Hepatitis C
Race/Ethnicity and HCV
Sexual Transmission of HCV
Race/Ethnicity
and HCV
Several recent reports have examined race/
ethnicity and how it impacts the natural history and treatment
of hepatitis C.
Treatment in African Americans
In the June 2004 issue of Hepatology, Lennox Jeffers,
MD, and colleagues reported on a study of 78 blacks and 28
whites receiving HCV treatment for the first time. Subjects
had genotype 1 HCV, elevated ALT, and no evidence of cirrhosis.
After being treated with Pegasys brand pegylated interferon
plus ribavirin for 48 weeks, 26% of blacks achieved a sustained
virological response (SVR), compared with 39% of whites. Paired
biopsies from 53 blacks and 16 whites revealed that more than
90% in both groups showed improved or stabilized fibrosis
progression; among the black subjects, 22% showed improvement
despite the lack of SVR. Side effect rates were generally
higher in whites, and more whites than blacks discontinued
due to adverse events, but more blacks had their Pegasys doses
reduced, usually due to neutropenia (low level of a type of
white blood cell called neutrophils; healthy blacks tend to
have naturally lower neutrophil levels than whites). Although
still lower than the SVR rate in whites with genotype 1 (40-50%
in most studies), the researchers noted that this study produced
“the highest response rate to treatment observed in
a black population” to date.
In a second study, reported in the May
27, 2004 issue of the New England Journal of Medicine,
Andrew Muir, MD, and colleagues treated 100 black and 100
white subjects (98% in both groups had genotype 1) with Peg-Intron
brand pegylated interferon plus ribavirin for 48 weeks. SVR
rates in this study were much lower for blacks than whites:
19% vs 52%, respectively. Black subjects also had lower early
virological response (at 12 weeks) and end-of-treatment response
rates.
Ethnicity, Transmission, and Disease Progression
In a study reported in the June 2004 issue of Clinical
Gastroenterology and Hepatology, Anne Celona and colleagues
examined demographic and laboratory data from 1,271 patients
with HCV antibodies at a Los Angeles clinic (about 7% Asian,
18% African American, 25% Caucasian, and 49% Latino). In terms
of exposure, injection drug use was the presumed cause of
infection for a majority of Caucasian men and women, and African
American and Latino men, but a negligible cause among Asians;
more Asians and Latinos had received blood transfusions than
Caucasians or African Americans. Among Asians, HCV prevalence
rates were similar in men and women, but in the other three
ethnic groups the majority of HCV-infected subjects were men.
Asians were most likely and Latinos least likely to be coinfected
with hepatitis B. Latinos had significantly higher ALT and
bilirubin levels and lower serum albumin levels than all the
other ethnic groups. Celona’s team did not look at liver
histology (tissue damage), but a previous study found higher
rates of liver fibrosis in Latino patients compared with whites
or blacks.
In the same issue, Kester Crosse and colleagues
reported on a retrospective comparison of laboratory and histological
findings in 87 black and 136 white subjects with chronic HCV
evaluated at the University of Maryland. Black patients were
on average three years older and were more likely to have
genotype 1 HCV (95% vs. 75%). Modes of HCV transmission, estimated
duration of infection, and rates of heavy alcohol use were
similar in both groups. However, the black subjects had lower
average ALT levels (and more had normal ALT), as well as lower
average total Knodell Histologic Activity Index (HAI) scores,
indicating less necrosis (liver cell death), fibrosis, and
inflammation. The authors concluded that black patients with
chronic HCV patients “have milder liver necroinflammation
and fibrosis than white patients with similar HCV duration.”
Other studies have similarly shown that African Americans
appear to be less likely than whites to suffer progressive
liver damage due to hepatitis C.
It is unclear why different racial and
ethnic groups appear to sustain different levels of liver
damage and respond differently to treatment for hepatitis
C. In an editorial accompanying the Celona and Cross articles,
Fareed Rahman, MD, and Barbara Rehermann, MD, examined some
of the factors that may come into play, including differences
in immune function (e.g., HCV-specific CD4 and CD8 cell activity,
types of HLA molecules) and different patterns of early (24-48
hour) response to interferon. A large National Institutes
of Health study called VIRAHEP-C is underway that will hopefully
shed further light on this issue.
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Sexual Transmission
of HCV
In the May 2004 issue of the American Journal of Gastroenterology,
Carmen Vandelli and colleagues published data that appear
to confirm that sexual transmission of hepatitis C among monogamous,
heterosexual couples is very rare. In this long-term prospective
study, the researchers followed 895 HCV-uninfected individuals
who had a monogamous sexual relationship with an HCV-infected
partner; 776 individuals were followed for 10 years (the rest
ended their relationships, were lost to follow-up, or the
infected partner clearly HCV with treatment and thus no longer
carried the virus). On average, the couples reported sexual
intercourse 1.8 times per week. They reported that they did
not use condoms, did not practice anal intercourse, and did
not have sex during menstruation.
Just three new HCV infections in the uninfected
partners were observed during follow-up, for an incidence
rate of 0.37 per 1,000 person-years. However, in one case
the newly infected partner had a different genotype than the
spouse, ruling out sexual transmission; in the other two cases,
the newly infected partners had different HCV viral isolates
than their spouses, again indicating that sexual transmission
was not the cause of infection.
“Our data indicate that the
risk of sexual transmission of HCV within heterosexual monogamous
couples is extremely low or even null,” the researchers
concluded. This study supports the usual recommendation that
monogamous heterosexual couples do not need to use condoms
to prevent transmission of hepatitis C. Other research, however,
suggests that sexual transmission rates are higher among men
who have sex with men and people with multiple sexual partners,
so for these groups safer sex practices are often advised.
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