Catherine L. Troisi

Hepatitis C Virus Infection-Related Morbidity and Mortality among Patients with Human Immunodeficiency Virus Infection

Hepatitis C virus (HCV) has emerged as a major pathogen among patients with human immunodeficiency virus (HIV). Morbidity and mortality were compared among 263 patients with HIV alone, 166 patients with HIV and HCV, and 60 patients with HCV alone (mean duration of follow-up, 2 years and 10 months). No differences in HIV loads and CD4 cells counts were observed between the HIV and HIV/HCV groups. Alanine aminotransferase levels were higher (52 U/L versus 35 U/L; P<.05) and albumin levels were lower (3.5 g/dL versus 3.8 g/dL; P <.02) among coinfected patients than they were among patients with HIV alone. Liver decompensation developed in 10% of patients with HIV/HCV coinfection. In contrast, no liver-related deaths or decompensation occurred in patients without coinfection (P<.05). Of the patients with HIV alone, 7% died, compared with 11% of the coinfected patients (P<.02); 47% of the deaths in the latter group were due to liver-related causes. In summary, HCV infection causes increased morbidity and mortality in patients with HIV infection.

Patients referred to an urban HIV clinic frequently fail to establish care: factors predicting failure

Abstract To measure the success with which patients newly entering outpatient care establish regular care, and assess whether race/ethnicity was a predictive factor, we conducted a medical record review of new patients seen 20 April 1998 to 31 December 1998 at The Thomas Street Clinic, a county clinic for uninsured persons. Patients were considered ‘not established’ if they never saw a physician in the 6 months after intake (the ‘initial period’), ‘poorly established’ if seen but a > 6-month gap in care began in the initial period, and ‘established’ if there were no such gaps. Of 404 patients, 11% were ‘not established’, 37% ‘poorly established’, and 53% ‘established’. Injection drug use as HIV risk factor (IDU), admitted current alcohol and drug use, age < 35 years, and CD4 count > / = 200 cells/mm3 were most common in the ‘not established’ group and least common in the ‘established’ group. In multivariate ordinal logistic regression, difficulty establishing care was associated with IDU, admitted current alcohol use, and admitted former drug use. Age > 35 years was protective. Half the indigent patients entering care in this single-site study fail to establish regular care. Substance use and younger age are predictors of failure to establish care.

Immunization of seronegative infants with hepatitis A vaccine (HAVRIX®; SKB): a comparative study of two dosing schedules

Hepatitis A virus (HAV) infection is of public health significance among infants and diapered children. Although two licensed HAV vaccines are available, they have not been assessed widely in children under the age of 2 years and are not currently licensed for this age group. The purpose of this study was to evaluate the immunogenicity and reactogenicity of HAV vaccine in seronegative infants. Fifty-three healthy infants were immunized with 360 ELISA Units (EL.U.) of an inactivated HAV vaccine at 2, 4, and 6 (Group 1) or 2, 4, and 15 months of age (Group 2). These injections were not received on the same day that participants received their routine childhood immunizations. HAV serum antibodies were detected using a modified radioimmunoassay procedure and concentrations were calculated using a World Health Organization serum anti-HAV reference standard. No serious-systemic or local reactions were noted among the immunized infants. Three months following the third immunization, seroconversion rates were 100% and 93% in groups 1 and 2, respectively. No significant differences were observed in the geometric mean anti-HAV concentrations between the two groups at comparable time points, i.e. 2 months after the second dose, 3 months after the third dose, and 19 months after the first dose. Three infants, not included in the data presented above, had preexisting maternal antibodies; one never responded to the vaccine and the other two did not respond until maternal antibody levels had become reduced. The results indicate that the inactivated HAV vaccine is highly immunogenic in seronegative infants and could be included in the routine harmonized infant immunization schedule.

Relationship of cosmetic procedures and drug use to hepatitis C and hepatitis B virus infections in a low‐risk population

We conducted an anonymous cross‐sectional seroprevalence study of a population with a low frequency of injection drug use to determine whether persons with a history of cosmetic procedures, such as tattooing and body piercing, or intranasal drug use were at increased risk for hepatitis C virus (HCV) or hepatitis B virus (HBV) infection. Students 18 years and older from eight college campuses in Houston, Texas, were invited to participate in the study. Of the 7,960 who completed a self‐administered questionnaire and provided a blood sample, 5,282 U.S.‐ or Canadian‐born participants were analyzed. Their median age was 21, 62% were female, 42% were white, 26% black, 22% Hispanic, and 10% Asian or other. Two percent reported injection drug use, 13.7% intranasal drug use, 21.2% body piercings, and 25.2% tattoos. The overall prevalence of HCV infection was 0.9% and of HBV infection was 5.2%. Higher HCV prevalence was independently associated with increasing age (odds ratio [OR] per year = 1.11; 95% confidence interval [CI] = 1.08‐1.14), history of injection drug use (OR = 18.24; 95% CI = 7.74‐42.92), blood transfusion before 1991 (OR = 3.21; 95% CI = 1.02‐10.12), and incarceration (OR = 3.48; 95% CI = 1.45‐8.37). Among 5,066 students who denied injecting drugs, HCV prevalence was 0.8% in those who reported intranasal drug use and 0.6% each in those who reported tattoos and those who reported body piercing. Increased HBV prevalence was associated with high‐risk sexual behaviors and black or Asian race. In conclusion, there was no increased risk for HCV or HBV infection in low‐risk adults based solely on history of cosmetic procedures or snorting drugs. However, proper infection control practices for cosmetic procedures should be followed, illegal drug use discouraged, and hepatitis B vaccination provided to adolescents and sexually active adults. (HEPATOLOGY 2006;44:341–351.)

Viral hepatitis risk in urban emergency medical services personnel

Houston has large groups of people known to be at high risk for hepatitis B virus (HBV) infection. Emergency medical services (EMS) personnel are continuously exposed to blood from these high-risk individuals. We sought to determine the prevalence of HBV infection in the citys EMS personnel. Of the 350 Houston firefighters assigned to EMS, 344 were surveyed by questionnaire and a blood specimen was obtained. Each sample was assayed by radio-immunoassay or enzyme-linked immunoassay for hepatitis A antibody (anti-HAV), hepatitis B surface antigen (HBsAg), and antibodies to HBsAg (anti-HBs) and hepatitis B core antigen (anti-HBc). A history of hepatitis was reported by 19 persons, 17 of whom had serologic evidence of infection with HAV (56%), HBV (26%), or both diseases (11%). The anti-HAV prevalence was 16% (12% in whites and 35% in nonwhites; P less than .001). No correlation was observed with years of occupational exposure. Of the 338 personnel evaluated for HBV seromarkers (six HBsAg-vaccinated subjects were excluded), 13% were positive; 0.6% had an active infection as determined by the presence of both HBsAg and anti-HBc; 6.8% were both anti-HBs and anti-HBc positive; 0.9% were positive for anti-HBc alone; and 4.7% of the sera contained only anti-HBs (all with geometric mean antibody levels of less than or equal to 13 mlU/mL). The 28 individuals (8.3%) whose sera contained anti-HBc were classified as cases of previous or concurrent HBV infection. A strong correlation (P less than .004) was observed between HBV infection and years of work exposure in EMS regardless of job description (paramedic versus emergency medical technician).(ABSTRACT TRUNCATED AT 250 WORDS)

Accelerated hepatitis B vaccination schedule among drug users: a randomized controlled trial.

BACKGROUND Hepatitis B vaccine provides a model for improving uptake and completion of multidose vaccinations in the drug-using community. METHODS The Drugs, AIDS, STDs, and Hepatitis (DASH) project conducted a randomized controlled trial among not-in-treatment current drug users in 2 urban neighborhoods. Neighborhoods were cluster-randomized to receive a standard behavioral intervention (which provided information on human immunodeficiency virus [HIV]) or an enhanced behavioral intervention (designed to increase acceptance of or adherence to the hepatitis B vaccination protocol). Participants within clusters were randomized to a standard vaccination schedule (vaccines at 0, 1, and 6 months) or an accelerated vaccination schedule (vaccines at 0, 1, and 2 months). The outcomes were completion of the 3-dose vaccine and seroprotection against hepatitis B virus (HBV). RESULTS Of participants with negative screening results for HIV and HBV, 77% accepted hepatitis B vaccination, and 75% of vaccinees received all 3 doses. Injection drug users (IDUs) on the accelerated schedule were significantly more likely to receive 3 doses (76%) than those on the standard schedule (66%; P = .04), although for drug users as a whole the corresponding adherence rates were 77% and 73%, respectively. No difference in adherence was observed between the behavioral intervention groups. Predictors of adherence were older age, African American race, stable housing, and alcohol use. Cumulative HBV seroprotection (≥10 mIU/mL) was gained within 12 months by 65% of those completing the schedule. Seroprotection at 6 months was greater for those on the accelerated schedule. CONCLUSION The accelerated vaccination schedule improves hepatitis B vaccination adherence among IDUs.

Detection of antibodies to hepatitis C virus in seronegative patients using an immune complex dissociation assay

Summary. Sera from a small percentage of hepatitis C virus (HCV)‐infected blood donors do not react in the currently available assays for detection of antibody to HCV (anti‐HCV) and, as a consequence, hepatitis C may develop in recipients of this blood. One possible explanation for this phenomenon is that antibody is present but cannot be detected because it is sequestered in circulating immune complexes. To test this hypothesis, an immune complex dissociation (ICD) assay was developed to disrupt any immune complexes that might be present in these anti‐HCV‐negative, HCV RNA‐positive sera. A positive result in this test would indicate that antibody is present in these patients but is not detectable under routine anti‐HCV testing conditions. Nine chronic and two acute HCV patients, all negative for antibody but positive for HCV RNA by reverse transcriptase‐polymerase chain reaction (RT‐PCR) were tested, together with appropriate controls. Three of the nine study patients with chronic HCV had evidence of anti‐HCV after immune complex dissociation compared with none of the two patients with acute HCV. Although the number of patients tested was small, the negative results in the patients with acute HCV presumably indicates that anti‐HCV seroconversion had not yet occurred. Incorporation of an ICD step into existing anti‐HCV assays may enable blood banks to detect those rare instances of patients with chronic HCV who are antibody negative; this would minimize potential cases of post‐transfusion hepatitis in recipients.

Depression and HIV risk among men who have sex with men in Tanzania

ABSTRACT Studies have shown high rates of depression among men who have sex with men (MSM) in developed countries. Studies have also shown association between depression and HIV risk among MSM. However, very little research has been done on depression among African MSM. We assessed depression and HIV risk among a sample of MSM in Tanzania. We reviewed data on 205 MSM who were recruited from two Tanzanian cities using the respondent driven sampling method. Demographic and behavioral data were collected using a structured questionnaire. HIV and sexually transmitted infections data were determined from biological tests. Depression scores were assessed using the Patient Health Questionnaire (PHQ-9). For the analysis, depression scores were dichotomized as depressed (PHQ > 4) and not depressed (PHQ ≤ 4). Bivariate and multivariable Poisson regression analyses were conducted to assess factors associated with depression. The prevalence of depression in the sample was 46.3%. The mean (±SD) age of the sample was 25 (±5) years. In bivariate analysis, depression was associated with self-identifying as gay (p = .001), being HIV positive (p < .001: <8% of MSM knew they were HIV infected) and having a high number of sexual partners in the last 6 months (p = .001). Depression was also associated with sexual (p = .007), physical (p = .003) and verbal (p < .001) abuse. In the Poisson regression analysis, depression was associated with verbal abuse (APR = 1.91, CI = 1.30–2.81). Depression rates were high among MSM in Tanzania. It is also associated with abuse, HIV and HIV risk behaviors. Thus, reducing the risk of depression may be helpful in reducing the risk of HIV among MSM in Africa. We recommend the colocation of mental health and HIV preventive services as a cost-effective means of addressing both depression and HIV risk among MSM in Africa.

Effect of age and frequency of injections on immune response to hepatitis B vaccination in drug users

Despite the high immunogenicity of the hepatitis B vaccine, evidence suggests that immunological response in drug users is impaired compared to the general population. A sample of not-in-treatment adult drug users from two communities in Houston, TX, USA, susceptible to hepatitis B virus (HBV), was sampled via outreach workers and referral methodology. Participants were randomized to either the standard multi-dose hepatitis B vaccine schedule (0, 1, and 6 months) or to an accelerated (0, 1, and 2 months) schedule. The participants were followed for 1 year. Antibody levels were measured at 2, 6 and 12 months after enrollment in order to determine the immune responses. At 12 months, cumulative adequate protective response was achieved in 65% of the HBV susceptible subgroup using both the standard and accelerated schedules. The standard group had a higher mean antibody titer (184.6 mIU/mL vs 57.6 mIU/mL). But at 6 months, seroconversion at the adequate protective response was reached by a higher proportion of participants and the mean antibody titer was also higher in the accelerated schedule group (104.8 mIU/mL vs. 64.3 mIU/mL). Multivariate analyses indicated a 63% increased risk of non-response for participants 40 years or older (p=0.046). Injecting drugs more than once a day was also highly associated with the risk of non-response (p=0.016). Conclusions from this research will guide the development of future vaccination programs that anticipate other prevalent chronic conditions, susceptibilities, and risk-taking behaviors of hard-to-reach populations.

Current tests for antibody to hepatitis B core antigen used to screen donors for non‐A, non‐B hepatitis are comparable to the original radioimmunoassay for hepatitis B core antigen

ABSTRACT: Prospective studies have shown a relationship between the transfusion of donor blood which is positive for antibodies to hepatitis B core antigen (anti‐HBc) and an increased incidence of non‐A, non‐B hepatitis. The anti‐HBc test was selected on the assumption that epidemiologic circumstances predisposing donors to hepatitis B infection also might favor exposure to non‐A, non‐B hepatitis. Current radioimmunoassays (RIA) and enzyme‐linked immunoassays (EIA) for anti‐ HBc utilize hepatitis B core antigen (HBcAg) prepared by recombinant DNA technology, whereas the original RIA anti‐HBc assay used HBcAg derived from hepatitis B virions. In the current study, 1329 sera were evaluated of which 23.3 percent were anti‐HBc positive. The results indicate that sensitivity, specificity, and positive and negative predictive values of the current EIA and RIA tests for anti‐HBc (Abbott Diagnostic Laboratories) are virtually identical to the original RIA test kit. In addition, all donor samples (128 specimens) administered to 57 cases of non‐A, non‐B hepatitis that were prospectively followed at Baylor College of Medicine for the Transfusion‐Transmitted Viruses (TTV) Study group were retested with the EIA‐recombinant anti‐HBc assay. All 21 samples which were reactive in the original RIA anti‐HBc test also were positive by the current EIA procedure. One sample was EIA positive/RIA negative, and 106 other samples were negative by both assays. Thus, commercial anti‐HBc kits based on HBcAg derived by recombinant DNA technology, should retain their predictive value for reducing the incidence of non‐A, non‐B hepatitis as described in the prospective studies.