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Iranian Journal of Clinical Infectious Diseases
2010;5(4):223-227
©2010 IDTMRC, Infectious Diseases and Tropical Medicine Research Center
ORIGINAL ARTICLE
Co-infection by hepatitis C virus in human immunodeficiency
virus infected patients in southwest of Iran
Ayyoob Khosravi1, Mirzakhalil Bahmani2*, Islam Ghezel-Sofla2
1
Medical Cellular and Molecular Research Center, Golestan University of Medical Sciences, Gorgan, Iran
2
HIV and Hepatitis Research Center, Shiraz University of Medical Sciences, Gerash, Iran
ABSTRACT
Background: Hepatitis C virus (HCV) has emerged as the cause of the second major epidemic of viral infection after
human immunodeficiency virus (HIV) within the past two decades, and co-infection of HIV and HCV represents a
growing problem for the future. The purpose of this study was to investigate the prevalence of HCV antibodies (antiHCV) in patients with HIV in Fars province.
Patients and methods: A total of 101 HIV-1-positive individuals (89 males, 12 females) from Fars province
(Counseling Behavioral Modification Center in Shiraz) were included in the study. They were distributed according to
risk factors for HIV infection as follows: 35(34.6%) IVDUs, 2(2%) sexual high-risk behavior, 50(49.5%) a combination
of IVDUs and sexual behavior, 12(12%) from HIV positive partners and 2(2%) unknown. Detection of HCV antibodies
was carried out by a third generation enzyme-linked immunosorbent assay.
Results: Totally, 87 (84 males, 3 females) of 101 HIV-infected patients (86.1%) had antibodies to HCV. The prevalence
of HCV antibodies was higher among the males (83.2%) than the females (3%). The prevalence of HCV antibodies was
94.4% in IVDUs, 96% in individuals with both IVDUs and sexual behavior risk factors and 25% in women who had
HIV-positive partner. All unknown cases were positive for HCV and none of individuals who had sexual high-risk
behavior were infected with HCV.
Conclusion: The overall prevalence of HCV infection in HIV-positive individuals was 84.1%. The consistently high
prevalence of HCV infection observed in HIV infected individuals supports the routine screening for HCV and
continuous educational programs in these patients, especially among IVDUs in Iran.
Keywords: Hepatitis C virus (HCV); Human immunodeficiency virus (HIV); Intravenous drug user (IVDU).
(Iranian Journal of Clinical Infectious Diseases 2010;5(4):223-227).
INTRODUCTION
1
Hepatitis C virus (HCV) continues to be a
major disease burden on the world. In 1999, the
WHO estimated a worldwide prevalence of about
3% with the virus affecting 170 million people
worldwide (1). HIV and HCV viruses share
Received: 30 August 2010 Accepted: 29 October 2010
Reprint or Correspondence: Mirzakhalil Bahmani.
HIV and Hepatitis Research Center, Shiraz University of
Medical Sciences, Gerash, Iran.
E-mail: [email protected]
common routes of transmission, especially the
parenteral route, and as a result co-infection rates
in intravenous drug users and hemophiliacs are
particularly high (60–90%). Other non-parenteral
routes of transmission are also important and there
is now increasing evidence that sexual and mother
to child HCV transmission is facilitated by HIV
infection (2).
Iranian Journal of Clinical Infectious Disease 2010;5(4):223-227
224 HCV and HIV co-infection
The presence of both HIV and HCV infection
may complicate the natural history of both viruses
and their treatment (3). For example, co-infected
patients have higher HCV viral loads than patients
infected with HCV alone. In addition, individuals
who are co-infected with both viruses are at risk of
progressive liver disease and consequently
cirrhosis, liver failure, and hepatocellular
carcinoma (4). In some studies, HIV/HCV coinfection was associated with a more rapid
progression to AIDS and death (5).
Approximately 30% of patients infected with
HIV in the USA and Europe are infected with the
HCV (3). A study of HIV-1 infected patients in
Europe and North America showed HCV
prevalence range between 7% (Sacramento, USA,
1991) and 57% (Spain, 1999). The majority (98%)
of HIV-1 infected hemophiliacs co-infected with
HCV (2).
A total of 11 published seroprevalence reports
based on various HIV-1 infected studies from
Asian countries are shown in table 1. HCV
prevalence ranged between 19.2% (Japan) and
97.1% (Taiwan) and these differences in
seroprevalence across the different studies were
largely determined by the HCV risk factor
distribution of the study population. Patients with
history of IDU had infection rates in excess of 80%
(6-16).
Available evidence from Iran shows that the
prevalence of HCV infection ranges between
0.12% (17) and 0.59% (18) among blood donors. It
seems that the prevalence of HCV infection is less
than 1 percent in our general population, but the
infection is emerging mostly because of problems
such as intravenous drug use and needle sharing
among drug addicts (19). Of 464 injecting drug
users in Shiraz, southwest Iran, 80.1% were HCV
positive (20). Also, of 417 injecting drug users in
Tehran, HIV and HCV prevalence were 24.4%, and
80%, respectively (21).
Several studies on HCV infection among
different populations were performed in Iran, but
studies on the HCV in HIV-positive individuals are
rare. The present study has been carried out to
determine the prevalence of HCV among HIVpositive individuals in Fars province, Shiraz, Iran.
This is aimed at providing baseline data on HCVHIV co-infection as part of the preliminary
investigation on the dynamics of HCV infection in
Iranian HIV positive patients.
Table 1. Seroprevalence of HCV in HIV-1 infected
patients and some high risk groups in Asian countries
Location
No.
Characteristics of study % of
population
HCV
Iran(our study) 101 HIV-positive patients
86.1
Japan(6)
4877 HIV-positive patients
19.2
Taiwan(7)
591 HIV-1-infected IDUs
97.1
India(8)
500 HIV-HCV co-infection
54.5
Malaysia(9)
159 Heroin-dependent subjects
89.9
China(10)
3062 HIV positive cases in farmers 85
China(11)
347 HIV positive IDUs, southern 95
Syria(12)
Thailand(13)
Indonesia(14)
Singapore(15)
Korea(16)
225
612
162
188
185
China
HIV-positive patients
HIV-infected men
HIV-HCV co-infection
HIV-positive IVDUs
Drug users and alcoholic
patients
43
49.5
62
45.5
80
PATIENTS and METHODS
HIV-infected patients: A total of 101 HIV-1
positive patients including 89 males and 12 females
(aged 23–58 years) from Counseling Behavioral
modification Center (CBMC) in Shiraz, Fars
province, constituted the study population. With
the assistance of the patients' physicians, informed
consent was obtained from each patient with the
assurance that all information obtained would be
treated with utmost confidentiality and just for
research purposes. They were distributed according
to risk factors for HIV infection as follows:
35(34.6%) IVDUs, 2(2%) sexual high-risk
behavior, 50(49.5%) a combination of IVDUs and
sexual behavior, 12(12%) from HIV positive
partners and 2(2%) unknown.
Hepatitis C antibody assay: Blood sample (5ml) was obtained from each HIV-1 positive patient
Iranian Journal of Clinical Infectious Disease 2010;5(4):223-227
Khosravi A. et al 225
at CBMC, transferred to the HIV and Hepatitis
Research Center in Gerash. Sera from 101
confirmed HIV-positive individuals were assayed
for the presence of antibodies to HCV. Detection of
HCV antibodies was carried out by a third
generation enzyme-linked immunosorbent assay
(ELISA) kit, commercially available (EIAgen HCV
Ab, ADALTIS, Bologna, Italy). Manufacturer's
instructions were strictly followed to determine the
serum samples that were seropositive for HCV
antibody.
The study was approved by ethics committee of
Shiraz University of Medical Sciences, Shiraz,
Iran.
Data were entered and analyzed using SPSS
software (version 11.5, SPSS Inc., Chicago, USA).
Seroprevalence of HCV was expressed in
percentages for the entire study group and by age
and sex.
Table 2. Demographic characteristics and risk factors of
HIV-1 positive patients
Frequency Percentage
Variable
Marital status
Married
Single
Divorced
Non-drug use
Drug use
Injecting
Non-injecting
Tattooing
Male
Female
History of prison
Male
Female
Job
Yes
No
History of blood transfusion
Sexual transmitted disease
HAART drugs
Male
Female
39
36
26
14
87
86
1
67
67/89
0/12
85
84
1
38.6
35.6
25.7
13.9
86.1
85.1
1
66.3
75.3
84.2
94.4
8.3
64
37
8
11
20
17/89
3/12
63.4
36.6
7.9
10.9
19.8
19.1
25
RESULTS
A total of 87 (84 males, 3 females) of 101 HIVinfected patients (86.1%) had antibodies to HCV.
The prevalence of HCV antibodies was higher
among the males (83.2%) than the females (3%) (p
=0.05).
Age related prevalence of HCV antibodies
among HIV-infected patients was assessed and
results showed that individuals aged 31-40 years
had the highest prevalence (90.2%). This was
followed by those aged 41-50 years (87%) (table
2).
Assessment of the risk factors of HCV
transmission showed that of 36 individuals who
had only history of IVDU, 34 (94.4%) had HCV
infection, while none of two individuals who had
sexual high-risk behavior, were infected with HCV
(table 3). Of 50 individuals who had both risk
factors (IVDUs and sexual behavior), 48 (96%)
were HCV-positive. Meanwhile, of 12 women who
had HIV-positive partner, 3(25%) were infected
with HCV (table 3).
Table 3. Age related prevalence and risk factors of HCV
transmission in the HIV positive patients (n=101)
Age
20-30
31-40
41-50
51-60
Total
Risk factors
Intravenous drug
use (IVDU)
sexual high-risk
behavior
Combination of
IVDU and sex
HIV positive
partner
Unknown
Number
(F/M)
HCV positive
%
(F/M)
16 (3/13)
51 (4/47)
23 (2/21)
11 (3/8)
101 (12/89)
13 (1/12)
46 (1/45)
20 (0/20)
8 (1/7)
87 (3/84)
81.3
90.2
87
72.8
86.1
36 (1/35)
34 (0/34)
94.4
2 (0/2)
-
-
50 (0/50)
48 (0/48)
96
12 (12/0)
3 (3/0)
25
2 (0/2)
2 (0/2)
100
DISCUSSION
In HIV infected patients, co-infection with HCV
has been associated with a reduced survival rate
Iranian Journal of Clinical Infectious Disease 2010;5(4):223-227
226 HCV and HIV co-infection
(22). The increased risk of HCV related advanced
liver diseases in people with HIV infection makes
early HCV diagnosis a priority (23). In the present
study, therefore, we have unequivocally established
the existence of HCV infection in HIV-infected
Iranian patients. Results showed more or less the
same seroprevalence compared to those reported in
HIV-infected patients in some high prevalence
countries such as Taiwan (97.1%) and China (95%)
(See table 1). The relatively high prevalence of
HCV infection in HIV-positive population in
southwest of Iran may be contributed to the high
number of IVDUs. Most cases of HCV infection in
this study may have resulted from intravenous drug
use as 94.3% (82 out of 87) of HCV-infected
individuals had history of intravenous drug use.
Although sexual behavior is usually considered of
secondary importance in determining the risk of
HCV infection (24), of 2 individuals who had
sexual high-risk behavior, none were infected with
HCV.
Analysis of HCV seroprevalence among HIVinfected patients showed that males were more
commonly infected than females. This could be in
part explained by the fact that most of our studied
males were intravenous drug user. Indeed, 81 of 89
men (91%) had history of injecting drug use and 76
were HCV-positive.
It has been established that the overwhelming
risk factor for HCV infection in almost all studies,
is a history of illicit injection drug use (24,25).
Demographic characteristics and risk factors of
HIV-1 positive patients are shown in table 2. The
consistently high prevalence of HCV infection
observed in HIV infected individuals supports the
routine screening for HCV and continuous
educational programs in these patients, especially
among IVDUs in Iran.
This study has contributed baseline data in HCV
and HIV co-infection from southwest of Iran and
can serve as a basis for further studies on this topic.
ACKNOWLEDGEMENT
The authors thank the personnel staff,
physicians and patients of the Counseling
Behavioral Modification Center, Shiraz, for their
collaboration to make this study possible.
REFERENCES
1. WHO. Global surveillance and control of hepatitis C.
Report of a WHO consultation organized in
collaboration with the Viral Hepatitis Prevention Board,
Antwerp, Belgium. J Viral Hepat. 1999;6:35–47.
2. Mohsen AH, Easterbrook P, Taylor CB, Norris S.
Hepatitis
C
and
HIV-1
coinfection.
Gut.
2002;51(4):601-8.
3. Sulkowski MS, Benhamou Y. Therapeutic issues in
HIV/HCV-coinfected patients. J Viral Hepat.
2007;14(6):371-86.
4. Matthews GV, Dore GJ. HIV and hepatitis C
coinfection. J Gastroenterol Hepatol. 2008;23:1000-8.
5. Darby SC, Ewart DW, Giangrande PL, Spooner RJ,
Rizza CR, Dusheiko GM, et al. Mortality from liver
cancer and liver disease in haemophilic men and boys in
UK given blood products contaminated with hepatitis C.
UK Haemophilia Centre Directors' Organisation.
Lancet. 1997;350:1425-31.
6. Koike K, Tsukada K, Yotsuyanagi H, Moriya K,
Kikuchi Y, Oka S, et al. Prevalence of coinfection with
human immunodeficiency virus and hepatitis C virus in
Japan. Hepatol Res. 2007;37(1):2-5.
7. Yuan-Ming Lee H-JL, Yen-Ju Chen, Cheng-Ming
Lee, Sheng-Fan Wang, et al. Molecular epidemiology of
HCV genotypes among injection drug users in Taiwan:
full-length sequences of two new subtype 6w strains and
a recombinant form_2b6w. J Med Virol. 2010;82:57–68.
8. Saravanan S, Velu V, Kumarasamy N, Nandakumar
S, Murugavel KG, Balakrishnan P, et al. Coinfection of
hepatitis B and hepatitis C virus in HIV-infected patients
in south India. World J Gastroenterol. 2007;13(37):
5015-20.
9. Chawarski MC, Mazlan M, Schottenfeld RS. Heroin
dependence and HIV infection in Malaysia. Drug
Alcohol Depend. 2006;82 Suppl 1:S39-42.
10. Han-Zhu Qian SHV, Richard A. Kaslow,
Christopher S. Coffey, Eric Chamot, et al. Co-infection
with HIV and hepatitis C virus in former plasma/blood
donors: challenge for patient care in rural China. AIDS.
2006;20(10):1429–35.
Iranian Journal of Clinical Infectious Disease 2010;5(4):223-227
Khosravi A. et al 227
11. Garten RJ, Zhang J, Lai S, Liu W, Chen J, Yu XF.
Coinfection with HIV and hepatitis C virus among
injection drug users in southern China. Clin Infect Dis.
2005;41 Suppl 1:S18-24.
12. ZS A. Seroepidemiology of HCV-HIV co-infection
in Syria. International Conference on AIDS.2004, July
11-16; Abstract no. B10182.
13. Chanbancherd P, Paris RM, Torugsa K, de Souza
M, Khin Saw Aye M, Chitpong A, et al. High frequency
of HIV-1 and hepatitis C co-infection among young
Thai men: evidence for a changing pattern of HIV
transmission in Thailand. Southeast Asian J Trop Med
Public Health. 2003;34(3):580-2.
14. Birowo NR DZ, Djauzi S. Prevalence of HIV and
HCV Co-infection among drug users. Antivir Ther.
2003;8 (Suppl.1): Abstract no. 987.
infected
patients.
1997;147(19):439-42.
Wien
Med
Wochenschr.
23. Amin MK, Skidmore S, Pillay D, Cooper DA. HIV
and hepatitis C coinfection within the CAESAR study.
HIV Medicine 2004;5:174–9.
24. Segurado AC BP, 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.
25. Verucchi G CL, Manfredi R, Chiodo
immunodeficiency virus and hepatitis
coinfection: epidemiology, natural history,
options
and
clinical
management.
2004;32(1):33-46.
15. Chapman Ca, Laudette-Aboulhab J, Soh Ch, Karim
F, Verghese I, et al. Seroprevalence of hepatitis C virus
among HIV-positive patients in Singapore. Interscience
Conference
on
Antimicrobial
Agents
and
Chemotherapy. 2000;17-20; 40: 259.
16. Kim HS CD. Prevalence of hepatitis C, B and
human immunodeficiency virus among drug users and
chronic alcoholic patients in Korea. Korean J Med
1997;52(6):754-62.
17. Alavian SM, Gholami B, Masarrat S. Hepatitis C
risk factors in Iranian volunteer blood donors: a casecontrol study. J Gastroenterol Hepatol. 2002;17(10):
1092-7.
18. Ghavanini AA, Sabri MR. Hepatitis B surface
antigen and anti-hepatitis C antibodies among blood
donors in the Islamic Republic of Iran. East Mediterr
Health J. 2000;6(5-6):1114-6.
19. Kabir A, Alavian SM, Keyvani H. Distribution of
hepatitis C virus genotypes in patients infected by
different sources and its correlation with clinical and
virological parameters: a preliminary study. Comp
Hepatol. 2006;5:4.
20. Mirahmadizadeh AR KM, Hemmati AR, Javadi A.
Infection with HIV and hepatitis C and B viruses among
injecting drug users in Shiraz, Southern Iran. 15th Int
Conf AIDS; Bangkok, Thailand. 2004 Jul 11-16.
21. Mostafa H, SeyedAhmad S A, Parastoo K,
GholamReza E J, Hadi S M. Prevalence and correlates
of co-infection with human immunodeficiency virus and
hepatitis C virus in male injection drug users in Iran.
Arch Irn Med. 2010;13:58-63.
22. Ockenga J SM, Tillmann HL, Trautwein C, Manns
MP, et al. Coinfection of hepatitis B and C in HIV-
Iranian Journal of Clinical Infectious Disease 2010;5(4):223-227
F. Human
C virus
therapeutic
Infection.