Hepatitis C is transmitted primarily by exposure to blood infected with the hepatitis C virus. Transmission rarely occurs from exposure to other infected body fluids, such as semen.

If you're in a long-term, monogamous relationship with a partner who has hepatitis C, your risk of sexual transmission is 0 percent to 0.6 percent per year. For monogamous couples, the Centers for Disease Control and Prevention (CDC) doesn't recommend routine condom use to prevent transmission. But couples should avoid sharing razors, toothbrushes and nail clippers.

The risk of transmission is slightly higher — about 1 percent per year — if you're involved in a short-term sexual relationship with someone who has hepatitis C. This risk increases if your partner is also infected with HIV. Under these circumstances, the CDC recommends routine condom use to reduce your risk of transmission.

If you're concerned about hepatitis C, talk to your doctor. Hepatitis C can be diagnosed by a blood test. Treatment may include medications to help clear the virus from your bloodstream.

Mayo Clinic infectious disease specialist James Steckelberg, M.D.,

Sexual Transmission Among Heterosexual Monogamous Couples

CDC Releases New Hepatitis C Fact Sheet For Gay and Bisexual Men That Recognizes Sexual Transmission Risk

Oct 17 09

AASLD: HCV Now an STD in New York

Nov 5 09

HCV Sexual Transmission Revisited: A Look at the Latest Research

Liz Highleyman

Sexual activity has traditionally been regarded as a rare route of hepatitis C virus (HCV) transmission. In the past few years, however, clusters of apparently sexually transmitted HCV – mostly among HIV positive gay men – have cast doubt on this assumption.

Transmission Among Monogamous Couples
Most studies indicate that sexual transmission of HCV is very uncommon among long-term, monogamous, HIV negative heterosexual couples, with rates in the range of 0%-3%. As reported in the May 2004 American Journal of Gastroenterology, for example, Carmen Vandelli and colleagues followed 895 HCV negative individuals who had monogamous sexual relationships with HCV positive partners. Over 10 years of follow-up, just three new HCV infections occurred, for an incidence rate of 0.37 per 1,000 person-years (PY). The authors concluded that “the risk of sexual transmission of HCV within heterosexual monogamous couples is extremely low or even null.” Likewise, V. Tahan and colleagues reported in the April 2005 American Journal of Gastroenterology that none of 216 HCV negative individuals with opposite-sex HCV positive spouses seroconverted during an average follow-up period of about three years.

Transmission Among HIV Positive Gay Men
But the picture is different for HIV positive individuals. At the 13th Conference on Retroviruses and Opportunistic Infections (CROI) this past February, two research teams presented the latest data on clusters of acute hepatitis among gay men in England and the Netherlands, while a French team reported on apparent sexually transmitted HCV in heterosexual women.

Since 2002, more than 200 cases of acute hepatitis C have been reported among men who have sex with men (MSM) in London and Brighton in the UK. Mark Danta from London’s Royal Free Hospital gave an update on a cohort of 111 HIV positive men diagnosed with HCV between October 2002 and August 2005 (CROI abstract 86). The men who contracted HCV had three times more sex partners (30 vs 10) in the past year than men who remained HCV negative. Other significant risk factors included unprotected receptive and insertive anal intercourse, fisting, use of sex toys, group sex, and sexual activity under the influence of recreational drugs (92% vs 62%). What’s more, these factors appeared to interact: individuals who engaged in three or four of these practices in group sex settings had 23 times the risk of HCV infection. In addition, the men who contracted HCV were more likely to meet partners in sex clubs or bathhouses or over the Internet, and most (92%) had concurrent sexually transmitted diseases (STDs). “High-risk and mucosally traumatic sexual factors are significantly associated with the recent transmission of HCV,” Danta concluded.

Roel Coutinho and Thijs van de Laar reported on a retrospective study of sexual transmission of HCV among 1,836 HIV positive and HIV negative gay men in the Amsterdam Cohort Study (CROI abstract 87). A total of 29 cases of acute HCV have been detected in Amsterdam since 2000, all but one in HIV positive men. The post-2000 HCV incidence rate among men with HIV was 0.87 per 100 PY – a 10-fold increase over the pre-2000 rate. The largest cluster of cases had HCV genotype 4, which is uncommon in Europe. Like Danta, the Dutch researchers found that among the 20 men interviewed about sex and drug use, HCV infection was associated with fisting (practiced by 50%) and STDs that cause genital ulcers (e.g., syphilis, genital herpes simplex, lymphogranuloma venereum)(reported by 65%). The researchers concluded that “HIV infection and/or mucosal trauma caused by extreme sexual techniques and concurrent STD might facilitate sexual transmission of HCV.”

Evidence from North America
Clusters of apparently sexually transmitted HCV among MSM have also been seen in France, but, interestingly, not in North America. In the March 2005 American Journal of Public Health, M. Alary and colleagues reported that in a cohort of 1,085 MSM in Montreal, only one new HCV infection was detected during eight months of follow-up (in a man who shared needles), despite the fact that 63% reported unprotected anal sex. After controlling for injection drug use, the researchers concluded that sexual behavior was not significantly linked to HCV infection (although this was not an HIV positive cohort). In the U.S., Srigayatri Bollepalli and colleagues found that injection drug use was the only risk factor significantly associated with HCV infection among HIV positive MSM in Arizona, concluding that “[s]exual transmission of HCV among HIV [positive] patients is extremely rare” (56th AASLD, 2005; abstract 65573).

But such cases aren’t unknown. In the January 1, 2006 Journal of AIDS, Annie Luetkemeyer and colleagues reported on a series of nine cases of acute HCV infection in HIV positive men seen at the University of California in San Francisco. Sex with men was the only risk factor reported by six of these individuals, while two reported unprotected sex with women, and three had concurrent STDs. The authors suggested that “MSM sexual activity as well as sexually transmitted infections may play an important role in HCV transmission in HIV-infected patients.”

What About Women with HIV?
A new development at this year’s Retrovirus conference was a report of acute HCV infections in HIV positive heterosexual women. J. Ghosn and colleagues analyzed data from 402 patients recently infected with HIV in the French PRIMO Cohort (abstract 843). They detected acute hepatitis C in two women and three men, for an incidence rate of 3.56 per 1000 PY (7.81 per 1000 PY for the women; 2.61 per 1000 PY for the men). As in Amsterdam, the incidence of acute hepatitis C increased in the early 2000s, from 1.81 per 1000 PY before January 2002 to 4.69 per 1000 PY after that date (all but one of the five new HCV infections were detected since 2002). Because none of the five reported “classical risk factors,” such as injection drug use or blood transfusions, the researchers concluded that “[t]he only identified risk factor for HCV acquisition was unsafe sex,” and suggested that “women are also at risk of acquiring HCV via the sexual route.”

Ghosn’s results conflict with a study from the U.S. Women’s Interagency HIV Study (WIHS), reported in the November 15, 2003 issue of Clinical Infectious Diseases, showing no evidence of sexual HCV transmission in this cohort of 2,059 HIV positive and 569 HIV negative women. On the other hand, as reported in the May 1, 2003 Journal of Infectious Diseases, data from the HIV Epidemiology Research Study (HERS), looking at 871 HIV positive and 439 HIV negative women, suggested that 10.5% of the women coinfected with HCV had sex as their only risk factor (some also had genital herpes simplex).

Better Safe than Sorry
Two other recent studies indicate that sexual HCV transmission is biologically plausible, since HCV is present in semen and female genital fluid. As reported in the November 4, 2005 issue of AIDS, Aureliea Briat and colleagues from Paris analyzed HCV RNA levels in the semen of 82 HIV/HCV coinfected and 38 HCV monoinfected men. They detected HCV genetic material more often in the seminal fluid of coinfected men than men with HCV alone (38% vs 18%). Similarly, as reported in the November 1, 2005 Journal of Infectious Diseases, M.J. Nowicki and colleagues measured HCV RNA levels in the cervicovaginal lavage fluid from 58 HIV/HCV coinfected and 13 HCV monoinfected women enrolled in WIHS. HCV RNA was detected in the genital fluid of 29% of the coinfected women, but none of the HCV monoinfected women.

While studies have yielded conflicting data, there is increasing evidence that sexual transmission of HCV may be more common than previously thought – and that it appears to be occurring more frequently in recent years. Until more is known, it is prudent for people with any of the risk factors seen in these studies (e.g., HIV positive, multiple sexual partners, fisting, STDs) to practice safer sex, including the use of latex condoms and gloves.

newsLett

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Sexual Transmission of HCV: An Emerging New Consensus?

Liz Highleyman

Traditionally, sexual activity has been regarded as an uncommon route of hepatitis C virus (HCV) transmission. According to the Centers for Disease Control and Prevention (CDC), sex with an HCV-infected person is “an inefficient means of transmission,” and the National Institutes of Health (NIH) states that “changes in sexual practices are not recommended” for monogamous people with chronic hepatitis C.

This information – which appears in most basic hepatitis C educational materials and most doctors give their patients – is based on observational studies of stable, presumably monogamous, HIV negative heterosexual couples with one HCV positive partner. Such studies have shown HCV sexual transmission rates ranging from 0% (no cases) to about 3%.
But a growing epidemic of apparently sexually transmitted acute HCV infection, primarily among HIV positive men who have sex with men (MSM), has led some experts to revisit this consensus.

An Emerging Epidemic?
Beginning in 2002, clinicians began reporting clusters of acute hepatitis C among HIV positive gay/bisexual men, first in London and Brighton in the U.K., and later in cities in France, Germany, the Netherlands, and Switzerland. While there were only a few cases in 2000-2004, the numbers increased dramatically around 2005-2006, and the count has now reached the hundreds.

A large proportion of the newly coinfected men in the various cities had HCV genotype 4, which is generally uncommon in Europe. Genetic studies showed that a majority of the men’s HCV strains were closely related, occurring in a number of well-defined clusters, suggesting transmission within sexual networks, and from network to network due to travel between the cities.

The men in these clusters had several sexual practices in common. Overall – though specific associations vary from study to study – men with acute hepatitis C were more likely to report fisting, unprotected anal sex, multiple sex partners, sex in a group setting (for example, at a sex club or bathhouse), other sexually transmitted diseases (STDs), and use of non-injected recreational drugs.

Now In the U.S.
As late as 2005, researchers from Canada and the U.S. were reporting very few cases of apparently sexually transmitted acute hepatitis C among MSM with no other risk factors, but this began to change around 2006. That year, Annie Luetkemeyer and colleagues published a report of nine cases of acute HCV infection among HIV positive men seen at San Francisco General Hospital (SFGH).

Speaking at a San Francisco community forum on sex and hepatitis C this past January, Brad Hare from the SFGH team reported that 42% of HIV positive men in the hospital’s Positive Health Program are coinfected with HCV, with a majority reporting only sexual risk factors. Michael Allerton from Kaiser Permanente Northern California said that 10% of the health plan’s HIV positive members also have HCV, and in an informal survey Kaiser doctors estimated that 70% to 100% of their coinfected patients contracted HCV through sex.

At the Conference on Retroviruses and Opportunistic Infection (CROI) in 2007, Daniel Fierer from Mt. Sinai School of Medicine in New York City first reported on a group of HIV positive MSM with acute hepatitis C who showed evidence of unusually rapid liver disease progression. At this year’s CROI in February, the Mt. Sinai team presented a comparison of the characteristics and risk behaviors of 20 men in their coinfected cohort and 60 similar men in the U.K.

The men in both groups were older than average for STD clinic patients, with a mean age of about 40 years. The New York men were less likely than the U.K. men to report insertive (33% vs. 73%) or receptive (24% vs. 57%) fisting during the past 12 months. Majorities in both cities reported both insertive and receptive unprotected anal sex. While the New York men were about one-third as likely to use non-injection recreational drugs, they reported more sharing of implements for drug smoking (48% vs. 20%) or injection (15% vs. 2%). Unlike European cohorts, 90% of the New York men had HCV genotype 1 and none had genotype 4.

Role of HIV
As noted, most of the recent cases of apparently sexually transmitted acute hepatitis C have been seen in HIV positive gay/bisexual men; in Paris, an HIV positive woman was among the newly coinfected.

This observation suggests that HIV may increase the risk of contracting HCV. It is already known that HIV positive people are less likely to spontaneously clear HCV without treatment, do not respond as well to interferon-based therapy, and appear to experience more rapid liver disease progression.

Disturbingly, Fierer reported that among 24 newly HCV-infected HIV positive men who underwent liver biopsies an average of four months after their first elevated ALT test, 18 (75%) already had moderate (stage 2) fibrosis, and only two had no evidence of fibrosis. However, among 10 individuals who completed treatment with pegylated interferon plus ribavirin, eight (80%) achieved sustained virological response – comparable to the success rate for HIV negative people.

HIV causes progressive immune suppression, but across the European and U.S. cohorts, newly coinfected HIV positive men had relatively high CD4 T-cell counts overall, above the current threshold for starting antiretroviral therapy (350) and sometimes as high as 500.

Another possible explanation is that HIV positive men are more likely to be tested for hepatitis C. While on antiretroviral therapy, HIV patients should have their liver enzymes monitored regularly to check for drug toxicity. If an individual has elevated ALT with no other apparent cause, they are likely to be tested for HCV, and thus may be diagnosed during acute infection, which is often asymptomatic. In contrast, HIV negative men seldom receive regular HCV screening. “I think if we start looking for it, we’re going to start finding it,” Allerton predicted at the forum.

However, the few studies that have looked at acute HCV infection among HIV negative men have not seen high rates. In Brighton, where all sexual health clinic clients have been routinely screened for HCV since 2000, several new HCV infections did turn up in HIV negative men, but their rate was 13 times lower than that of HIV positive men.

Growing Awareness
Awareness of the potential for sexual transmission of HCV has begun to emerge among gay men, particularly within groups – including the leather/BDSM (bondage & discipline/sadism & masochism) community – that engage in practices associated with transmission. Unfortunately, the awareness of healthcare providers may be lagging: several forum participants related that they were refused HCV testing if they had never injected drugs.

The specific sexual risk factors for sexual HCV transmission remain unclear, since study results are mixed. Unlike most studies, for example, Fierer found that receptive anal or oral sex were associated with acute HCV infection, while fisting was not. But correlation does not necessarily imply causality. Multiple risk factors tend to occur together, and most gay/bisexual men do not engage in only a single sexual activity.

In its latest hepatitis C information, the CDC acknowledges that “the risk of transmission from sexual contact…increases for those who have multiple sex partners, have a sexually transmitted disease, engage in rough sex, or are infected with HIV.”

Larry Shockey, who hosts fisting parties now strongly encourages the use of gloves for fisting and uses a strong quaternary disinfectant on all play equipment before and after each use. HCV is harder to kill than HIV, and can live longer outside the body. Very small amounts of blood on surfaces and implements (e.g., whips, canes, needles for play piercing) – which may not even be visible – can potentially spread the virus.

Importantly, HIV positive men who have unprotected sex only with other HIV positive men still remain at risk for hepatitis C.

While small amounts of HCV may be present in semen, Hare said that blood is “probably the major route of exposure” to HCV during sex. Anal sex may be an efficient route of transmission because the rectal lining is prone to damage that could allow contact with blood – especially during prolonged sex facilitated by drugs such as crystal meth.

“HCV may have risk factors we don’t understand yet because the studies haven’t been done,” noted Allerton.

http://www.hcvadvocate.org/news/newsLetter/2009/advocate0409.html#6

No Evidence of Sexual Transmission of Hepatitis C among Monogamous Couples: Results of a 10-Year Prospective Study

The risk of sexual transmission of hepatitis C virus (HCV) infection was evaluated among 895 monogamous heterosexual partners of HCV chronically infected individuals in a long-term prospective study, which provided a follow-up period of 8,060 person-years. Seven hundred and seventy-six (86.7%) spouses were followed for 10 yr, corresponding to 7,760 person-years of observation.

One hundred and nineteen (13.3%) spouses (69 whose infected partners cleared the virus following treatment and 50 who ended their relationship or were lost at follow-up) contributed an additional 300 person-years.

All couples denied practicing anal intercourse or sex during menstruation, as well as condom use. The average weekly rate of sexual intercourse was 1.8.

Three HCV infections were observed during follow-up corresponding to an incidence rate of 0.37 per 1,000 person-years. However, the infecting HCV genotype in one spouse (2a) was different from that of the partner (1b), clearly excluding sexual transmission.

The remaining two couples had concordant genotypes, but sequence analysis of the NS5b region of the HCV genome, coupled with phylogenetic analysis showed that the corresponding partners carried different viral isolates, again excluding the possibility of intra-spousal transmission of HCV.

The authors conclude, “Our data indicate that the risk of sexual transmission of HCV within heterosexual monogamous couples is extremely low or even null. No general recommendations for condom use seem required for individuals in monogamous partnerships with HCV-infected partners.”

06/21/04

Reference
Carmen Vandelli and others. Lack of Evidence of Sexual Transmission of Hepatitis C among Monogamous Couples: Results of a 10-Year Prospective Follow-Up Study. American Journal of Gastroenterology 99(6): 855-859. May 2004.

Link to Index of all HCV articles
http://www.hivandhepatitis.com/hep_c/news/2004/062104_c.html

Sexual Transmission of HCV

The hepatitis C virus (HCV) often causes liver inflammation. In up to 80% of people initially infected with HCV, the disease becomes chronic, potentially leading to long-term liver damage. A small percentage (about 20%) of those who are HCV positive will progress to liver cirrhosis, and approximately 3-5% of those with chronic HCV infection will develop liver cancer. Experts estimate that at least four million Americans are currently chronically infected with HCV; the number of new cases of HCV in the U.S. is decreasing. Fortunately, there are several measures people can take to protect themselves from this potentially life-threatening disease.

How is HCV Spread?

HCV is a blood-borne disease, that is, it is transmitted by blood-to-blood contact. Any activity that lets one person's blood or body fluids to come into contact with another person's blood or mucous membranes can potentially transmit HCV. However, some activities are much more likely than others to spread the virus. HCV can be transmitted by sharing equipment for injection and non-injection drugs (for example, needles, cookers, cocaine straws, and crack pipes). Needles used for tattooing, body piercing, and acupuncture may also spread HCV. Sharing personal items like razors, toothbrushes, or nail files is a less likely – but still possible – transmission route. In the past, many people contracted HCV through blood transfusions, but since 1992 there has been a reliable HCV blood test and today donated blood is safe. Today the likelihood of contracting HCV through infected blood is less than .001%

Sex and HCV

We know that blood-borne viruses can be transmitted through certain types of sexual activity. HCV has rarely been detected in semen and vaginal fluids. However, most studies suggest that the virus is not often found in these body fluids, or that it is present in very low amounts and the virus particles may be noninfectious.

Most experts believe that the risk of sexual transmission of HCV is low. Most studies show that only a small percentage of people – usually ranging from 0-3% – contract HCV through unprotected heterosexual intercourse with a long-term, monogamous HCV-positive partner. Health Canada estimates the risk that a person will get HCV from unprotected sex with a steady HCV-infected partner at 2.5% over 20 years.

Some studies indicate that sexual transmission from men to women is more efficient than transmission from women to men.

Since HCV is spread through blood, the risk of sexual transmission may be higher when a woman is having her menstrual period.

According to the most recent (1997) National Institutes of Health consensus statement, people who have multiple sex partners should practice safer sex. Those in stable, monogamous relationships do not need to change their current sexual practices, although they should discuss safer sex options if either partner is concerned about sexual transmission.

Among people in so-called "high risk" groups (gay men, prostitutes, people with multiple sex partners, people seen at STD clinics), sexual transmission of HCV appears to be more common. The fact that people with more sex partners and other sexual risk factors have higher rates of HCV indicates that the disease is can be sexually transmitted. On the other hand, if sexual transmission of HCV were common, we would expect to see many more new cases of the disease among people whose partners are HCV positive.

Sexual transmission of HCV between men who have sex with men and women who have sex with women has not been well studied. Many studies show higher rates of HCV infection in gay men, but it is not known whether this is related to sexual activity. Anal sex may be a more efficient route of transmission than vaginal sex because the delicate lining of the rectum is more prone to damage that allows contact with blood.

There are no known cases of HCV being transmitted through oral sex on a man (fellatio) or a woman (cunnilingus). However, it is theoretically possible that the virus could be transmitted this way if a person has mouth sores, bleeding gums, or a throat infection.

There are no known cases of HCV being spread through kissing, including deep, open-mouth, or “French” kissing. It is theoretically possible that HCV could be transmitted this way if one partner has mouth sores, bleeding gums, or any other condition that could permit blood-to-blood contact. But this mode of transmission is believed to be very rare.

Special Considerations

Experts believe that HCV (like HIV) is more likely to be transmitted if either the positive or the negative partner has another sexually transmitted disease (STD), especially one that causes sores or lesions (for example, herpes or syphilis). Always have any suspicious symptoms checked by a doctor, and get prompt treatment for curable STDs such as

chlamydia, gonorrhea, and syphilis.

Some studies suggest that people who are co-infected with both HCV and HIV are more likely to transmit HCV; the same may also be true for people co-infected with both HCV and hepatitis B virus (HBV). In addition, a person with HIV whose immune system is compromised may be at higher risk for contracting HCV.

Safer Sex

Some people feel more secure knowing that they are doing everything they can to prevent sexual transmission of HCV. Safer sex practices can also help prevent the spread of hepatitis A and B, HIV, and other STDs.

Using condoms is the surest way to prevent transmission of HCV and other STDs. Latex condoms are best for disease prevention; natural skin condoms have small pores that can let viruses through. Polyurethane (plastic) condoms are also a good choice, especially for people who are sensitive to latex. Internal or “female” condoms (brand name “Reality”) are polyurethane sheaths worn inside the vagina rather than on the penis.

Learn how to use condoms correctly. Most “condom failure” is really caused by incorrect use. Pinch the tip as the condom is rolled on in order to create an air pocket that will leave room for the semen. Hold onto the base of a regular condom or hold an internal condom in place when withdrawing after sex to keep the semen from spilling. Tie the condom to prevent spills, and dispose of it properly. Condoms (both regular condoms and internal condoms) should be used only once.

Some people choose to use condoms for oral sex on a man. For oral sex on a woman, barriers can be used to reduce the risk of disease transmission. Commonly used barriers include latex dental dams, sheets of plastic wrap, and latex sheets sold specifically for sex.

To prevent disease transmission through broken skin, some people use latex or nitrile (plastic) gloves or “finger cots” for manual sex. It is a good idea to cover any cuts or sores with a bandage that will not allow fluids to seep through.

Use only water-based lubricants with latex condoms or barriers. KY jelly and most commercial lubricants sold specifically for sex are water-based. Avoid oil-based lubricants (such as Vaseline, coconut oil, or moisturizing lotion) since these damage latex and can cause a condom or barrier to break. Avoid lubricants or pre-lubricated condoms

that contain nonoxynol-9. Recently manufacturers stopped including this ingredient after it was shown that nonoxynol-9 caused irritation and damage to mucous membranes of the vagina, rectum, and penis that may actually increase the risk of disease transmission.

To reduce the risk of HCV transmission during oral sex or deep kissing, practice regular good oral hygiene – healthy teeth and gums may be the best defense against the spread of diseases through the mouth. Many experts recommend that people avoid brushing or flossing their teeth right before or after oral sex or deep kissing, since these can cause bleeding gums and tiny abrasions.

Conclusion

While sexual transmission of HCV remains somewhat controversial, most studies indicate that transmission through sexual activity is uncommon, and most experts believe the risk of sexual transmission is low. According to the National Institutes of Health, people in stable, monogamous relationships do not need to change their current sexual practices, although they should discuss safer sex options if either partner is concerned about sexual transmission. People with multiple sex partners should practice safer sex, in particular the use of latex condoms.

Disclaimer

The information in this brochure is designed to help you understand and manage hepatitis C virus infection. It is not intended as medical advice. People with hepatitis C should consult a medical professional for diagnosis and treatment.

About the Hepatitis C Support Project

This information is provided by the Hepatitis C Support Project. The Hepatitis C Support Project offers support to people affected by hepatitis C. The Project provides information, education, and support groups.

HCV Advocate is a monthly newsletter of the Hepatitis C Support Project. It is available free of charge on our web site:

www.hcvadvocate.org

Hepatitis C Support Project

Alan Franciscus, Executive Director

PO Box 427037

San Francisco, CA 94142-7037

Email: sfhepcat@pacbell.net

Additional Resource:

www.hepcbc.org

Writer and editor:

Liz Highleyman

Medical reviewer:

Robert Gish, MD

Director of Liver Transplantation

California Pacific Medical Center

San Francisco, CA

2002 CDC SEXUAL TRANSMISSION GUIDELINES FOR
HEPATITIS A, B AND C

Hepatitis A

Hepatitis A, caused by infection with HAV, has an incubation period from time of exposure to onset of symptoms of approximately 4 weeks (range: 15–50 days). HAV replicates in the liver and is shed in high concentrations in feces from 2 weeks before to 1 week after the onset of clinical illness. HAV is most commonly transmitted by the fecal-oral route. Although viremia occurs early in infection and can persist for several weeks after onset of symptoms, bloodborne transmission of HAV is uncommon.

HAV infection produces a self-limited disease that does not result in chronic infection or chronic liver disease. However, 10%–15% of patients may experience a relapse of symptoms during the 6 months after acute illness. Acute liver failure from hepatitis A is rare (0.3% overall case-fatality rate), but occurs more frequently in older persons (1.8% case fatality rate in adults >50 years of age) and persons with underlying chronic liver disease. The risk for symptomatic infection is directly related to age, with >80% of adults having symptoms compatible with acute viral hepatitis and most children having either asymptomatic or unrecognized infection. Antibody produced in response to HAV infection persists for life and confers protection against reinfection.

Approximately 33% of the U.S. population has serologic evidence of prior HAV infection, which increases directly with age and reaches 75% among persons aged >70 years. Most cases of hepatitis A result from person-to-person transmission during community-wide outbreaks. The most frequently reported source of infection (12%–26%) is either household or sexual contact with a person who had hepatitis A. In addition, outbreaks regularly occur among users of injection and non-injection drugs and among MSM. In the United States, up to 10% of reported cases of HAV occur among persons reporting these behaviors. Approximately 50% of persons with hepatitis A do not have an identified source for their infection.

Hepatitis A, like other enteric infections, can be transmitted during sexual activity. Recent outbreaks of hepatitis A among MSM have occurred in urban areas in the United States. Although

some studies have associated having a greater number of sex partners, frequent oral-anal contact, insertive anal intercourse, or serologic evidence of other STDs with HAV infection, other studies have not found specific risk factors for infection.

Unlike persons with most other STDs, HAV-infected persons are infectious for only a relatively brief period of time. However, many sexual practices facilitate fecal-oral transmission of HAV, and inapparent fecal contamination is commonly present during sexual intercourse. Measures typically used to prevent the transmission of other STDs (e.g., use of condoms) do not prevent HAV transmission, and maintenance of “good personal hygiene” has not been successful in interrupting out-breaks of hepatitis A. Vaccination is the most effective means of preventing HAV transmission among persons at risk for sexual transmission of this virus and among persons who use injection and non-injection illegal drugs, many of whom may seek services in STD clinics.

Diagnosis

The diagnosis of hepatitis A cannot be made on clinical grounds alone and requires serologic testing, which is available commercially. The presence of IgM antibody to HAV is diagnostic of acute HAV infection. A positive test for total anti-HAV indicates immunity to HAV infection but does not differentiate acute from past HAV infection. Tests can be positive after hepatitis A vaccination.

Treatment

Patients with hepatitis A usually require only supportive care, with no restrictions in diet or activity. Hospitalization may be necessary for patients who become dehydrated because of nausea and vomiting and for patients with signs or symptoms of acute liver failure. Medications that might cause liver damage or are metabolized by the liver should be used with caution among persons with HAV.

Prevention

Two products are available for the prevention of hepatitis A: hepatitis A vaccine (Table 2) and immune globulin (IG) for IM administration (2). Inactivated hepatitis A vaccines are prepared from formalin-inactivated, cell-culture-derived HAV and have been available in the United States since 1995 for persons aged >2 years. Administered in a two-dose series, these vaccines induce protective antibody levels in virtually all adults. By 1 month after the first dose, 94%–100% of adults have protective antibody levels; 100% of adults develop protective antibody following a second dose. In randomized controlled trials, the equivalent of one dose of hepatitis A vaccine administered before exposure has been 94%–100% effective in preventing clinical hepatitis A (3). Kinetic models of antibody decline indicate that protective levels of antibody persist for at least 20 years.

A combined hepatitis A and B vaccine has been developed for adults. When administered on a 0-, 1-, 6-month schedule, the vaccine has equivalent immunogenicity to that of the monovalent vaccines.

TABLE 2. Recommended regimens: dose and schedule for hepatitis A vaccines

Vaccine	Age (yrs)	Dose*	Volume (ml)	Two-dose schedule (months)☺
HAVRIX (SKB Biologicals)	2-18	720 (EL.U.)	0.05	0, 6-12
HAVRIX (SKB Biologicals)	>18	1,440 (EL.U.)	1.0	0, 6-12

VAQTA (Merck & Co., Inc.)	2-18	25 (U)	0.5	0, 6-12
VAQTA (Merck & Co., Inc.)	>18	50 (U)	1.0	0, 6-12

* EL.U=Enzyme-linked immunosorbent assay (ELISA) units; U=Units.

☺0 months represent timing of the initial dose; subsequent numbers represent months after the initial dose.

IG is a sterile solution of concentrated immunoglobulins prepared from pooled human plasma processed by cold ethanol fractionation. In the United States, IG is produced only from plasma that has tested negative for HBV, antibody to HIV, and antibody to HCV. In addition, the manufacturing process must either include a viral inactivation step or the final product must test negative for HCV RNA. When administered before or within 2 weeks after exposure to HAV, IG is >85% effective in preventing hepatitis A.

Preexposure Immunization

Persons in the following groups should be offered hepatitis A vaccine:

MSM, including those who report having minimal or no current sexual activity;

illegal drug users (both injection and non-injection drug users); and

persons with chronic liver disease, including persons with chronic HBV and HCV infection who have evidence of chronic liver disease.

Hepatitis A vaccine currently is available for children and adolescents aged <19 years through the Vaccines for Children (VFC) program (tel: 800-232-2522).

Prevaccination Serologic Testing for Susceptibility

Screening for HAV infection may be cost-effective in populations where the prevalence of infection is likely to be high (e.g., older persons and persons born in areas of high HAV endemicity). The potential cost-savings of testing should be weighed against the likelihood that testing will interfere with initiating vaccination. Vaccination of a person who is already immune is not harmful.

Postvaccination Serologic Testing

Postvaccination serologic testing is not indicated because most persons respond to vaccine. In addition, the commercially available serologic test is not sensitive enough to detect the low, but protective, levels of antibody produced by vaccination.

Postexposure Prophylaxis

Previously unvaccinated persons exposed to HAV (e.g., through household or sexual contact or by sharing illegal drugs with a person who has hepatitis A) should be administered a single IM dose of IG (0.02 mL/kg) as soon as possible, but not >2 weeks after exposure. Persons who have had one dose of hepatitis A vaccine at least 1 month before exposure to HAV do not need IG. If hepatitis A vaccine is recommended for a person receiving IG, it can be administered simultaneously at a separate anatomic injection site. The use of hepatitis A vaccine alone is not recommended for postexposure prophylaxis.

Special Considerations

Limited data indicate that vaccination of HIV-infected persons results in lower seroprotection rates and antibody concentrations (3). Antibody response may be directly related to CD4+ levels.

Hepatitis B

Hepatitis B is caused by infection with HBV. The incubation period from time of exposure to onset of symptoms is 6 weeks to 6 months. HBV is hepatotropic, is found in highest concentrations in the blood, and is found in lower concentrations in other body fluids (e.g., semen, vaginal secretions, and wound exudates). HBV infection can be self-limited or chronic. In adults, only 50% of acute HBV infections are symptomatic and about 1% of cases result in acute liver failure and death. Risk for chronic infection is associated with age at infection: about 90% of infected infants and 60% of infected children aged <5 years become chronically infected compared with 2%–6% of adults. Among persons with chronic HBV infection, the risk of death from cirrhosis or hepatocellular carcinoma is 15%–25%.

In the United States, an estimated 181,000 persons were infected with HBV in 1998, and about 5,000 deaths occurred from HBV-related cirrhosis or hepatocellular carcinoma. An estimated 1.25 million people are chronically infected with HBV, serve as a reservoir for infection, and are at increased risk for death from chronic liver disease. HBV is efficiently transmitted by percutaneous or mucous membrane exposure to infectious body fluids. Sexual transmission among adults accounts for most HBV infections in the United States. In the 1990s, transmission among hetero-sexual partners accounted for about 40% of infections, and transmission among MSM accounted for another 15% of infections. The most common risk factors for heterosexual transmission include having multiple sex partners (i.e., more than one partner in a 6-month period) or a recent history of an STD. Risk factors for infection among MSM include having multiple sex partners, engaging in unprotected receptive anal intercourse, and having a history of other STDs. Changes in sexual practices among MSM to prevent HIV infection have resulted in a lower risk for HBV infection than that observed in the late 1970s, when studies found up to 70% prevalence of HBV markers among adult MSM. Recent surveys of young MSM (aged 15–22 years) indicated that 6%–13% of participants had evidence of HBV infection, whereas 3%–27% had evidence of having been immunized against hepatitis B.

Among persons with acute hepatitis B, up to 70% have previously received care in settings where they could have been vaccinated (e.g., STD clinics, drug treatment programs, and correctional facilities). A 1997 survey of STD clinics demonstrated that hepatitis B vaccine was routinely offered in only 5% of these settings.

Diagnosis

The diagnosis of acute or chronic HBV infection cannot be made on clinical grounds, but requires serologic testing (Table 3). Hepatitis B surface antigen (HBsAg) is present in either acute or chronic infection. The presence of IgM anti-body to hepatitis B core antigen (IgM anti-HBc) is diagnostic of acute HBV infection. Antibody to HBsAg (anti-HBs) is produced following a resolved infection and is the only HBV antibody marker present following immunization. The presence of HBsAg with a negative test for IgM anti-HBc is indicative of chronic HBV infection. The presence of anti-HBc may indicate either acute, resolved, or chronic infection.

Table 3. Serologic markers in different stages of hepatitis B virus (HBV) infection

*Stages of HBV Infection*	*HbsAg* *(Hep B Surface Antigen)*	*Anti-HBs (Antibodies to hepatitis B surface antigen)*	*Anti-HBc* *(Antibodies to hepatitis B core antigen)*	*Total IgM* *(The total anti-HBc assay detects both IgM and IgG antibody)*
Late Incubation Period	+	-	-	+/-
Acute	+	-	+	+
Chronic	+	-	+	-
Chronic		(+ rarely)
Recent (<6 months) Window period	-	+/-	+	+
Recent (<6 months) Window period
Distant (>6 months);
Resolved**	-	+	+	-
Immunized	-	+ *	-	-

* Anti-HBs >10mIU/ml

** “Resolved” indicates that the patient no longer has the disease

Treatment

Laboratory testing should be used to confirm suspected acute or chronic HBV infection, and infected persons should be referred for medical follow-up and possible treatment of chronic infection. In addition, contacts should be vaccinated (see Exposure to Persons who have Acute Hepatitis B) and receive postexposure prophylaxis. No specific therapy is available for persons with acute HBV infection; treatment is supportive.

Antiviral agents (i.e., alpha-interferon or lamivudine) are available for treatment of persons with chronic hepatitis B. To determine the likelihood of response to treatment, an initial evaluation is required to determine the status of the chronic HBV infection and the extent of liver disease. For this reason, treatment should be offered by health-care professionals with experience in the treatment of hepatitis B.

Prevention

Two products have been approved for hepatitis B prevention: hepatitis B immune globulin (HBIG) and hepatitis B vaccine. HBIG is prepared from plasma known to contain a high titer of anti-HBs and is used for postexposure prophylaxis. The recommended dose of HBIG for children and adults is 0.06 mL/kg. The dose is 0.5 mL to prevent perinatal HBV infection among infants born to HBsAg-positive mothers.

Hepatitis B vaccine uses HBsAg produced in yeast by recombinant DNA technology and provides protection from HBV infection when used for both preexposure immunization and postexposure prophylaxis. The two available monovalent hepatitis B vaccines for use in adolescents and adults are Recombivax HB ® (Merck and Co., Inc.) and Engerix-B (SmithKline Beecham Biologicals).

The recommended vaccine dose varies by product and age of recipient (Table 4). Vaccine should be administered IM in the deltoid muscle and can be administered simultaneously with other vaccines. Many vaccination schedules have been used for both adults and adolescents. A two-dose schedule has been approved for adolescents aged 11–15 years using the adult dose of Recombivax HB ® . If the vaccination series is interrupted after the first or second dose of vaccine, the missed dose should be administered as soon as possible. The series does not need to be restarted if a dose has been missed.

Table 4. Recommended regimen: doses and schedules of currently licensed hepatitis B vaccines for adolescents and adults

*Group*	Recombivax HB dose (µg) (ml)	Engerix-B Dose (µg) (ml)	Schedule (months)
Adolescents (aged 11-19 years)*	5 0.5 (pediatric formulation)	10 0.5 (pediatric formulation)	0, 1, 6, or 0, 2, 4, or 0, 1, 4, or 0, 12, 24
Adolescents (aged 11-15 years)*	10 1.0 (adult formulation)		0,4
Adults (aged ≥ 20 years)	10 1.0 (adult formulation)	20 1.0 (adult formulation)	0, 1, 6 or 0, 2, 4, or 0, 1, 4, or 0, 1, 2, 12**

* Eligible persons < 19 years can receive free vaccine under the Vaccines for Children (VFC) program

** This schedule has been used for persons requiring rapid protection (e.g. international travelers)

In adolescents and healthy adults aged <40 years, approximately 50% develop a protective antibody response (anti-HBs >10 mIU/mL) after the first vaccine dose, 70% after the second, and >90% after the third dose. Because relatively high rates of protection are achieved following each vaccine dose, hepatitis B vaccination should be initiated even if completion of the series cannot be ensured. Because most fully vaccinated persons have long-lasting protection from HBV infection, periodic testing to determine antibody levels in immune competent persons is not necessary, and booster doses of vaccine are not recommended.

Hepatitis B vaccine has been shown to be safe; more than 20 million adolescents and adults have been vaccinated in the United States. The vaccine is well tolerated by most recipients. Pain at the injection site or low grade fever is reported by a minority of recipients. Anaphylaxis is estimated to occur in one in 600,000 doses of vaccine administered; no deaths have been reported following anaphylaxis. Hepatitis B vaccine has not been associated with multiple sclerosis, diabetes, or other autoimmune or neurologic diseases in any controlled epidemiologic study. Vaccine is contraindicated in persons with a history of anaphylaxis after a previous dose of hepatitis B vaccine and in persons with a known anaphylactic reaction to yeast.

CDC’s national immunization strategy to eliminate transmission of HBV infection includes a) prevention of perinatal infection through maternal HBsAg screening and postexposure prophylaxis of at-risk infants, b) universal infant immunization, c) universal immunization of previously unvaccinated adolescents aged 11–12 years (99), and d) vaccination of adolescents and adults at increased risk for infection (100). Although high immunization coverage rates have been achieved among infants and younger adolescents, hepatitis B incidence rates remain high because most infections now occur in adults. Although the cost of vaccine remains a barrier to adult vaccination, vaccine purchase and provider reimbursement should not be a barrier for vaccination of adolescents aged <19 years, who may be eligible for free vaccine under the Vaccines for Children (VFC) program (tel: 800-232-2522).

Preexposure Immunizations

Hepatitis B vaccine is recommended for all persons who attend STD clinics who have not been previously vaccinated. In the non-STD clinic setting, the following persons should be vaccinated: a) persons with history of an STD, persons who have had multiple sex partners, those who have had sex with an injection-drug user, and sexually active MSM; b) persons engaging in illegal drug use; c) household members, sex partners, and drug-sharing partners of a person with chronic HBV infection; and d) persons on hemodialysis, persons receiving clotting factor concentrates, or persons who have occupational exposure to blood. In addition, hepatitis B vaccine should be offered to all persons who have not been previously vaccinated who receive services in drug treatment programs and long-term correctional facilities.

Prevaccination Antibody Screening

Based on the current cost of hepatitis B vaccine, revaccination serologic testing may be cost-effective in adult populations with a high prevalence of HBV infection (>2% HBsAg positive or >30% anti-HBc positive). However, prevaccination testing is not cost-effective in any adolescent populations. Adult populations with high prevalence of HBV infection include injection-drug users, MSM, sexual contacts of persons with chronic HBV infection, and persons from countries with endemic HBV infection. When testing is performed, anti-HBc is the test of choice. Testing should not be a barrier to vaccination of susceptible persons, especially in populations that are difficult to access, and the first dose of vaccine should be administered at the same time that serologic testing is initiated.

As hepatitis B vaccination becomes more widespread, more persons will present with a history of vaccination and most will not have a personal vaccination record. However, serologic testing in persons with a history of previous hepatitis B vaccination may not be helpful because of the loss of detectable antibody. Without a vaccination record, obtaining a careful history (e.g., number of doses, schedule, and age at immunization) is the only way to determine if the person most likely received the complete hepatitis B vaccine series. Administration of additional doses of vaccine beyond the three-dose series is not harmful.

Postexposure Prophylaxis

Exposure to Persons Who Have Acute Hepatitis B

Sex Contacts. Previously unvaccinated sex partners of persons with acute hepatitis B should receive postexposure immunization with HBIG and hepatitis B vaccine within 14 days after the most recent sexual contact. HBIG has been shown to be required for effective postexposure protection in this setting. Administration of vaccine with HBIG in this setting confers long-term protection in the event the person with acute hepatitis B becomes chronically infected; simultaneous administration of HBIG and hepatitis B vaccine does not reduce vaccine effectiveness. Testing sex partners for susceptibility to HBV infection (anti-HBc) can be considered if it does not delay postexposure immunization beyond 14 days.

Nonsexual Household Contacts. Nonsexual household contacts of patients who have acute hepatitis B are not at increased risk for infection unless they have other risk factors or are exposed to the patient’s blood (e.g., by sharing a toothbrush or razor blade). However, vaccination of household contacts is encouraged, especially for children and adolescents. If the patient with acute hepatitis B becomes chronically infected (i.e., remains HBsAg-positive after 6 months), all household contacts should be vaccinated.

Exposure to Persons Who Have Chronic HBV Infection

Most HBsAg-positive persons are identified during routine screening (e.g., blood donation and prenatal evaluation) or clinical evaluation. Active postexposure prophylaxis with hepatitis B vaccine alone is recommended for sex or needle-sharing partners and non-sexual household contacts of persons with chronic HBV infection. Because identifying the time of the last contact can be difficult, hepatitis B vaccination provides both preexposure and postexposure protection. Although the effectiveness of active postexposure immunization has not been evaluated for sex contacts of persons with chronic HBV infection, it provides high-level protection (90%) against perinatal HBV infection, where the intensity of exposure is greater than that among household or sex contacts of chronically infected persons.

Postvaccination testing (anti-HBs) should be considered for sex partners of persons with chronic HBV infection. Although most persons are expected to respond to vaccination, those found to be antibody-negative should receive a second, complete vaccination series. Those persons found to be antibody-negative after revaccination should be counseled about abstinence and the use of other methods to protect them from sexual HBV transmission.

Special Considerations

Pregnancy

All pregnant women receiving STD services should be tested for HBsAg, regardless of whether they have been previously tested. If positive, this test result should be reported to state perinatal immunization or HBV prevention programs to ensure proper case management of the mother and appropriate postexposure immunization of her at-risk infant. HBsAg-negative pregnant women seeking STD treatment who have not been previously vaccinated should receive hepatitis B vaccine, as pregnancy is not a contraindication to vaccination.

HIV Infection

HBV infection in HIV-infected persons is more likely to result in chronic HBV infection. HIV infection also can impair the response to hepatitis B vaccine. Therefore, HIV-infected persons who are vaccinated should be tested for anti-HBs 1–2 months after the third vaccine dose. Revaccination with three more doses should be considered for persons who do not respond initially to vaccination. Those who do not respond to additional doses should be advised that they might remain susceptible to HBV infection and should be counseled in the use of methods to prevent HBV infection.

Victims of Sexual Assault

Studies have not determined the frequency with which HBV infection occurs following sexual abuse or rape. Fully vaccinated victims of sexual assault are protected from HBV infection and do not need further doses. For a victim who is not fully vaccinated, the vaccine series should be completed as scheduled. Unvaccinated persons in this setting should be administered active postexposure prophylaxis (i.e., vaccine alone) upon the initial clinical evaluation. Unless the offender is known to have acute hepatitis B, HBIG is not required. Because sexual abuse of children frequently occurs over a prolonged period of time, the last exposure is often difficult

to determine. However, when sexual abuse is identified, hepatitis B vaccination should be initiated in previously unvaccinated children.

Hepatitis C

HCV infection is the most common chronic bloodborne infection in the United States; an estimated 2.7 million persons are chronically infected (101). More than two thirds of all infected persons are aged <50 years. Persons with acute HCV infection typically are either asymptomatic or have a mild clinical illness. The average time from exposure to seroconversion is 8–9 weeks, and antibodies to HCV (anti-HCV) can be detected in >97% of persons by 6 months after exposure. Chronic HCV infection develops in most persons (75%–85%) after acute infection; 60%–70% have evidence of active liver disease. Most infected persons may not be aware of their infection because they are not clinically ill. However, infected persons serve as a source of transmission to others and are at risk for chronic liver disease or other HCV-related chronic diseases for at least 2 decades after infection.

HCV is most efficiently transmitted by direct percutaneous exposure to infected blood (e.g., by receipt of blood transfusion from an infected donor or through use of injection drugs). Although less efficient, occupational, perinatal, and sexual exposures also can result in transmission of HCV. No association has been documented between HCV and military service or HCV and exposures resulting from medical, dental, or surgical procedures; tattooing; acupuncture; ear piercing; or foreign travel (102).

The greatest variation in prevalence of HCV infection occurs among persons with different risk factors for infection. The highest prevalence of infection is found among those with substantial or repeated direct percutaneous exposures to blood (e.g., IDUs, persons with hemophilia treated with clotting factor concentrates produced before 1987, and recipients of transfusions from HCV positive donors). Moderate prevalence is found among persons with frequent but limited direct percutaneous exposures (e.g., long-term hemodialysis patients). Lower prevalence occurs among persons with inapparent percutaneous or mucosal exposures or sexual exposure and among those with limited, sporadic percutaneous exposures (e.g., health-care workers). Lowest prevalence of HCV infection is found among persons with no high-risk characteristics (e.g.,blood donors).

Sexual Activity

Although the role of sexual activity in the transmission of HCV remains controversial, results from several types of studies indicate that sexual activity is associated with HCV transmission (103,104). These studies reported independent associations between HCV infection and a) exposure to an infected sex partner, b) increasing numbers of partners, c) failure to use a condom, d) history of STD, e) heterosexual sex with a male IDU, and f) sexual activities involving trauma.

In contrast, a low prevalence (average: 1.5%; range: 0%–4.4%) of HCV infection has been demonstrated in studies of long-term spouses of patients with chronic HCV infection who had no other risk factors for infection. One study has found an association between HCV infection and male homosexual activity, and at least in STD clinic settings, the prevalence rate of HCV infection among MSM generally has been similar to that of heterosexuals (105). Because sexual transmission of bloodborne viruses is more efficient among homosexual men compared with heterosexual men and women, it is unclear why HCV infection rates are not substantially higher among MSM compared with heterosexuals. This observation and the low prevalence of HCV infection observed among the long-term steady sex partners of persons with chronic HCV infection have raised doubts about the importance of sexual activity in the transmission of HCV. Unacknowledged percutaneous exposures (i.e., illegal injection-drug use) might contribute to increased risk for HCV infection among such persons.

Although inconsistencies exist between studies, data indicate overall that sexual transmission of HCV can occur and accounts for up to 20% of HCV infections (102). The substantial contribution of sexual transmission to the disease burden in the United States relative to the inefficiency with which the virus appears to be spread in this manner can be explained. Because sexual activity with multiple partners is a common behavior among chronically infected persons and because of the substantial number of these persons, multiple exposure opportunities exist. However, more data are needed to determine the risk for, and factors related to, transmission of HCV between sex partners, including whether other STDs promote the transmission of HCV by influencing viral load or modifying mucosal barriers.

Increased HCV viral load or coinfection with HIV (known to increase perinatal transmission of HCV) may increase the risk for sexual transmission. A recent study involving hemophilic men demonstrated that dually infected men had a higher HCV load than those infected with HCV alone, and that a higher HCV load was associated, though not significantly, with an increased risk for HCV transmission to female partners (106).

Diagnosis and Treatment

The diagnosis of HCV infection can be made by detecting either anti-HCV or HCV RNA. Anti-HCV is recommended for routine testing of asymptomatic persons and should include use of both EIA to test for anti-HCV and a supplemental antibody test (i.e., recombinant immunoblot assay

[RIBA]) for all positive anti-HCV results. In settings where clinical services for liver disease are provided, use of reverse transcriptase polymerase chain reaction (RT-PCR) to detect HCV RNA might be appropriate to confirm the diagnosis of HCV infection (e.g., in patients with abnormal alanine aminotransferase[ALT] levels or with indeterminant supplemental anti-HCV test results), although RT-PCR assays are not currently FDA-approved. Current approved therapy for HCV-related chronic liver disease includes alpha interferon alone or in combination with the oral agent ribavirin for a duration of 6–12 months. Because of advances in the field of antiviral therapy for chronic hepatitis C, standards of practice might change, and clinicians should consult with specialists knowledgeable about this virus. The National Institutes of Health Consensus Development Conference Panel recommended that therapy for hepatitis C be limited to those patients with persistently elevated ALT levels, detectable HCV RNA, and histologic evidence of progressive disease (as characterized by liver biopsy findings indicating either portal or bridging fibrosis or at least moderate degrees of inflammation and necrosis).

Prevention

No vaccine for hepatitis C is available, and prophylaxis with immune globulin is not effective in preventing HCV infection after exposure. Reducing the burden of HCV infection and disease in the United States requires implementation of both primary and secondary prevention activities. Primary prevention reduces or eliminates HCV transmission; secondary prevention activities reduce liver and other chronic diseases in HCV-infected persons by identifying them and

providing appropriate medical management and antiviral therapy, if necessary (102). Persons seeking care in STD clinics or other primary-care settings should be screened for risk factors

for HCV infection, and those with the following risk factors should be offered counseling and testing:

illegal injection drug use, even once or twice many years ago;

blood transfusion or solid organ transplant before July 1992;

receipt of clotting factor concentrates produced before1987; and

long-term hemodialysis.

Regardless of test results, persons who use illegal drugs or have multiple sex partners should be provided with information regarding how to reduce their risk for acquiring bloodborne and sexually transmitted infections and how to avoid transmitting infectious agents to others (e.g., through vaccination against hepatitis B and, if appropriate, hepatitis A). Persons who inject drugs should be counseled to stop using and get into a treatment program. If they are found at any follow-up visit to be continuing the use of these drugs, they should be counseled on how to inject safely (i.e., use of sterile, single-use equipment, including needles, syringes, cookers, cottons, and water each and every time they inject). Persons with multiple sex partners should be counseled regarding how to reduce the transmission of STDs (e.g., through abstinence or by decreasing the number of sex partners).

Persons who test negative for HCV who had a previous exposure should be reassured that they have not been exposed. Persons who test positive for HCV infection should be provided information regarding how to protect their liver from further harm, how to prevent transmission to others, and the need for medical evaluation for chronic liver disease (CLD) and possible

treatment. To protect their liver from further harm, HCV-positive persons should be advised to avoid alcohol, avoid taking any new medicines (including over-the-counter and herbals) without checking with their doctor, and become vaccinated against hepatitis A or hepatitis B if they are not immune. To reduce the risk for transmission to others, HCV-positive persons should be advised not to donate blood, body organs, other tissue, or semen and not to share any personal

items that may have blood on them (e.g., toothbrushes and razors). HCV-positive persons with one long-term, steady sex partner do not need to change their sexual practices. They should

discuss the low but present risk for transmission with their partner and discuss the need for counseling and testing. HCV-positive women do not need to avoid pregnancy or breastfeeding.

Postexposure Follow-Up

No postexposure prophylaxis is effective against HCV. Testing to determine whether HCV infection has developed is recommended for health-care workers after percutaneous or

permucosal exposures to HCV-positive blood and for children born to HCV-positive women.

To view the entire guidelines, please go to http://www.cdc.gov/std/treatment/rr5106.pdf

Questions : Sex and HCV

Many people with HCV are worried about spreading the virus to their sex partners. This Web page talks about how likely it is to spread the hepatitis C virus through sex. If you have hepatitis C, it is not very likely that you will spread the virus through sex. But it is still possible. That is why it is very important to talk honestly and openly with your sex partner.

Can I give hepatitis C to my sex partner?
Yes, but it is not likely. Compared to hepatitis B virus and the human immunodeficiency virus (HIV), it is less likely that you will spread the hepatitis C virus to your sex partner.

If you have one long-term sex partner, you do not necessarily need to change your sex habits. But, if either you or your partner is worried about the small chance of spreading the hepatitis C virus, you can use latex condoms. This will make it almost impossible to spread the virus. Long-term partners of people with hepatitis C should get tested for the virus. If the test is negative, you will probably not need to repeat it.

If you have more than one sex partner, you are more likely to spread the virus. In this case, reduce the number of sex partners you have, practice safer sex, and always use latex condoms. Are Condoms Foolproof, or for Fools?

Can I get hepatitis C through other types of sexual contact, such as oral and anal sex?
We do not know if the virus can be spread by oral or anal sex. There is no proof that anyone has ever spread the virus through oral sex, although it may be possible. Anal sex may damage the lining of the rectum, and make it easier to pass the virus through the blood. Using condoms might help to prevent spreading the hepatitis C virus, and they could give you some possible protection against other sexually transmitted diseases such as HIV (human immunodeficiency virus) and hepatitis B.

You can not spread the hepatitis C virus through other types of contact, such as hugging or kissing someone on the cheek.

I know the hepatitis C virus is in my blood but is it in my saliva, semen or vaginal secretions?
Some studies show that the virus may live in your saliva, semen or vaginal secretions, but no one knows for sure. We also don't know exactly how much of the virus may live in these bodily fluids, or if it can be passed on to sex partner(s) from these fluids.

If I have large amounts of virus in my blood, am I more likely to spread the disease to my sex partner?
Some studies suggest that a lot of the virus in the blood might make it easier to spread the virus. But even with high levels of the virus, you are still not very likely to spread the virus through sex. You do not necessarily have to change your sex habits if you have higher levels of the hepatitis C virus.

What kind of birth control methods will prevent the spread of the hepatitis C virus?
If you are worried about the small risk of spreading the virus through sex, you should use latex condoms. Other types of birth control methods, like birth control pills, vasectomy, intrauterine devices (IUD's), or diaphragms do NOT decrease the risk of spreading the hepatitis C virus.

Can my partner get pregnant, and if so, what is the risk that the baby will get hepatitis C?
It is possible to get pregnant if you or your partner has hepatitis C. If you are a male with hepatitis C, and your female partner does not have hepatitis C (throughout the entire pregnancy), then there is no chance that the baby will contract the virus from the mother. If you are a pregnant female who already has hepatitis C (or gets hepatitis C at some point during the pregnancy), the chance of passing the virus to your baby is low, less than 5%. The risk becomes greater if the mother has both hepatitis C and HIV. With proper prenatal care, babies born to hepatitis C positive mothers or fathers are usually quite healthy.

I am on combination treatment (ribavirin and interferon). Do I need to use birth control methods?
Yes! Ribavirin can cause severe birth defects, and you or your partner should NOT get pregnant while you are taking it. If you are taking ribavirin to treat your hepatitis C, you must use two effective forms of birth control, one for you and one for your partner. For example: the man uses a condom, and the woman uses a diaphragm or birth control pill. You must continue this type of birth control for 6 months after your last dose of combination treatment.

What makes me more likely to spread the hepatitis C virus to my sexual partner (s)?

You may be more likely to spread the virus if you:

1. do not use latex condoms
2. have more than one sex partner
3. have had sexually transmitted diseases (STD's) before
4. also have another virus, such as HIV

How can I reduce the chances of spreading the hepatitis C virus through sexual contact?

To reduce this chance, use the following guidelines:

1. Have sex with only one person, or not at all.

2. Tell your sex partner that you have HCV and that it is unlikely, but still possible, to spread it to them.

3. Use latex condoms, correctly and every time, especially if:
a) you have more than one sex partner.
b) you have 'rough' sex which might make one of you bleed.
c) you have sex during your or your partner's menstrual period.
d) you have sex when you or your partner has an open sore or cut on your genitals.

The risk of spreading hepatitis C to your sex partner is small.

If you can talk openly about the disease, and are careful and respectable with your sex life, you can have a safe, healthy, wonderful sex life.

http://www.va.gov

http://www.hcvanonymous.com/new22.htm

Michael Carter

January 14 2004

No sexual transmission of HCV seen in repeat HIV testers in San Francisco

No cases of sexual transmission of hepatitis C virus were found in a three year San Francisco study published in the January 2004 edition of Sexually Transmitted Diseases. The study, conducted amongst repeat HIV testers, the overwhelming majority of whom were gay men, also failed to find any association between unprotected anal sex and new hepatitis C infections. These findings stand in contrast to a recent observational study conducted in the UK that found that unprotected anal sex was the sole common risk factor for hepatitis C transmission amongst HIV-positive gay men (see link to this and other recent news stories on the sexual transmission of hepatitis C below).

Investigators from San Francisco conducted a retrospective study involving 981 repeat HIV testers between 1997 and 2000. The investigators aimed to establish the prevalence of hepatitis C infection amongst this population and the incidence of new hepatitis C infections.

The overwhelming majority of individuals included in the analysis were gay men (754 people, 77%), 135 (1%) were women and 92 (15%) were heterosexual men.

A total of 576.6 person years of observation were contributed by the 703 individuals who had blood samples for both HIV tests. There were no new cases of hepatitis C detected giving a hepatitis C incidence of zero. However, six new cases of herpes simplex virus-2 (HSV-2) and ten new HIV infections occurred (incidence rates 2.8 per 100 person years and 1.8 per 100 person years respectively).

The hepatitis C prevalence was 2.5%, and was highest in heterosexual men (4.3%), followed by heterosexual women (3.7%). The prevalence in gay men was 2.1%. Univariate analysis showed that individuals with a history of injecting drug use were over 33 times more likely to be infected with hepatitis C than individuals with no history of injecting drugs.

Gay men over 50 years of age were more likely to be infected with hepatitis C than gay men aged under 30 (odds ratio 6.6; 95% CI, 1.2 - 44.0). HIV-positive gay men were also more likely to be hepatitis C-positive than gay men who were not infected with HIV (odds ratio 5.4; 95% CI, 1.2 - 19.1).

No statistically significant association was found between recent sexual risk behaviour, including either insertive or receptive unprotected anal sex and hepatitis C infection. However, an association was found with increasing age (p=0.01), but not for the number of lifetime sexual partners (p=0.35).

In multivariate analysis, age 50 or above (odds ratio 8.5; 95% CI, 2.6 ?27.7), HIV infection (odds ratio, 5.7; 95% CI, 1.6 - 20.6) remained associated with hepatitis C infection.

”Despite having more than 575 person-years of observation in this sexually active sample and documented new sexually transmitted viral infections like HSV-2 and HIV, no cases of HCV antibody seroconversion were detected? note the investigators. They add, “In addition, no correlation was found between HCV antibody prevalence and recent sexual behaviors such as number of sexual partners in the past year or unprotected insertive or receptive anal sex…HCV is inefficiently spread through sexual contact." They conclude that hepatitis C prevention efforts should focus on injecting drug users, “as the sexual transmission of hepatitis C continues to appear uncommon."

Lack of Evidence of Sexual Transmission of Hepatitis C Among Monogamous Couples: Results of a Ten-Year Prospective Follow-Up Study

C. Vandelli¹ ,F. Renzo¹,L. Romano² S. Tisminetzky³ ,M. De Palma⁴, T. Stroffolini⁵ ,E. Ventura¹, A. Zanetti²

¹Department of Internal Medicine, Policiinico of Modena, Modena, Italy; ² of Virology, University of Milano, Milano, Italy; ³ Trieste, Italy; ⁴Bank, Policlinico of Modena, Modena, Italy; ⁵ Department, S. Giacomo Hospital, Roma, Italy

Introduction

We have evaluated the risk of sexual transmission of hepatitis C virus (HCV) infection among 895 monogamous heterosexual partners of HCV chronically infected individuals in a long-term prospective study.

Methods / Results

The follow up period was 8060 person-years; 776 (86.7%) spouses were followed up for ten years. corresponding to 7760 person-years of observation and 119(13.3%) spouses (69 whose infected partners cleared the virus following treatment and 50 who ended their relationship or were lost at follow- up) contributed for additional 300 person-years.

During the follow-up three HCV infections were observed corresponding to an incidence rate of 0.37 per 1,000 person-years. However, in one case the infecting HCV genotype in a spouse was different from that of the partner ((2a, 1b), likely excluding a sexual route of transmission. Despite the remaining two couples had concordant genotypes, sequence analysis of the NS5b region of the HCV genome, coupled with a phylogenetic analysis showed that the corresponding partners carried different viral isolates, again excluding the possibility of intraspousal transmission of HCV.

Conclusion

These findings indicate an extremely low or even null risk of HCV transmission within heterosexual monogamous couples

www.hcvadvocate.com

Is Hepatitis C a Sexually Transmitted Disease?

The hepatitis C virus can be sexually transmitted, but the risk is low. Some studies in which it was claimed that HCV was sexually transmitted are known to be flawed because the group tested (mostly prostitutes) also had other risk factors, such as lifestyle risks, (sharing razors, piercing, manicure equipment, toothbrushes and generally an un-sterile environment) and most notably- intravenous drug use.

According to Health Canada, however, "The risk of infection through sexual intercourse with a carrier is estimated at 2.5% over 20 years. Transmission from mother to child is uncommon, and the question of risk to breast-fed infants of infected mothers is unresolved."

Hepatitis C is spread mainly by blood to blood contact. Thus it is conceivable that sharing a toothbrush or a razor- or even deep kissing after dental flossing- might be more risky than actual sex!

Health Canada concludes that heterosexual transmission of hepatitis C is extremely uncommon, despite frequent and unprotected sexual intercourse.

Other studies suggest that body fluids of patients with chronic hepatitis C are rarely, if ever, contaminated with the hepatitis C virus. This may help to explain the infrequent transmission of this disease by sexual or close physical contact.

Some Guidelines for Sex and HCV

If someone has Hep C, it might be passed to another person through sex, but the possibly only if there is contact with blood and or lesions. The presence of herpes sores etc, may make it easier to pass on hepatitis C through sex.

The current recommendations from Health Canada are:

People with multiple partners should practice "safer sex", (use male and or female condoms).

Longstanding sexual monogamous partners do not need to change their sexual practices if one of them is found to be infected with Hepatitis C.

Oral Sex

It is unknown for Hepatitis C to be passed to someone through oral sex, but it could possibly be passed on if there are cuts or sores in the mouth, bleeding gums, or a throat infection.

If menstrual fluid (blood of an Hep C infected woman) is also present, there will be more risk of infection. There are no confirmed reports of infection occurring by this route.

There is probably not enough Hep C in saliva that is not contaminated with blood to infect another person.

Information supplied by HEPCBC

Sexual Activity as a Risk Factor for Hepatitis C Infection

Norah A. Terrault, M.D., M.P.H.

Percutaneous exposures are well-recognized risk factors for HCV, hepatitis B virus (HBV), and HIV. However, there are clear differences between these viruses with respect to their frequency of transmission through sexual contact. The accumulated epidemiological evidence indicates that HCV can be sexually transmitted but much less efficiently than HBV and HIV.

Epidemiological studies evaluating the magnitude of risk of HCV transmission by sexual activity have several methodological shortcomings that tend to overestimate the proportion of HCV infections associated with sexual contact. Early studies used first-generation anti-HCV assays, which have a higher false positive rate than second- and third-generation assays. Studies vary in the completeness of risk ascertainment and many fail to carefully exclude HCV acquisition from non-sexual sources. Non-disclosure of injection drug use (IDU) as a risk factor is particularly important since assessing the contribution of sexual activity to HCV transmission is difficult in the presence of IDU. Finally, only a limited number of studies perform virological analyses to confirm that sexual partners are infected with the same virus and to exclude acquisition from outside sources.

Reported rates of HCV infection in sexual partners differ by geographical region, with higher rates reported in countries with higher endemic rates of HCV infection. Rates of anti-HCV positivity also vary by risk group, with higher rates of HCV reported in persons with a history of sexually transmitted diseases (STDs) and lower rates in heterosexual partners in long-term relationships. This difference may reflect the frequency of exposure to different HCV-infected sexual partners (higher in those with multiple partners than those in monogamous relationships). Alternatively, these risk groups may reflect differing rates of exposure to other non-sexual sources of HCV, such as IDU. The findings regarding sexual transmission in one group may not be generalizable to other groups or to the general population.

How Prevalent is the Risk Factor “Sexual Activity” in Persons with Acute Hepatitis C?

The Centers for Disease Control and Prevention collects detailed risk factor data on newly diagnosed cases of acute hepatitis C. In these surveillance studies, 15–20 percent of cases of acute community-acquired HCV occur in persons who report unprotected sexual contact with an anti-HCV positive person in the preceding 6-month period (two-thirds of cases) or multiple sexual partners (one-third of cases) as their only risk factor for HCV acquisition. Limited access to the sexual contacts prevents virological evaluation of the transmission events.

What is the Prevalence of HCV in Persons at Risk for Sexually Transmitted Diseases?

In U.S. seroprevalence studies conducted among sex workers, persons attending STD clinics, or persons participating in HIV surveillance studies, 1.6–25.5 percent of individuals are anti-HCV positive. In studies including persons with a history of IDU, anti-HCV positivity is more strongly associated with IDU than with factors related to sexual practices. In studies limited to individuals without a history of IDU, anti-HCV positivity is identified in 1.6–7 percent of STD clinic attendees, and risk factors associated with HCV are number of recent and lifetime partners, high-risk sexual contact (variably defined), and anti-HIV positivity. In homosexual and bisexual men, rates of anti-HCV positivity range from 2.9–12.7 percent with higher rates among those with HIV infection, but again IDU rather than sexual risk factors is most strongly associated with being HCV-positive.

What is the Prevalence of HCV in Monogamous Heterosexual Couples?

Among steady heterosexual partners of HCV-infected, HIV-negative persons, 0–24 percent are anti-HCV positive, with marked geographical variability. The median rate of anti-HCV positivity in sexual partners is 1.0 percent in North America and Northern Europe, 6 percent in Southern Europe, and 11 percent in Southeast Asia. Studies using genotyping or viral sequence analysis to assess anti-HCV concordant couples find lower rates of HCV transmission than studies using antibody testing alone. The duration of the sexual relationship is not predictive of HCV positivity in partners after adjusting for age. In studies comparing HCV positivity among sex partners vs. other family members, the rates of HCV positivity are higher in spouses than in other family members. However, after controlling for age and other parenteral exposures, anti-HCV positivity is no longer consistently associated with the type of relationship.

The majority of the published studies use genotyping rather than viral sequence analysis to evaluate anti-HCV concordant couples. Genotyping is suboptimal since HCV genotypes that are prevalent in the population may be present in partners even though they may have acquired the virus from different sources. For example, a study of 24 anti-HCV concordant couples found that 12 had concordant genotypes, 7 had discordant genotypes, and 5 were un-typable. Seven of the 12 couples could be analyzed by sequence analysis, and only 3 were highly homologous and consistent with transmission. Thus, overestimation of HCV sexual transmission occurs if genotyping rather than sequence analyses is used to evaluate infected partners.

What is the Incidence of HCV Infection in “At Risk” Individuals?

In prospective studies (1–3.7 years follow-up) conducted in high-risk cohorts of non-IDU sex workers and patients in STD clinics, the incidence of HCV is 0.4–1.8/100 person-years (~1 percent). Small sample size precludes evaluation of specific sexual practices as risks for HCV acquisition. Undisclosed IDU may contribute the higher incidence of infection in this subgroup.

Based upon results from a prospective cohort of 499 Italian couples followed for a mean of 12.4 months, the incidence of new infection in sexual partners is 12 per 1,000 person-years. Sequence analysis of the HCV-positive couples reveals a high degree of sequence homology in only 50 percent of the couples, suggesting non-sexual sources of HCV acquisition and a true incidence of no more than 6 per 1,000 person-years. In retrospective cohorts of female partners of hemophiliacs, the incidence is 1 to 1.87 per 1,000 person-years; among male partners of women infected by contaminated anti-D immunoglobulin, the incidence is 0.28 per 1,000 person-years; and among liver clinic patients and their sexual partners, the incidence is 1 to 3.86 per 1,000 person-years.

Factors That May Affect the Risk of HCV Transmission by Sexual Contact

In studies involving persons at risk for STDs, HIV co-infection is an independent predictor of anti-HCV positivity in the majority of studies. In studies involving hemophiliacs with HIV and HCV, the rate of anti-HCV positivity is higher in female partners of dually-infected men compared to men with HCV infection only. Studies from STD clinic attendees also suggest that co-infection with other STDs or sexual practices which may traumatize the mucosa (anal receptive sex) may increase the risk of sexual transmission of HCV. Whether the risk of HCV transmission differs for males vs. females is unclear. In one study of heterosexual couples in STD clinics, females with HCV-positive partners were 3.7 times more likely to have HCV than females with HCV-negative partners; this pattern was not evident in males. The titer of HCV RNA and HCV genotype do not appear to influence the risk of HCV transmission, but high-quality studies to assess these virological factors are lacking.

Summary

The available data indicate that HCV can be sexually transmitted but the efficiency of transmission by the sexual route is low. The risk of sexual transmission of HCV is estimated to be 0.03 percent to 0.6 percent per year for those in monogamous relationships, and 1 percent per year for those with multiple sexual partners. Given these estimates of risk, the current recommendations are: 1) HCV-positive individuals in longer-term monogamous relationships need not change their sexual practices. If couples wish to reduce the already low risk of HCV transmission by sexual contact, barrier precautions may be used. Partners of HCV-positive persons should be considered for anti-HCV testing and 2) For HCV-infected individuals with multiple or short-term sexual partners, barrier methods or abstinence are recommended. Additional common-sense recommendations include the use of barrier precautions if other STDs are present, if having sex during menses, or if engaging in sexual practices that might traumatize the genital mucosa. Finally, couples should not share personal items that may be contaminated by blood such as razors, toothbrushes, and nail-grooming equipment.

References

Centers for Disease Control and Prevention. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR 1998;47 (No. RR-19):1–33.
Leruez-Ville M, Kunstmann JM, De Almeida M, et al. Detection of hepatitis C virus in semen of infected men. Lancet 2000;356:42–3.
Neumayr G, Propst A, Schwaighofer H, et al. Lack of evidence for the heterosexual transmission of hepatitis C. Q J Med 1999;92:505–8.
Piazza M, Sagliocca L, Tosone G, et al. Sexual transmission of the hepatitis C virus and efficacy of prophylaxis with intramuscular immune serum globulin. Arch Intern Med 1997;157:1537–44.
Rooney G, Gilson RJC. Sexual transmission of hepatitis C virus infection. Sex Transm Inf 1998;74:399–404.
Thomas DL, Zenilman JM, Alter HJ, et al. Sexual transmission of hepatitis C virus among patients attending sexually transmitted disease clinics in Baltimore—An analysis of 309 sex partnerships. J Infect Dis 1995;17:768–75.
Zylberberg H , Thiers V, Lagorce D, et al. Epidemiological and virologicalanalysis of couples infected with hepatitis C virus. Gut 1999;45:112–116.

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Sexual Transmission of HCV

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2002 CDC SEXUAL TRANSMISSION GUIDELINES FOR HEPATITIS A, B AND C

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Lack of Evidence of Sexual Transmission of Hepatitis C Among Monogamous Couples: Results of a Ten-Year Prospective Follow-Up Study

Is Hepatitis C a Sexually Transmitted Disease?

Some Guidelines for Sex and HCV

The current recommendations from Health Canada are:

Oral Sex

Sexual Activity as a Risk Factor for Hepatitis C Infection

2002 CDC SEXUAL TRANSMISSION GUIDELINES FOR
HEPATITIS A, B AND C